SARS-COV-2 INFECTION AND INVOLVEMENT OF PERIPHERAL NERVOUS SYSTEM: A CASE SERIES OF CARPAL TUNNEL SYNDROME AGGRAVATION OR NEW ONSET WITH COVID-19 DISEASE AND A REVIEW OF LITERATURE.

COVID-19 may be asymptomatic or have a typical presentation with fever, cough, anosmia, lymphocytopenia. In some cases, it occurs with a "chimeric" presentation, with more subtle and ambiguous symptoms which may be initially misdiagnosed and are referred to in long covid condition. A possible central and peripheral nervous system involvement has been recognized. We present our experience and review the literature about association between carpal tunnel syndrome (CTS) and hand's arthritis presenting a case series of patients who firmly state that their condition of CTS arised or got worse during a typical presentation of COVID-19. The outbreak of COVID-19 has resulted in significant global healthcare implications. While the respiratory manifestations of COVID-19 have been widely studied, there is emerging evidence suggesting potential associations between COVID-19 and various other health conditions. This review of the literature aims to investigate the potential relationship between COVID-19 and the development or exacerbation of CTS. By synthesizing the available literature on this topic, we aim to provide a comprehensive overview of the current knowledge and enhance our understanding of the potential implications of COVID-19 on CTS. Case series: In this article we report 13 cases of typical presentations of COVID-19 with fever, myalgia, and respiratory system involvement, with a simultaneous aggravation of the median nerve pre-existing neuralgia and some cases that developed a median nerve neuralgia during COVID-19, which came to the attention of the hand surgeon. Some cases had stable symptomatic CTS and were on waiting list for surgical carpal tunnel release, some cases were previously asymptomatic and developed a median nerve neuralgia during COVID-19. All patients referred to a rapid worsening of acral paraesthesia and neuralgic pain of the same quality of CTS and in the median nerve topography. Some patients developed typical COVID-19 symptoms and died; the others were surgically treated. CTS could be an atypical presentations of COVID-19 or a condition of long-covid disease and clinical and epidemiological significance needs to be fully studied. We presented cases of worsening of the median nerve neuralgia which presented among other symptoms of COVID infection. We conclude a causal relation may exist and needs to be further investigated.

Preliminary data on the neurophysiological evaluation of male sexual dysfunction in patients with pelvic ring fractures: a multicenter retrospective study.

OBJECTIVE: Traumatic pelvic ring fractures include several comorbidities due to the close anatomical relationship between the skeletal system, pelvic organs, and neurovascular structures. In this retrospective multicenter study, we evaluated patients complaining of sexual dysfunction following pelvic ring fractures, assessed through different neuro-physiological examinations. PATIENTS AND METHODS: Patients were enrolled one year after the injury according to their reported ASEX scores and evaluated on the basis of the Tile's type of pelvic fracture. Lower limb and sacral somatosensory evoked potentials, pelvic floor electromyography, bulbocavernosus reflex and pelvic floor motor evoked potentials were recorded, according to the neurophysiological indications. RESULTS: A total of 14 male patients (mean age 50.4; 8 subjects Tile-type B and 6 Tile-type C) were enrolled. The ages between the Tile B group and the Tile C group of patients were not significantly different (p=0.187), while the ASEX scores were significantly different (p=0.014). In 57% of patients (n=8), no alterations in nerve conduction and/or pelvic floor neuromuscular responses were found. In 6 patients, electromyographic signs of denervation were revealed (2 patients), and alterations of the sacral efferent nerve component were detected in 4 patients. CONCLUSIONS: Sexual dysfunctions after a traumatic pelvic ring fracture are more common in Tile-type B. Our preliminary data did not reveal a significant association with neurogenic aetiology. Other causes could explain the complaining impairments.

PATTERN OF A PRIMARY B-CELL LYMPHOMA IN ULNAR NERVE: INTRANEURAL OR EXTRANEURAL.

Primary lymphomas of peripheral nerves (PLPNs) are extremely rare and most commonly reported in lumbar nerves and have been found in only five cases in the upper extremities. We describe two patterns of presentation focusing on clinical, radiological, and pathological findings of two patients affected by primary multifocal lymphoma of the ulnar nerve without systemic involvement or other medical conditions. We report a case of extraneural lymphoma in a 72-years-old (patient #1) and a case of intraneural lymphoma in a 45-years old woman (Patient #2). Magnetic resonance imaging and ultrasound findings were similar to Peripheral Nerve Sheath Tumors (PNST). Surgical exploration and excision were performed. Morpho pathological results revealed in both cases a diffuse large B-cell non-Hodgkin lymphoma. In patient #1, the disease relapsed after only 4 months with brachial plexus involvement. The patient died about 10 months after the onset of symptoms. Patient #2 did not have post-surgical sensory or motor deficit and follow up at 6 years did not show recurrence or any other localizations. PLPN is a rare and challenging condition and is frequently misdiagnosed. PLPNs could have an intraneural or an extraneural pattern. As peripheral neuropathy may be caused by a nervous involvement by a lymphoma, in patients with atypical lesions, a complete preoperative imaging should be acquired.

Resurfacing Capitate Pyrocarbon Implant for the treatment of advanced wrist arthritis in the elderly: a retrospective study.

OBJECTIVE: Advanced forms of wrist osteoarthritis in the elderly are quite common and often under-treated, preferring a conservative management of the condition due to the age of the patient. However, in elderly people who are still active, sporty and physically demanding, surgical management of wrist osteoarthritis should be considered. Proximal Row Carpectomy associated with a Resurfacing Capitate Pyrocarbon Implant (RCPI), allows the management of a wide range of wrist arthrosis, involving both the radio-carpal and the mid-carpal joints. This treatment has been already reported as a solution in younger people affected by degenerative pathologies of the wrist, giving overall good results. Authors aimed at verifying how this technique could be useful in elderly patients, resolving the severe pain often related to this pathology and letting them recover strength and motion. PATIENTS AND METHODS: This is a retrospective analysis involving 7 cases of elderly men (mean age = 68 y.o.), suffering from severe wrist arthritis and treated with RCPI between 2016 and 2021. RESULTS: All patients reported a return to manual activities between 6 and 12 months after surgery, significantly improving pain. Two patients complained moderate pain under strain at follow-up, with residual difficulty in performing manual tasks. In all cases, an increase of strength and improvement in terms of stiffness was registered. No cases of infections or implant mobilization were reported. CONCLUSIONS: RCPI combined with proximal row carpectomy shows satisfying results in all published studies and it has been confirmed in our series as well. Indications for this procedure should be widened to elderly people, as useful alternatives to more aggressive salvage procedures, such as total prosthesis or arthrodesis.

DOES AN EARLY POST-OPERATIVE PAIN RELIEVE INFLUENCE THE FUNCTIONAL OUTCOME OF PATIENTS WITH COLLES FRACTURES TREATED WITH EG-BLOCK SYSTEM?

Distal Radius Fractures (DRFs) represent one of the most common elderly patient's fractures. Often DRFs required surgical treatment based on instability of the fragments and due to the high functional demand from patients. A general agreement on the best pharmacological treatment in the post-operative is still missing. The present study describes the clinical outcome in patients who underwent surgery for Colles fracture using ES fixation osteosynthesis. ; The present investigation represents a one center retrospective analysis. In this study, two different medical treatments were recognized, and groups consequently set (Group A: Ketoprofene 100 mg twice a day for 5 days, 59 patients; Group B: Tramadol 75 mg and Dexketoprofen 25 mg, 62 patients). Outcomes were the functionality of the affected wrist through AROM assessment and the evaluation of painkillers intake, pain itself and Quick-DASH.; 121 patients were included in the present study. The pharma blending of Tramadol 75 mg and Dexketoprofen 25 mg resulted effective for the rapid recovery of the treated wrist motion. In fact, in the group B motion was better compared to group A (p<0.05) for any movement examined (flexion, extension, pronation, supination) until the last follow-up (70 days).; Associations of different painkillers are common, even if a general agreement on the most effective combination is still missing. Tramadol and Dexketoprofen provide a good clinical result, less side effects and a better functional recovery of the wrist motion. This guarantees a fewer social cost and a best management of post-operative physiotherapy.

OUTCOMES OF A LONG-TERMS MICROVASCULAR TRAINING FOR RESIDENTS IN ORTHOPEDIC.

The acquisition of specific technical skills in the field of microsurgery like the use of operating microscope and microsurgical instruments, arterial and venous anastomosis, vascular grafts, nerve sutures and tenorrhaphies, is very important during the training in Orthopedics and in Hand Surgery in order to deal with management of complex and amputative traumas of the upper limb. The learning curve in microsurgical techniques is significantly shortened for surgeons who benefit from pre-clinical courses on an animal model. The aim of this study was to standardize a long-term microsurgical activity during the training in Orthopedics and Hand Surgery and to document the benefits that the residents of the School of Specialization got by chance of practicing weekly this discipline on in-vivo model. In 2016, a protocol for teaching in vivo microsurgery on Wistar rats for orthopedics and hand surgery residents was approved. In the first 3 years of graduation course, the students performed the training aimed at acquiring manual dexterity and confidence with the microsurgical instrumentations on nonliving models. Subsequent exercises were performed ex vivo on chicken leg models under the microscope or loupes. Finally, the in-vivo rat exercises were intended for residents in the last 2 years who required access to the supplementary diploma in hand surgery. Outcome evaluations consisted of the Global Rating Scale score and time to completion. Two-tailed Student t test was performed to compare initial and final outcome evaluations (p<0.05). Only 8 residents completed the microvascular training of almost thirty microsurgical teaching sessions administered on a weekly basis. The total mean GRS score (and standard deviation) improved from 15±2 points for the initial score to 21±6 points for the final score (p<0.005). Time to completion of the anastomosis also significantly improved (p<0.005), from a mean score of 31:18±9:21 minutes for the initial time to 21:15±6:10 minutes for the final time. A microvascular training curriculum utilizing a live rat model, preceded by a training on non-living models, provides a superior surgical simulation experience and is effective at improving resident microvascular surgical skills.

Neutrophil-to-lymphocyte ratio but not monocyte-to-HDL cholesterol ratio nor platelet-to-lymphocyte ratio correlates with early stages of lower extremity arterial disease: an ultrasonographic study.

OBJECTIVE: The role of inflammatory markers as neutrophil-to-lymphocyte ratio (NLR), monocyte-to-high-density lipoprotein-cholesterol ratio (MHR), and platelet-to-lymphocyte ratio (PLR) in cardiovascular diseases has been widely investigated in recent years. In the context of lower extremity arterial disease (LEAD), this association has been mainly studied in the advanced stages. The aim of our study was to investigate the role of these inflammatory markers in all stages of LEAD, including early ones, using ultrasonography as diagnostic tool, together with ankle-brachial index (ABI) determination. PATIENTS AND METHODS: In this cross-sectional observational study, we enrolled 240 patients undergoing ultrasonographic evaluation of the lower limb arteries and ABI determination because of symptoms suggestive of LEAD or presence of known cardiovascular risk factors. RESULTS: In our study population, we found that ultrasonographic categories of LEAD were associated with NLR, but not with MHR and PLR. CONCLUSIONS: These results confirm that a specific pattern of inflammation can be found in all stages of LEAD, including early ones.

The effects of collagenase of Clostridium Histolitycum (CCH) in Dupuytren's disease: a histological study on cell mediated mechanisms that allow enzymatic fasciotomy.

Dupuytren Disease is a benign fibromatosis of palmar fascia of the hand, whose pathophysiology is not completely understood. The present study is intended to provide a description of the effects of Collagenase of Clostridium Hystoliticum (CCH) into an injected cord of Dupuytren. Our experimental study wanted to evaluate the histological effects of injection of CCH in the first 24 hours, without manipulating the specimens. MATERIALS AND METHODS: Surgical specimens were injected with CCH, and then fixed in formalin every six hours, up to 24 hours. Those specimens were compared to control specimen (non-injected), fixed and analyzed at the same times. RESULTS: In the injected specimens, the number of CD68 positive cells increased into and outside the cords compared to non injected specimens, within the same time from the surgical removal. CONCLUSION: CCH has a proinflammatory activity and provokes a short ray chemotactic action on white blood cells. The lysis of the cord induced by CCH stimulates the inflammatory response. The role of the inflammatory infiltration deserves to be investigated in a more accurate way, preferably by using in vivo studies.

The Use of Alfa-Lipoic Acid-R (ALA-R) in Patients with Mild-Moderate Carpal Tunnel Syndrome: A Randomised Controlled Open Label Prospective Study.

INTRODUCTION: Carpal tunnel syndrome is one of the most common peripheral neuropathies. Only a few studies evaluate the efficacy of "nutraceuticals" on peripheral nerves and neuropathic pain. The aim of the present investigation is to evaluate the role of Alfa-Lipoic Acid-R (ALA-R) on clinical and functional outcomes in patients affected by mild to moderate carpal tunnel syndrome. MATERIAL AND METHODS: The present investigation is a prospective randomised controlled open label study, performed at our Hand Surgery Department (Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome) from October 2018 to March 2019. The enrolled patients were divided in two groups: Group A (ALA-R 600mg once day for 60 days) and Group B (control Group, no drug administration). RESULTS: 134 patients (74 F, 60 M) met the inclusion and exclusion criteria. In Group A, there was a statistically significant pain reduction compared to the control Group. Using the Boston Carpal Tunnel Questionnaire, there were no significant improvements in the other symptoms and function. CONCLUSION: ALA-R full dose administration for two months leads to positive short term results in terms of symptoms and function improvement, even if the surgical carpal tunnel release remains the treatment of choice.

The Use of Alfa-Lipoic Acid-R (ALA-R) in Patients with Mild-Moderate Carpal Tunnel Syndrome: A Randomised Controlled Open Label Prospective Study

@#Introduction:Carpal tunnel syndrome is one of the most common peripheral neuropathies. Only a few studies evaluate the efficacy of “nutraceuticals” on peripheral nerves and neuropathic pain. The aim of the present investigation is to evaluate the role of Alfa-Lipoic Acid-R (ALA-R) on clinical and functional outcomes in patients affected by mild to moderate carpal tunnel syndrome. Material and Methods: The present investigation is a prospective randomised controlled open label study, performed at our Hand Surgery Department (Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome) from October 2018 to March 2019. The enrolled patients were divided in two groups: Group A (ALA-R 600mg once day for 60 days) and Group B (control Group, no drug administration). Results: 134 patients (74 F, 60 M) met the inclusion and exclusion criteria. In Group A, there was a statistically significant pain reduction compared to the control Group. Using the Boston Carpal Tunnel Questionnaire, there were no significant improvements in the other symptoms and function. Conclusion: ALA-R full dose administration for two months leads to positive short term results in terms of symptoms and function improvement, even if the surgical carpal tunnel release remains the treatment of choice.

Ultra-micronized Palmitoylethanolamide Effects on Sleep-wake Rhythm and Neuropathic Pain Phenotypes in Patients with Carpal Tunnel Syndrome: An Open-label, Randomized Controlled Study.

BACKGROUND: Patients with carpal tunnel syndrome often suffer from fragmentary sleep. This study was designed to assess the effectiveness of treatment with ultramicronized palmitoylethanolamide in reducing pain intensity and improving quality of sleep in patients with neuropathic pain due to carpal tunnel syndrome. METHODS: An open, controlled study was conducted on 42 patients awaiting carpal tunnel syndrome surgery, suffering from sleep disorders and painful symptoms and randomized into two groups. One group received ultramicronized palmitoylethanolamide (600 mg twice daily) during the pre- and postsurgery periods, while the other group did not receive any treatment except surgical therapy. The primary outcome measure was sleep quality assessment by the Pittsburgh Sleep Quality Index, with secondary outcome as painful symptomatology intensity evaluated by the Numeric Rating Scale. RESULTS: At the end of the pre-surgery period (T1) there was a highly significant improvement (p<0.0001) in overall sleep quality with an increase of continuous sleep time and a reduction of sleep latency and disturbances as well as a significant mitigation (p<0.0001) of painful symptoms in favor of the treated group. CONCLUSION: Disturbed sleep patterns are very common in patients suffering from neuropathic pain due to carpal tunnel syndrome. Our results, albeit preliminary, suggest that ultramicronized palmitoylethanolamide administration favors a clear improvement of sleep quality, confirming a correlation between sleep disorders and pain intensity.

Spontaneous gait recovery after sciatic nerve transection impairs the non-invasive evaluation of artificial nerve guides in rats.

PURPOSE: The study of the in-vivo regeneration of a nerve, made by purely histological methods, requires a high number of animals: this poses serious problems of technique, ethics and funding. A cheaper analysis, performed on the same animal along the duration of a study, is seeked with favour and Authors wanted to evaluate gait recovery after sciatic nerve transection as a non-invasive method to evaluate the performance of an artificial nerve-guide in rats. METHODS: Male Wistar rats (n=16) were divided into three groups: in group A (n=5) the experimental gap produced was bridged by a custom-made guide; in group B (n=7) animals were "sham-operated"; in group C (n=4) a PMMA cap sealed the proximal nerve stump. RESULTS: In group A a regenerated nerve was retrieved after 8 weeks, in all animals. In group B it was possible to retrieve mostly bulbous neuromatous stumps. In group C all the animals presented a voluminous neuroma. Signs of auto-mutilation had the following distribution: 1/5 in group A; 4/7 in group B; 3/4 in group C. A clear difference in gait recovery exists only between group C (no recovery) and the two other groups (early recovery in both). CONCLUSIONS: The present study highlights that in the male Wistar rat sciatic model a spontaneous recovery in gait pattern occurs very early (within the first or second week); with this animal model, a recovery in gait is likely to ensue irrespective of the kind of device eventually tested since it may happen even without a device.