Symptomatic coracoclavicular joint: incidence, clinical significance and available management options.

PURPOSE: Coracoclavicular joint (CCJ) is a rare anomalous joint occasionally found between the coracoid process of scapula and the conoid tubercle of clavicle. The articulation has been extensively studied by means of anatomical, osteological and radiological investigations. Most cases are discovered incidentally, with the symptomatic variety remaining an exceptional rarity. Our aim was to review all reported symptomatic CCJ to increase the level of evidence and formulate a treatment algorithm to aid clinicians in management planning. METHODS: A thorough literature search was performed, and data from 17 (n = 17) symptomatic cases of CCJ were analysed. RESULTS: CCJ is a rare finding and mostly an incidental discovery, which is rarely symptomatic. However, when symptomatic, the most common symptom is shoulder pain. The mean age at presentation is 42 years, with a male:female ratio of 1.4:1. Brachial plexus involvement was the most common pathophysiological explanation provided. First-line treatment was conservative, with a very low success rate of 5.9%. Surgical intervention in the form of excision of anomalous joint by osteotomy had success rate of 100%. CONCLUSIONS: Symptomatic CCJ is rare, and its rarity leads to lack of awareness in the general orthopaedic community. When symptomatic, CCJ may lead to delayed diagnosis or inappropriate management due to lack of evidence and poor description in most orthopaedic textbooks. Despite its low success rate, conservative treatment is advocated before embarking upon surgical intervention.

Neurological Presentations of COVID-19: Characteristic Features in a Case Series of Hospitalized Patients from Abu Dhabi, UAE.

BACKGROUND: COVID-19 patients can present with neurological manifestations in the form of headache, dizziness, hyposmia, myalgia, peripheral neuropathy, acute cerebrovascular disease, and encephalopathy. Neurological involvement could be due to virus-induced brain hypoxia, brain infection, or immune reaction. We aim to describe the neurological presentation of COVID-19 patients and study their neuroimaging findings and disease outcome. METHOD: The study is a single-centre, retrospective, observational study in Sheikh Shakhbout Medical City (SSMC), Abu Dhabi, UAE. Patients diagnosed with COVID-19 between March and May 2020 who presented with neuropathological features with or without respiratory manifestations of COVID-19 were enrolled. Electronic records were studied for age, sex, duration of hospitalization, detailed neurological presentation, history or documented concomitant fever and respiratory features of COVID-19, inflammatory markers, neuroimaging, progress, and disease outcome. RESULTS: Thirty-three patients of 10 nationalities presented with neurological manifestations. Mean (range) age was 51.4 (21-86) years. Twenty-four had comorbidities, and 18 had no prior or concomitant respiratory symptoms. Ten patients presented with encephalopathy and exhibited altered behavior/sensorium: 7 presented with myositis, 8 with stroke, and 4 with seizures, and 4 had peripheral and cranial nerve involvement. The mean (average) duration of hospital stay was 11.4 days (1-38) with the longest observed in stroke patients. Fifteen patients (45%) died and 3 (9%) had residual weakness. Serum ferritin, CRP, and procalcitonin were higher in the severe disease group and correlated with risk of death. Twelve of 22 brain images showed abnormalities including haemorrhage, infarcts, small vessel ischemia, and oedema. Risk of death was higher in older age but did not differ based on the underlying neuropathology. CONCLUSION: COVID-19 patients who present with neurological involvement have a higher risk of mortality which is aggravated by older age and higher inflammatory markers. The type of neurological pathology does not seem to influence the risk of mortality.

Impact of Ethnicity and Underlying Comorbidity on COVID-19 Inhospital Mortality: An Observational Study in Abu Dhabi, UAE.

BACKGROUND: The UAE reported its first cluster of COVID 2019 in a group of returned travellers from Wuhan in January 2020. Various comorbidities are associated with worse disease prognosis. Understanding the impact of ethnicity on the disease outcome is an important public health issue but data from our region is lacking. AIM: We aim to identify comorbidities among patients hospitalized for COVID-19 that are associated with inhospital death. Also, to assess if ethnicity is correlated with increased risk of death. Patients and Method. The study is a single-centre, observational study in Shaikh Shakhbout Medical City, Abu Dhabi. Patients admitted with COVID-19, between 1st of March and the end of May, were enrolled. Records were studied for demography, comorbidity, and ethnicity. Ethnicity was divided into Arabs (Gulf, North Africa, and the Levant), South Asia (India, Pakistan, Bangladesh, Nepal, and Afghanistan), Africans, the Philippines, and others. The study was approved by the Department of Health of Abu Dhabi. RESULTS: 1075 patients (972 males) were enrolled. There were 24 nationalities under 5 ethnicity groups. Mean (average) age was 51 years (20-81). 101 (9.4%) died with deceased patients being significantly older. Death risk was not significantly influenced by sex. Duration of hospitalization among survivors was 6.2 days (0.2-40.4) with older patients and men staying longer (P < 0.01). Comorbidities of diabetes, hypertension, cardiovascular disease, chronic renal disease, liver disease, and malignancy were associated with higher risk of mortality univariate, but only liver disease reached statistical significance after adjustment for age. The highest percentage of death was seen in Arab Levant (21.2) followed by the Asian Afghan (18.8); however, differences among ethnicities did not reach statistical significance (P = 0.086). CONCLUSION: COVID-19 outcome was worse in older people and those with comorbidities. Men and older patients required longer hospitalization. Ethnicity is not seen to impact the risk of mortality.

A prospective study of two methods of analgesia in shoulder arthroscopic procedures as day case surgery.

BACKGROUND & PURPOSE: The recent advances in anaesthesia and analgesia have significantly improved the early recovery and effective post-operative pain control in day care surgery e.g. shoulder arthroscopic procedures. Adequate analgesia improves the early rehabilitation for a better outcome. We prospectively evaluated the post-operative pain relief following the two methods of analgesia i.e. regional Inter-scalene block (ISB) vs Intra-articular (IA) injection using 0.5% Chirocaine in various therapeutic arthroscopic shoulder procedures. METHODS: A prospective comparative study was performed on a group of 105 patients (ASA grade I or II) who underwent the following procedures at two different hospitals: diagnostic arthroscopy, subacromial decompression (SAD) alone, SAD in combination with mini open cuff repairs or distal clavicle excision, anterior stabilization (Bankart's repair) and inferior capsular shift. A successful Inter-scalene block (0.5% Chirocaine-30mls) preceded the general anaesthesia (Group 1-52 patients). Local intra-articular infiltration (0.5% Chirocaine - 20 mls) was given postoperatively (Group 2-53 patients). Post operatively visual analogue scores (VAS) from 0 (no pain) to 10 (severe pain) were assessed in post-anaesthesia care unit (PACU), at 4hrs, at 24hrs and at 48 h. The amount of morphine consumption for the first 2 days after surgery was recorded. RESULTS: Patient characteristics were similar in both groups at both the hospitals. The median postoperative pain score of VAS <3 was observed in both groups. Significant difference (p < 0.0001) was observed in the VAS scores between the two groups at all the time intervals. The mean length of adequate sensory block in group 1 was significantly higher than in group 2 [20.5 h: 4.2 h] (p < 0.001). The mean analgesic (morphine) consumption was lower in Group 1 as compared to Group 2 [4.6 mg/24 h: 18.8mg/24 h](p < 0.0001). Bone shaving procedures e.g. SAD, SAD + Rotator Cuff repair, SAD + Lateral clavicular excision required significantly higher analgesia in both groups compared to the soft tissue procedures. CONCLUSION: Single dose ISB provided longer and effective postoperative analgesia. The bone shaving procedures required more analgesia in IA Group as compared to ISB Group.

Successful ACL reconstruction with a variant of the pes anserinus.

An anatomical variant of the pes anserinus encountered during anterior cruciate ligament reconstructive surgery which has not been previously described is discussed. During routine harvesting, the sartorius fascia was incised and the semitendinosus and gracilis tendons were identified. At the distal portion, it was noted that each tendon gave off an additional tendinous slip. The slip from the semitendinosus tendon had attached to the gracilis tendon and vice versa, thereby creating a double pes anserinus. This variant was used to construct the graft, and at 1 year review the patient had returned to full sporting activities with no complications encountered.

Functional outcome after computer-assisted total knee arthroplasty using measured resection versus gap balancing techniques: a randomised controlled study.

PURPOSE: To compare the 2-year outcome of total knee arthroplasty (TKA) using the measured resection versus the gap balancing techniques. METHODS: 21 men and 31 women aged 41 to 89 (mean, 73) years who underwent primary TKA by a single surgeon for osteoarthritis and had an American Society of Anesthesiologists I or II physical status were prospectively studied. Patients were randomised to undergo computer-assisted TKA using the measured resection technique (n=26) or the gap balancing technique (n=26). At the 2-year follow-up, patients were assessed by a single orthopaedic registrar blinded to the type of surgery using the Knee Society score (KSS), functional Knee Society score (FKSS), and revised Oxford Knee score (ROKS). RESULTS: In the measured resection group, the mean KSS, FKSS, and ROKS increased from 34.3, 48, and 21 to 85.9, 89.6, and 36.5, respectively. In the gap balancing group, the respective scores increased from 35.4, 50, and 22.5 to 89.1, 92.4, and 40.6. Postoperative increases in the respective scores were slightly better with the gap balancing technique; the respective p values were 0.46, 0.44, and 0.12. CONCLUSION: Improvements in the knee scores were comparable with the 2 techniques.

Post-partum septic arthritis of the knee: a case report.

INTRODUCTION: Septic arthritis is rare in the post-partum period. This is the first case of a post-partum staphylococcal septic arthritis of the knee reported. CASE PRESENTATION: This report describes a lady who developed symptoms of septic arthritis of the knee within one month of giving birth. CONCLUSION: The management of septic arthritis does not differ from standard practice when encountered in the post-partum period. Urgent washout of the joint and antibiotic usage is associated with a favourable outcome.

Bilateral undisplaced insufficiency neck of femur fractures associated with short-term steroid use: a case report.

INTRODUCTION: We present an interesting and unusual case of a 61-year-old woman with bilateral, undisplaced, stress neck of femur fractures associated with short-term steroid use. Insufficiency fractures of the neck of femur without preceding trauma have been described in the literature, although bilateral involvement is infrequent. These fractures have been associated with strenuous exercise, seizures, renal osteodystrophy, fluoride treatment, long-term corticosteroid use, amenorrhoea, abnormal anatomy and osteomalacia due to nutritional and/or hormonal factors. CASE PRESENTATION: The case we present differs from other published reports, in that the patient's symptoms developed acutely after only a short course of steroids and with no associated trauma or strenuous exercise. It is also the only case described where no operative intervention was required. CONCLUSION: Our case reiterates the importance of considering insufficiency or stress fractures in high-risk patients who present with musculoskeletal pain. Institution of bone protection should also be considered in these patients. Morbidity related to delayed treatment has been well documented, so a high level of clinical suspicion is imperative.

Post-traumatic myositis ossificans of the sternocleidomastoid following fracture of the clavicle: a case report.

BACKGROUND: Fractures of the clavicle are common injuries. The complications have been well documented in the literature. CASE PRESENTATION: Despite it close proximity to the sternocleidomastoid muscle and myositis ossificans recognised as a known complication of any fracture, the two have never previously been described in association secondary to a fracture of the clavicle. We present a case where myositis ossificans affecting the sternocleiodomastoid was detected in the post-injury phase of a clavicle fracture. CONCLUSION: This case highlights that traumatic myositis ossificans circumscipta can arise in the sternocleidomastoid muscle following a fracture of the medial third of the clavicle.

A ganglion cyst at the elbow causing superficial radial nerve compression: a case report.

INTRODUCTION: We report a rare case of a ganglion cyst at the elbow causing neurological symptoms by stretching the superficial radial nerve alone. Ganglia associated with radial nerve palsy at the elbow have been reported previously involving the deep branch of the posterior interosseous nerve and the superficial radial nerve, but not the superficial radial nerve alone. CASE PRESENTATION: A 45-year-old woman presented with a 4-month history of a painful lump in the anterior aspect of her left elbow associated with altered sensation in the dorsoradial aspect of her left hand. There was no history of trauma or any exacerbating factors. On examination the altered sensation was in the superficial radial nerve distribution and she had a positive Tinel's sign over the site of the swelling which was located over the anterior aspect of the radiocapitellar joint. CONCLUSION: The unique clinical symptoms and signs of our diagnosis of superficial radial nerve compression were confirmed by magnetic resonance imaging and then operative findings.

Acute isolated acetabular fracture following a game of squash: a case report.

Although hip injuries do not account a large amount of the Sports Physician's workload they can result in significant morbidity. We present a case where an acetabular fracture was sustained in a relatively young female while playing squash without any history of fall or injury but was treated successfully non-operatively. Such patients who present with acute hip pain must not be dismissed as simply having a soft tissue injury.

Successful removal of a telephone cable, a foreign body through the urethra into the bladder: a case report.

The variety of foreign bodies inserted into or externally attached to the genitourinary tract defies imagination and includes all types of objects. The frequency of such cases renders these an important addition to the diseases of the genitourinary organs. The most common motive associated with the insertion of foreign bodies into the genitourinary tract is sexual or erotic in nature. In adults this is commonly caused by the insertion of objects used for masturbation and is frequently associated with mental health disorders. We report a case of insertion of telephone cable wire into the urethra. Our case highlights the importance of good history, clinical examination, relevant radiological investigation and simple measures to solve the problem.

A prospective randomized double-blind trial of the use of intrathecal fentanyl in patients undergoing lumbar spinal surgery.

STUDY DESIGN: A randomized, double-blind controlled study. OBJECTIVE: To assess the efficacy and safety of intrathecal fentanyl in the relief of postoperative pain in patients undergoing lumbar spinal surgery. SUMMARY OF BACKGROUND DATA: Fentanyl has been used as a spinal analgesic in surgery and obstetrics with several studies promoting its efficacy and safety. There is no evidence in the literature about intrathecal fentanyl in lumbar spinal surgery. Previous studies have looked at the use of intrathecal morphine and conclude that it is effective but also associated with respiratory depression. METHODS: Sixty patients undergoing posterior lumbar spine decompression with or without instrumented fusion were randomized to receive either 15 mug of fentanyl intrathecally under direct vision or nothing just before wound closure. After surgery, all patients received intravenous (IV) morphine via patient-controlled analgesia system (PCA) syringe driver. Outcome measures included visual analogue scores (VAS) for pain, time to first bolus of IV morphine PCA, and total amount of morphine PCA used. RESULTS: The patients who received fentanyl demonstrated a significant decrease in their mean pain VAS, an increase in the time to first PCA bolus, and a 41% reduction in the total PCA morphine received. No patients had respiratory compromise requiring treatment. There was no significant difference between the two groups with respect to age, gender, and case mix. CONCLUSION: Intrathecal fentanyl is effective at reducing pain and morphine PCA use after lumbar spinal surgery with minimal respiratory depression.