Management of orthopaedic and traumatology patients during the Coronavirus disease (COVID-19) pandemic in northern Italy

Purpose: This article aims to share northern Italy\u2019s experience in hospital re-organization and management of clinical pathways for traumatic and orthopaedic patients in the early stages of the COVID-19 pandemic. Methods: Authors collected regional recommendations to re-organize the healthcare system during the initial weeks of the COVID-19 pandemic in March, 2020. The specific protocols implemented in an orthopaedic hospital, selected as a regional hub for minor trauma, are analyzed and described in this article. Results: Two referral centres were identified as the hubs for minor trauma to reduce the risk of overload in general hospitals. These two centres have specific features: an emergency room, specialized orthopaedic surgeons for joint diseases and trauma surgeons on-call 24/7. Patients with trauma without the need for a multi-disciplinary approach or needing non-deferrable elective orthopaedic surgery were moved to these hospitals. Authors report the internal protocols of one of these centres. All elective surgery was stopped, outpatient clinics limited to emergencies and specific pathways, ward and operating theatre dedicated to COVID-19-positive patients were implemented. An oropharyngeal swab was performed in the emergency room for all patients needing to be admitted, and patients were moved to a specific ward with single rooms to wait for the results. Specific courses were organized to demonstrate the correct use of personal protection equipment (PPE). Conclusion: The structure of the orthopaedic hubs, and the internal protocols proposed, could help to improve the quality of assistance for patients with musculoskeletal disorders and reduce the risk of overload in general hospitals during the COVID-19 pandemic

Fibromyalgia and Shoulder Surgery : a Systematic Review and a Critical Appraisal of the Literature

Fibromyalgia is a common musculoskeletal syndrome characterized by chronic widespread pain and other systemic manifestations, which has demonstrated a contribution to higher postoperative analgesic consumption to other surgeries such as hysterectomies and knee and hip replacements. The aim of this review is to search current literature for studies considering the impact of fibromyalgia on clinical outcomes of patients undergoing shoulder surgery. A systematic literature review was conducted in PubMed/Medline, Embase, and ClinicalTrials.gov in February 2019. Studies were selected based on the following participants, interventions, comparisons, outcomes, and study design criteria: adult patients undergoing surgery for shoulder pain (P); diagnosis of fibromyalgia (I); patients without fibromyalgia (C); outcome of surgery in terms of pain or analgesic or non-steroidal anti-inflammatory drugs consumption (O); case series, retrospective studies, observational studies, open-label studies, randomized clinical trials, systematic reviews and meta-analyses were included (S). Authors found 678 articles, of which four were found eligible. One retrospective study showed that patients with fibromyalgia had worse clinical postoperative outcomes; two retrospective studies reported a higher opioid prescription in patients with fibromyalgia and one prospective observational study found that a higher fibromyalgia survey score correlated with lower quality of recovery scores two days after surgery. The scarce and low-quality evidence available does not allow confirming that fibromyalgia has an impact on postoperative outcomes in shoulder surgery. Future studies specifically focusing on shoulder surgery outcomes may help improvement and personalization of the management of patients with fibromyalgia syndrome (PROSPERO 2019, CRD42019121180)

Ultrasound-Guided Percutaneous Tenotomy of the Long Head of Biceps Tendon in Patients with Symptomatic Complete Rotator Cuff Tear: In Vivo Non-contRolled Prospective Study

Background: We prospectively tested technical feasibility and clinical outcome of percutaneous ultrasound-guided tenotomy of long head of biceps tendon (LHBT). Methods: We included 11 patients (6 women; age: 73 \ub1 8.6 years) with symptomatic full-thickness rotator cuff tear and intact LHBT, in whom surgical repair was not possible/refused. After ultrasound-guided injection of local anesthetic, the LHBT was cut with a scalpel under continuous ultrasound monitoring until it became no longer visible. Pain was recorded before and at least six months after procedure. An eight-item questionnaire was administered to patients at follow-up. Results: A median of 4 tendon cuts were needed to ensure complete tenotomy. Mean procedure duration was 65 \ub1 5.7 s. Mean length of skin incision was 5.8 \ub1 0.6 mm. Pre-tenotomy VAS score was 8.2 \ub1 0.7, post-tenotomy VAS was 2.8 \ub1 0.6 (p < 0.001). At follow-up, 5/11 patients were very satisfied, 5/11 satisfied and 1/11 neutral. One patient experienced cramping and very minimal pain in the biceps. Six patients had still moderate shoulder pain, 1/11 minimal pain, 2/11 very minimal pain, while 2/11 had no pain. No patients had weakness in elbow flexion nor limits of daily activities due to LHBT. One patient showed Popeye deformity. All patients would undergo ultrasound-guided tenotomy again. Conclusion: ultrasound-guided percutaneous LHBT tenotomy is technically feasible and effective

Distance of the posterior interosseous nerve from the radial head during elbow arthroscopy : an anatomical study

Purpose The aims of this study were to measure the distance of the posterior interosseous nerve (PIN) from the radial head (RH) and its variations with forearm movements. Methods Five fresh frozen cadaver specimens were dissected under arthroscopy. An anterior capsulectomy extended to the entire lateral compartment was performed. The need of soft tissue dissection to isolate the nerve in the extracapsular space was recorded. The distance between the nerve and the anterior part of the RH was then measured with a graduated caliper inserted via the midlateral portal with the forearm in neutral position, full pronation, and full supination. Results The PIN was identifiable in all the specimens. In four cases, it was surrounded by a thick layer of adipose tissue, and further dissection was necessary to isolate it. Damage of the PIN during dissection occurred in one case, in which the proximal part of the nerve was accidentally cut. In three of the remaining cases, an increased distance was measured with the forearm in supination, as compared with neutral and full pronation position. Conclusion This anatomical study suggests that in most of the cases, the PIN does not lay just extracapular at the level of the radiocapitellar joint, but is surrounded by a thick layer of adipose tissue. Furthermore, its distance from the RH appears to increase with forearm supination. This position could increase the safe working space between RH and PIN. Clinical Relevance Knowledge of PIN position in relation to the anterior elbow capsule and its changes with forearm movements can help reduce the iatrogenic injuries during elbow arthroscopy

Open questions in the treatment of anterior shoulder instability

Risk factors for recurrence of shoulder instability after Bankart repair