COVID-19 Neuromuscular Involvement in Post-Acute Rehabilitation

Background: Coronavirus disease 2019 (COVID-19) is associated with muscle and nerve injuries as a consequence of prolonged critical illness or the infection itself. In this study, we evaluated neuromuscular involvement in patients who underwent post-acute intensive rehabilitation after COVID-19. Methods: Clinical and neurophysiological evaluations, including nerve conduction studies and electromyography, were performed on 21 consecutive patients admitted for rehabilitation after COVID-19. Results: Clinical signs suggesting muscle or nerve involvement (weakness, reduced deep tendon reflexes, impaired sensitivity, abnormal gait) were found in 19 patients. Neurophysiological examinations confirmed neuromuscular involvement in 17 patients: a likely association of critical illness myopathy (CIM) and critical illness polyneuropathy (CIP) was found in 5 patients; CIM alone was found in 4 patients; axonal sensory-motor polyneuropathy was found in 4 patients (CIP in 2 patients, metabolic polyneuropathy in 2 patients); Guillain-Barré syndrome was found in 2 patients (classical demyelinating sensory-motor polyneuropathy and acute motor axonal neuropathy, respectively); peroneal nerve injury was found in 1 patient; and pre-existing L4 radiculopathy was found in 1 patient. Conclusions: Neuromuscular involvement is a very common finding among patients admitted for rehabilitation after COVID-19, and proper investigation should be conducted when muscle or nerve injury is suspected for adequate rehabilitative strategy planning.

Ezrin Prompted Myoblast Differentiation and Muscle Fiber Specialization and Gastrocnemius Muscle Repair in Peroneal Nerve Injury Model through PKA-NFATs Signaling Pathway

Background: Muscular dystrophy is a destructive neuromuscular disease characterized by progressive muscle weakness and muscle atrophy. The role of Ezrin in myoblast differentiation/fusion and muscle atrophy is still unknown.Method: Gastrocnemius muscle atrophy model were prepared by mechanical clamp of peroneal nerve. Differentiating C2C12 cells treated with Ad-Ezrin or Ad-shEzrin were detected by gene chip, Q-PCR, immunofluorescence staining and Western blot.Results: Ezrin was expressed in MyHC I/II myofibers in vivo, and time-dependently increased during myoblast differentiation/fusion characterized by MyoG+/MEF2c nuclei and MyHC+ myotubes in vitro. Overexpression of Ezrin promoted myoblast differentiation/fusion in time-dependent manner, inducing the increased MyHC-I+ and MyHC-II+ muscle fiber specialization, the specific effects could be abolished by addition of Ad-Periaxin. Ad-Ezrin did not alter PKA and PKAreg II α levels, but PKAreg I α/β. The PKA inhibitor, H-89, remarkably abolished the over-expression effects by Ezrin on an increased myoblast differentiation/fusion. By contrast, Knockdown of Ezrin by shRNA significantly delayed myoblast differentiation/fusion accompanied by the decreased PKA reg I/II ratio, the inhibitory effects could be eliminated by PKAreg I activator N6-Bz-cAMP. Meanwhile, Ad-Ezrin enhanced type I muscle fiber specialization, accompanied by the increased levels of NFATc1/c2.Furthermore, Ad-NFATc2 or Ad-NFATc4 reversed the inhibitory effects of Ad-shEzrin on myoblast differentiation/fusion. Importantly, in vivo transfection of Ad-Ezrin into gastrocnemius muscles in peroneal nerve injury model increased the numbers of MyHC-I+ and MyHC-II+ myofibers, reducing muscle atrophy and fibrosis.Conclusions: Ezrin activated PKA-NFAT-MyoD/MyoG/MEF2C signaling pathway, triggering myoblast differentiation/fusion and muscle fiber specialization in periaxin-depentdent manner, contributing to gastrocnemius muscles repair.

A case report of rhabdomyolysis and osteofascial compartment syndrome in a patient with hypothyroidism and diabetes

Background Hypothyroidism is frequent and has various forms of muscle involvement. We report the diagnosis and treatment of a case of rhabdomyolysis, bilateral osteofascial compartment syndrome (OCS) of the lower extremities, and peroneal nerve injury causing bilateral foot drop in a diabetic patient with hypothyroidism. Case presentation A 66-year-old man with diabetes for 22 years was admitted because of drowsiness, tiredness, facial swelling, and limb twitching for 2 months, and red and swollen lower limb skin for 3 days. Serum creatinine kinase (CK), CK-MB, myoglobin (Mb), blood glucose, and HbA1c were elevated. TSH, thyroid peroxidase antibodies, and antithyroglobulin antibodies were elevated. FT3 and FT4 were low. Urine was dark brown. He was diagnosed with hypothyroidism, rhabdomyolysis, and OCS. CK, CK-MB, and Mb returned to normal after treatment with thyroid hormone, insulin, albumin infusion, ceftriaxone, ulinastatin, and hemofiltration, and the redness and swelling of the lower limbs were relieved, but the patient developed dropping feet. The patient recovered well but had to undergo rehabilitation. Conclusion Hypothyroidism may induce rhabdomyolysis, OCS, and other complications. This case reminds us of the importance of screening for hypothyroidism and strengthens the clinicians’ understanding of the disease.

Complications of surgical reconstruction of multiligament injuries of the knee joint: diagnosis, prevention and treatment

The main complications of surgical reconstruction of multiligament injuries of the knee joint are residual or recurrent instability, arthrofibrosis, popliteal artery injury, common peroneal nerve injury, compartment syndrome, fluid extravasation, symptomatic heterotopic ossification, wound problems and infection, deep venous thrombosis, and revision surgery. Careful surgical planning and execution of the primary surgical reconstruction of multiligament injuries of the knee joint can minimize the risk of the aforementioned complications. Careful postoperative follow-up is required to detect complications. Early recognition and prompt treatment are of paramount importance. To obtain good results in the revision surgery of failed multiligamentary knee reconstructions, it is crucial to perform a thorough and exhaustive evaluation to detect all the causes of failure. Addressing all associated injuries during revision surgery will lead to the best possible subjective and objective results, although functional outcomes are often modest. However, advanced age and high-energy injuries have been associated with the poorest functional outcomes after revision surgery of failed multiligament injuries of the knee joint. Cite this article: EFORT Open Rev 2021;6:973-981. DOI: 10.1302/2058-5241.6.210057

Common Peroneal Nerve Injury in a Patient with COVID-19 Infection

This report described a 46-year man with the characteristic Computerized Tomography (CT) scan findings of Corona Virus Disease Infection 19 (COVID-19) who presented to the hospital with right ankle weakness three weeks after the pneumonitis. He had been initially hospitalized, complaining of fever, myalgia, cough, and dyspnea. Electromyogram (EMG) revealed obvious evidence of increased insertional activity (IA) and significant denervation potentials, including positive sharp waves (PSW) and fibrillation potentials, particularly in ankle dorsiflexor muscles. Moreover, no voluntary motor unit action potential (MUAP) was observed. Eventually, the patient was diagnosed with severe axonal mononeuropathy of the right CPN, which could be considered a rare complication of COVID-19.

The Neurosurgical Management of Peroneal Nerve Injury: An Experience of 14 Cases

Objectives: To describe the neurosurgical technical nuances of peroneal nerve injury management and to analyze the outcomes of patients diagnosed with peroneal nerve injury operated on at a single institution. Methods: Fourteen patients, all with electroneuromyography confirmation of peroneal nerve injury, were retrospectively analyzed. The variables analyzed included patient demographic characteristics, etiology of the lesion, preoperative neurological status, location of the lesion, perioperative findings, surgical technique, complications, and neurological status six months postoperatively. Results: Traumatic injury was the most common cause of peroneal nerve injury, accounting for 64.27% of cases. Concerning surgical technique, neurolysis was the preferred technique in most cases. Isolated neurolysis was performed in 50% of the cases, neurolysis combined with graft in 7.14%, and neurolysis combined with ganglion cyst excision in 21.43%. In our study, surgical treatment led to improvement in foot strength, with statistical relevance, in both sexes. Only one complication was observed. Conclusions: Surgical exploration and repair of peroneal nerve injuries achieved good results in this series, with functional improvement of the analyzed patients in both sexes. When appropriate, surgical repair can lead to favorable outcome and early surgery can be a therapeutic strategy in selected cases.