Non-Hodgkin's Lymphoma: An Unusual Cause of Shoulder Pain.

Shoulder pain is a common complaint seen in the orthopedic clinic. Here, we report a rare case of primary extranodal ileocecal with exceedingly rare right shoulder deltoid non-Hodgkin's lymphoma (NHL). A 67-year-old female presented with abdominal swelling for four months associated with loss of appetite, loss of weight, and night sweats. Abdominal contrast-enhanced CT and cecal biopsy confirmed the diagnosis of ileocecal NHL. A right hemicolectomy was performed, and the patient completed six cycles of chemotherapy. The patient developed right shoulder pain with swelling three months later and was diagnosed with a relapse ileocecal lymphoma with dissemination to the right deltoid muscle after a repeat positron emission tomography scan. Clinicians need to consider NHL as a differential diagnosis in evaluating shoulder pain or swelling even though it is exceedingly rare. A partial or non-response to chemotherapy with dissemination to skeletal muscle carries a poor prognosis.

High Sural Nerve Trifurcation: A Rare Anatomical Variation.

The sural nerve is a commonly encountered anatomical structure in foot and ankle surgeries. Knowledge of its location and course is imperative in performing surgeries within its vicinity to avoid neurological deficits. We herein report a rare anatomical variation of the sural nerve where it trifurcates above the level of the lateral malleolus that was discovered in a patient who underwent internal fixation for a trimalleolar ankle fracture with ipsilateral navicular fracture. This study aimed to raise awareness on a unique anatomical variation of the sural nerve in order to reduce the risk of iatrogenic injury.

The impact of COVID-19 pandemic on orthopaedic specialty in Malaysia: A cross-sectional survey.

PURPOSE: This study aims to investigate further how the coronavirus disease 2019 (COVID-19) pandemic is affecting orthopaedic surgeon in Malaysia in terms of exposure, general perceptions of risk, and the impact on their current and future practice. METHODS: Orthopaedic surgeons nationwide were invited through email and text messages to answer an online self-administered questionnaire collecting demographic information, COVID-19 exposure experience, perception of risk, and impact on orthopaedic practice. RESULTS: Of the respondents, 4.7% and 14.0% were involved in frontline treatment for COVID-19 patients with non-orthopaedic and orthopaedic problem, respectively. Respondents working in Ministry of Health had highest percentage of involvement as frontliner, 7.8% (8/103) and 20.4% (21/103) for non-orthopaedic and orthopaedic related COVID-19 treatment, respectively (not significant). Their main concern was an infection of family members (125/235, 53.2%). Majority of respondents were still working (223/235, 94.9%), running outpatient clinics (168/223, 75.3%), and continued with their semi-emergency (190/223, 85.2%) and emergency surgeries (213/223, 95.5%). Of the surgeons, 11.2% (25/223) did not screen their patients for COVID-19 prior to elective surgeries, 30.9% (69/223) did not have any training on proper handling of personal protective equipment (PPE), 84.8% (189/223) make decision to manage more conservatively due to COVID-19 and 61.9% (138/223) had their income affected. Of the surgeons, 19.3% (43/223) started using telehealth facilities. CONCLUSION: Direct exposure to treatment of COVID-19 patients among the respondent is low and the main concern was infecting their family member. There are still several surgeons who did not conduct preoperative COVID-19 screening and practice without proper PPE training.

An Unusual Case of Chronic Partial Quadriceps Tear in a Child: A Case Report.

Quadriceps tendon rupture usually occurs in adults and is rare in children. A six-year-old boy was playing at home and had a fall. He was unable to extend his right knee but there was no gap felt over the patella tendon or quadriceps. He was first seen by a family doctor and presented late to the surgeon three months after the injury. Radiographs and ultrasound were performed. The magnetic resonance imaging confirmed the findings of partial quadriceps tear. The patient was put in a cylinder case with the knee in extension for two months. Six months post-injury, he regained full range of motion without any complications. We present an unusual case of partial quadriceps tear in an otherwise healthy six-year-old boy that was treated successfully despite a delayed presentation. Besides a high index of suspicion, magnetic resonance imaging is a good modality to detect partial quadriceps tear in children.

Osteomyelitis post acromioclavicular joint reconstruction.

Acromioclavicular joint (ACJ) injury is a common shoulder injury. There are various techniques of ACJ reconstruction. Superficial infection after ACJ reconstruction is not an uncommon complication. However, osteomyelitis post ACJ reconstruction has never been highlighted as a possible complication. Our patient is a 31-year-old male who sustained a Rockwood 5 ACJ dislocation and had anatomical ACJ reconstruction with autogenous gracilis and semitendinosus graft. Our technique involved the anatomical reconstruction of the ACJ and the coracoclavicular ligament with the usage of two bioscrews and the temporary stabilisation of the ACJ with two k-wires. As in any orthopaedic surgery, infection is often disastrous especially when the surgery involves implants. It can be disastrous with high morbidity to the patient as well as a costly complication to treat. Therefore, we wish to highlight this case as despite its rarity, osteomyelitis can be devastating to the patient and should be prevented if possible.

Arthroscopic excision of os acromiale: effects on deltoid function and strength.

Arthroscopic excision of os acromiale is a feasible alternative to open excision or fusion. This article describes the authors' experience with 28 patients (31 shoulders) who underwent arthroscopic excision of os acromiale and its effect on shoulder pain and function, with specific emphasis on deltoid strength measurement. Thirty-one os acromiale (all persistent unfused pre- and meso-acromions) in 28 patients were excised arthroscopically. Sixteen patients underwent concomitant rotator cuff repair (9 arthroscopic and 7 mini-open). At an average follow-up of 41 months, the patients were assessed using the American Shoulder and Elbow Surgeons (ASES) score, and deltoid function and strength were measured. Pain was completely alleviated postoperatively in 20 (65%) shoulders, and 9 (29%) shoulders had less pain postoperatively. Pain worsened postoperatively in 2 patients, both of whom had features of glenohumeral arthritis at arthroscopy. Average postoperative ASES score (80.33) was significantly improved compared with the average preoperative score (33.71). No significant loss of deltoid strength occurred compared with the contralateral side. No objective or subjective loss of normal deltoid appearance occurred. Rotator cuff repair did not compromise deltoid strength or significantly reduce ASES score irrespective of repair technique (arthroscopic vs mini-open). With careful attention to surgical technique maintaining an intact periosteal sleeve to preserve the integrity of the deltoid attachment, arthroscopic excision is an effective management tool for mobile os acromiale in a painful shoulder requiring surgical intervention.

Arthroscopic suprascapular neurectomy for the management of severe shoulder pain.

HYPOTHESIS: Arthroscopic suprascapular neurectomy is an effective option in the management of patients with severe shoulder pain MATERIALS AND METHODS: We describe and evaluate a technique of suprascapular neurectomy, performed arthroscopically for the treatment of severe shoulder pain in 20 patients (17 with a rotator cuff arthropathy, two with glenohumeral arthritis and one with a rotator cuff deficient shoulder following an unsuccessful arthrodesis). Post-operative pain relief was measured using a new pain scoring system, which combined an assessment of the frequency and severity of pain experienced at night, at rest, with activities and any change in analgesic consumption. RESULTS: At an average follow-up of 29 months, 75% of our patients reported good to excellent pain relief scores, 85% reported less night pain, 90% had less rest pain, 70% reported less pain on movement, whilst 75% reported less consumption of pain medication. There were no surgical complications. DISCUSSION: Suprascapular neurectomy performed arthroscopically provides an additional surgical option in the management of pain in patients with cuff tear arthropathy and in other selected patients with no functioning rotator cuff. The pain scoring system introduced in this article provides a more comprehensive assessment of shoulder pain than existing pain scores. CONCLUSION: We conclude that arthroscopic suprascapular neurectomy introduces an additional effective option in the management of pain in patients with these pathologies. LEVEL OF EVIDENCE: Level 4; Retrospective case series, no control group.