Clinical and Molecular Characteristics of PRKACA L206R Mutant Cortisol-Producing Adenomas in Korean Patients

Background@#An activating mutation (c.617A>C/p.Lys206Arg, L206R) in protein kinase cAMP-activated catalytic subunit alpha (PRKACA) has been reported in 35% to 65% of cases of cortisol-producing adenomas (CPAs). We aimed to compare the clinical characteristics and transcriptome analysis between PRKACA L206R mutants and wild-type CPAs in Korea. @*Methods@#We included 57 subjects with CPAs who underwent adrenalectomy at Seoul National University Hospital. Sanger sequencing for PRKACA was conducted in 57 CPA tumor tissues. RNA sequencing was performed in 13 fresh-frozen tumor tissues. @*Results@#The prevalence of the PRKACA L206R mutation was 51% (29/57). The mean age of the study subjects was 42±12 years, and 87.7% (50/57) of the patients were female. Subjects with PRKACA L206R mutant CPAs showed smaller adenoma size (3.3±0.7 cm vs. 3.8±1.2 cm, P=0.059) and lower dehydroepiandrosterone sulfate levels (218±180 ng/mL vs. 1,511±3,307 ng/mL, P=0.001) than those with PRKACA wild-type CPAs. Transcriptome profiling identified 244 differentially expressed genes (DEGs) between PRKACA L206R mutant (n=8) and wild-type CPAs (n=5), including five upregulated and 239 downregulated genes in PRKACA L206R mutant CPAs (|fold change| ≥2, P<0.05). Among the upstream regulators of DEGs, CTNNB1 was the most significant transcription regulator. In several pathway analyses, the Wnt signaling pathway was downregulated and the steroid biosynthesis pathway was upregulated in PRKACA mutants. Protein-protein interaction analysis also showed that PRKACA downregulates Wnt signaling and upregulates steroid biosynthesis. @*Conclusion@#The PRKACA L206R mutation in CPAs causes high hormonal activity with a limited proliferative capacity, as supported by transcriptome profiling.

The Significance of Calcaneal Posterior Tuberosity Fragment Reduction When Treated with Open Reduction in Displaced Intra-Articular Calcaneal Fractures

PURPOSE: We attempt to evaluate the significance of calcaneal posterior tuberosity fragment reduction when treated with surgical open reduction in displaced intra-articular calcaneal fractures. MATERIALS AND METHODS: A total of 90 patients with displaced intra-articular calcaneal fracture, between January 2010 and December 2015, treated with open reduction and internal fixation were enrolled in this study. At postoperative 3 months, we evaluated the reduction state of calcaneal posterior tuberosity fragment by measuring the degree of lateral displacement of the posterior tuberosity fragment on the calcaneal axial view. Moreover, we also evaluated the difference in the calcaneal length and height with the uninjured side on the lateral view of both sides. In addition, we estimated the reduction state of the posterior facet by measuring the degree of gap and step-off on the semi-coronal view of postoperative computed tomography and estimated the restoration of calcaneal angle by measuring the difference in Böhler's and Gissane angle with the uninjured side on the lateral view of both sides. RESULTS: The correlation coefficient with 3 components for evaluating the reduction state of posterior tuberosity fragment and gap and step-off of posterior facet was r=0.538, 0.467, r=0.505, 0.456, r=0.518, and 0.493, respectively, and restoration of Böhler's and Gissane angle was r=0.647, 0.579, r=0.684, 0.630, r=0.670, and 0.628, respectively. The relationship of each component shows a significant correlation as all p-values were <0.01. CONCLUSION: The precise reduction of calcaneal posterior tuberosity fragment developed by the primary fracture line was considered as an important process of anatomical reduction of calcaneal body, including the posterior facet and calcaneal angle restoration.

Vertebral Recompression after Vertebroplasty or Kyphoplasty

PURPOSE: The purpose of this study was to examine incidence of recompression and risk factors in the patients with osteoporotic vertebral compression fracture (OVCF) after vertebroplasty or kyphoplasty. MATERIALS AND METHODS: This study was conducted on 179 vertebral bodies of 126 patients who underwent vertebroplasty or kyphoplasty on OVCF from January 2004 to August 2013. RESULTS: When anterior vertebral height of fractured vertebrae declined by more than 3 mm from the height immediately after vertebroplasty or kyphoplasty, it was judged that recompression had occurred. Recompression was observed in a total of 58 vertebrae (32.4%). Recompression occurrences were found to be decreasing significantly when fractured vertebrae were the thoracic spine. In addition, osteonecrosis occurred in the preoperative vertebrae and restoration degree of anterior vertebral height immediately after vertebroplasty or kyphoplasty affected recompression occurrences significantly. The other factors (age, sex, bone mineral density, steroid medication history, follow-up duration, cement volume, vertebroplasty or kyphoplasty, and approach method) were compared, but no statistical significance was found. CONCLUSION: The risk of vertebral recompression is more common, especially when osteonecrosis occurred in preoperative vertebrae or when vertebroplasty or kyphoplasty achieved remarkable restoration of anterior vertebra height. When performing vertebroplasty or kyphoplasty, such conditions should be considered carefully.

Comparison of Blood Leptin Concentration and Colonic Mucosa Leptin Expression in Colon Adenoma Patients and Healthy Control / 대한소화기학회지

BACKGROUND/AIMS: Obesity increases the risk of colorectal cancer and adenomatous polyp, and one of the underlying mechanisms of this increase is considered to be due to the growth promoting effects of adipokines, such as leptin. In order to investigate this finding, leptin expression in the colonic tissue and blood leptin concentration of the colonic adenoma patients were compared to those of the control group. METHODS: Colonic adenoma tissues were obtained by polypectomy (n=60). In these patients, normal colonic mucosa at remote areas from the polyp was also obtained and blood samples were collected as well. Age and sex matched control subjects were selected among those who showed normal colonic mucosa in health screening colonoscopy (n=60). RESULTS: There was no significant difference in serum leptin concentration between the colonic adenoma patients and control subjects. Leptin expression was noted in 43.3% of the colonic adenomas, but only in 6.7% of normal colonic mucosa from the control subjects (p<0.01). There were ten cases of concurrent adenocarcinoma in situ in adenoma patients, eight cases of which expressed leptin (p=0.01). In adenoma group, leptin expression rate was significantly high in larger adenomas and in obese patients (p<0.05). However, there was no statistically significant relationship between leptin expression in colonic mucosa and serum leptin level. CONCLUSIONS: Leptin expression was more frequently observed in colonic adenomas, especially in larger adenomas associated with adenocarcinoma in situ, but blood leptin level was not related to tissue leptin expression. Leptin expression was more frequently observed in obese patients from the adenoma group. Therefore, leptin may play an important role in colonic tumorigenesis and progression, especially in obese patient.

Comparison of Blood Leptin Concentration and Colonic Mucosa Leptin Expression in Colon Adenoma Patients and Healthy Control / 대한소화기학회지

BACKGROUND/AIMS: Obesity increases the risk of colorectal cancer and adenomatous polyp, and one of the underlying mechanisms of this increase is considered to be due to the growth promoting effects of adipokines, such as leptin. In order to investigate this finding, leptin expression in the colonic tissue and blood leptin concentration of the colonic adenoma patients were compared to those of the control group. METHODS: Colonic adenoma tissues were obtained by polypectomy (n=60). In these patients, normal colonic mucosa at remote areas from the polyp was also obtained and blood samples were collected as well. Age and sex matched control subjects were selected among those who showed normal colonic mucosa in health screening colonoscopy (n=60). RESULTS: There was no significant difference in serum leptin concentration between the colonic adenoma patients and control subjects. Leptin expression was noted in 43.3% of the colonic adenomas, but only in 6.7% of normal colonic mucosa from the control subjects (p<0.01). There were ten cases of concurrent adenocarcinoma in situ in adenoma patients, eight cases of which expressed leptin (p=0.01). In adenoma group, leptin expression rate was significantly high in larger adenomas and in obese patients (p<0.05). However, there was no statistically significant relationship between leptin expression in colonic mucosa and serum leptin level. CONCLUSIONS: Leptin expression was more frequently observed in colonic adenomas, especially in larger adenomas associated with adenocarcinoma in situ, but blood leptin level was not related to tissue leptin expression. Leptin expression was more frequently observed in obese patients from the adenoma group. Therefore, leptin may play an important role in colonic tumorigenesis and progression, especially in obese patient.

Factors Influencing the Miss Rate of Polyps in a Tandem Colonoscopy Study / 대한소화기학회지

BACKGROUND/AIMS: The miss rate of colon polyps and its related factors have not been clearly identified yet. This study aims to review the miss rate of polyps both on the patient-level and on the polyp-level and to analyze the factors affecting the miss rate such as those related to the endoscopist, procedure, patient, and polyp. METHODS: From August 2011 to August 2013, patients who underwent elective second colonoscopy for resection of polyps, the sizes of which were not small enough to be resected by biopsy forceps alone at first colonoscopy, were enrolled retrospectively. RESULTS: The miss rate on the patient-level was 59.2% (234/395) and on the polyp-level was 27.9% (578/2,068). There was no significant difference in the miss rate depending on the experience of the endoscopists or characteristics of the patients. In terms of the procedure, the miss rate was higher when the colonoscopy was performed in the afternoon (OR 1.632, p=0.046). It was found that the miss rate of polyps increased when the polyps were small (OR 4.595, p<0.001 in <5 mm/OR 3.447, p<0.001 in 5-10 mm), flat or sessile (OR 2.406, p<0.001 in flat/OR 1.768, p=0.002 in sessile), and located in the left colon (OR 1.391, p=0.007). CONCLUSIONS: The experience of endoscopists did not have influence on the accuracy of polyp detection. However, the fatigue of endoscopists in the afternoon is considered to render polyp detection less accurate. Also, the large curves and folds of the sigmoid colon are regarded as a reason for the higher miss rate of polyps in the left colon.

Is Endoscopic Retrograde Cholangiopancreatography Safe in Patients 90 Years of Age and Older?

BACKGROUND/AIMS: This case-control study evaluated the safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP) in patients 90 years of age and older. METHODS: From January 2005 to August 2011, 5,070 cases of ERCP were performed at our institution. Of these, 43 cases involved patients 90 years of age and older (mean age, 91.7+/-1.9 years). A control group of 129 cases (mean age, 65.7+/-14.8 years) was matched by the patient sex, sphincterotomy, and presence of choledocholithiasis using a propensity score. The patients' medical records were retrospectively reviewed for comorbidity, periampullary diverticulum, urgent procedure, conscious sedation, technical success, procedure duration, ERCP-related complication, and death. RESULTS: Between the case and control groups, there was no significant difference with regard to comorbidity, periampullary diverticulum, and urgent procedure. Conscious sedation was performed significantly less in the patient group versus the control group (28 [65%] vs 119 [92%], respectively; p=0.000). There was no significant difference in the technical success, procedure duration, or ERCP-related complications. In both groups, there was no major bleeding or perforation related to ERCP. Post-ERCP pancreatitis occurred significantly less in the patient group compared to the control group (0 vs 13 [10%], respectively; p=0.004). One death occurred from respiratory arrest in the case group. CONCLUSIONS: ERCP can be performed safely and successfully in patients aged 90 years and older without any significant increase in complications.

Primary Cementless Total Hip Arthroplasty with a Ceramic Sandwich Liner and a Third Zweymuller Stem: Minimum 8-Year Follow up Results / 대한고관절학회지

PURPOSE: The purpose of this study is to evaluate the minimum eight-year follow up results of primary total hip arthroplasty (THA) performed using an alumina sandwich liner and the third Zweymuller stem. MATERIALS AND METHODS: A total of 86 patients (107 hips) who underwent a THA with alumina sandwich liners and the third Zweymuller stems from July 2001 to December 2003 were analyzed. Mean age of patients at the time of THA was 50.8 years (range, 17-77 years) and the mean follow-up period was 112 months (range, 98-127 months). Clinical evaluation was performed using the Harris hip score and level of thigh pain. The radiographic evaluation was performed in terms of the radiolucent line, subsidence of the stem, migration of the acetabular cup, and proof of loosening. RESULTS: At the final follow-up, mean Harris hip score had improved from 57.8 points to 91.9 points. Radiolucent line was observed at Gruen zone 1 in 40 cases (37%) and at zone 7 in 35 cases (33%); however, no detectable loosening was observed. There were six cases (5.6%) of fracture of the ceramic liner, one case of ceramic liner dissociation, and one case of stem loosening due to infection. CONCLUSION: At the minimum eight-year follow up, survival rate of the third Zweymuller stem was 99.1%. However, owing to the high rate of fractures of the ceramic sandwich liners, the survival rate of the ceramic liner was 93.5%.

Outcome of Surgical Treatment of AO Type C Pelvic Ring Injury / 대한고관절학회지

PURPOSE: To evaluate the radiologic and clinical outcomes of AO type C pelvic ring injury and identify the prognostic factors. MATERIALS AND METHODS: We studied 53 patients who were treated for AO type C pelvic ring injury from January 2002 to February 2010. Mean age and mean follow-up duration were 42.4 years and 14 months, respectively. We had 8 cases of AO type C1-1, 19 cases of C1-2, 11 cases of C1-3, 6 cases of C2 and 9 cases of C3 injury. We analyzed type of fracture, displacement, method of fixation and associated injuries. Radiologic outcome was evaluated with Matta and Saucedo criteria and clinical outcome was evaluated using Majeed score. RESULTS: The average Majeed score was 86.2 distributing as 36 excellent cases, 15 good cases and 2 fair cases. Using radiologic Matta and Saucedo criteria, patients were divided as 31 excellent cases, 17 good cases and 5 fair cases. There was no significant difference between the outcomes of anterior, posterior and antero-posterior fixation. Neurologic injury was the reason for an unsatisfactory functional outcome. We identified two cases with complication, one with postoperative infection and the other with nonunion following anterior-posterior fixation. CONCLUSION: Satisfactory radiologic and clinical outcomes were obtained with open reduction and internal fixation in the management of AO type C pelvic ring injuries. Neurologic injuries affected the clinical outcome.

Subphrenic Esophageal Diverticulum Associated with Esophageal Dysmotility and Leiomyoma / 대한내과학회지

Lower esophageal diverticula are frequently related to esophageal motor disorders. An epiphrenic esophageal diverticulum can also have a mechanical cause, such as an esophageal web, benign stricture, or leiomyoma. For a good therapeutic outcome, symptomatic patients with an esophageal diverticulum require a tailored approach. Therefore, it is important to evaluate motor disorders and other associated diseases in a patient with an esophageal diverticulum before devising a therapeutic strategy. We report a case of subphrenic diverticulum associated with an esophageal leiomyoma and motility disorder in a 58-year-old man who had suffered from intermittent regurgitation of food and epigastric soreness.

Cementless Total Hip Arthroplasty Using a Ceramic on Ceramic Bearing Surface: The Clinical Results of a Minimum 10-year Follow-up for Patients with Short Term Follow-up / 대한고관절학회지

PURPOSE: The purpose of this study is to report on the clinical results of more than 10 years of follow-up after ceramic articulation total hip arthroplasty in patients younger than 50 years old who had reported a result of short-term follow-up. MATERIALS AND METHODS: We studied 25 patients who underwent cementless THA using ceramic on ceramic articulation between Jan 1998 and Dec 2001. They were followed up for 2-4 years, with good results, and could be followed up for more than 10 years. The evaluation of clinical results included Harris hip score (HHS) and occurrence of thigh pain. Radiologic evaluation was based on osteolysis and the stability of components. RESULTS: The mean HHS improved from 57.7 to 93.3 during the period of 2-4 years of follow-up and 91.0 at more than 10 years of follow-up. Two patients experienced thigh pain during the period of 2-4 years of follow-up and none of the patients had thigh pain at more than 10 years of follow-up. On the last radiographs, stable fixation was observed in all cases, except for one case of ceramic fracture. CONCLUSION: Clinical and radiologic observations of cementless ceramic on ceramic articulation THA in active patients younger than 50 years old who reported a favorable short-term result showed a satisfactory long-term result.

Functional Outcomes of Percutaneous K-Wire Fixation for Distal Radius Fractures with or without Osteoporosis

PURPOSE: To determine the influence of osteoporosis on the results of percutaneous K-wire fixation for distal radius fractures. MATERIALS AND METHODS: Between March 2007 and February 2011, Fifty seven patients who underwent fixative surgery with K-wires after closed reduction and those available for follow-up for at least 6 months were reviewed. They were divided into the two groups of T score -3 or more (group 1) and T score less than -3 (group 2). These groups were compared by the range of motion of the wrist and Disabilities of the Arm, Shoulder and Hand (DASH) score. Radiologic evaluations consisting of radial length, radial inclination and volar tilt were compared. In group 1 with 34 cases, the average age was 65.4 years (50 to 78 years) and T score was -1.97 (-0.1 to -2.93). In group 2 with 23 cases, the average age was 74 years (54 to 89 years) and T score was -4.11 (-3.1 to -6.97). RESULTS: There was no statistical difference between group 1 and group 2 in terms of range of motion, DASH score and radiologic evaluations. CONCLUSION: In the case of no volar side cortical comminution, percutaneous K-wire fixation can be applied for the treatment of distal radius fracture with osteoporosis.

Analysis of Factors That Affect the Outcome of Skin Grafts / 대한정형외과학회잡지

PURPOSE: This study aimed to investigate factors that affect the successful outcome of skin grafts. MATERIALS AND METHODS: One-hundred and one patients undergoing split-thickness skin grafts were reviewed between March 2000 and March 2008. The mean age of the patients was 39 years (16 to 67 years). The numbers of male and female patients were 63 (62.4%) and 38 (37.6%), respectively. The average follow up period was 8 weeks (2 to 23 weeks). For the analysis, patients were classified by patient factors and wound factors affecting the outcome of skin grafts. The criteria for the successful outcome of skin grafts were as follows: over 80% of skin ingestion rate, no exposure of subcutaneous tissue, no distinct signs of infection, and no need for reoperation. Also, statistical analysis was used to identify the correlation between each factor regarding the outcome of each skin graft. RESULTS: The preoperative serum levels of c-reactive protein (CRP) and white blood cell (WBC) were significantly correlated with the success of skin grafts (p<0.05). The cut-off value of WBC and CRP were 10.500x103/microl and 1.02 mg/dl, respectively. Each factor showed 27.6 and 9.5 times of association strength. CONCLUSION: Among the various factors, the preoperative serum levels of CRP and WBC had significant correlations regarding the successful outcome of skin grafts. This result suggests that those levels can be objective indexes to predict the outcome of skin grafts.

Two Cases of Severe Pancytopenia Associated with Low-Dose Methotrexate Therapy in Patients with Chronic Kidney Disease and Rheumatoid Arthritis / 영남의대학술지

Due to its efficacy and tolerability, low dose oral methotrexate(MTX) therapy has been widely used for treatment of rheumatoid arthritis(RA). However, it can rarely cause serious, life-threatening hematologic toxicities, such as pancytopenia. We report here on two patients with chronic kidney disease(CKD), who developed severe pancytopenia after 5 years (cumulative dose 1,240mg) and 4 years(cumulative dose 1,320mg) of low dose MTX therapy for treatment of RA, respectively. Both patients presented with renal insufficiency, hypoalbuminemia, concurrent use of nonsteroidal anti-inflammatory drugs, and elevated mean corpuscular volume of red blood cells(RBCs), all of which are known as risk factors of MTX-induced pancytopenia. Despite receiving treatment, which included RBC and platelet transfusions, antibiotic therapy, granulocyte colony stimulating factor, and leucovorin rescue, one patient died of sepsis. Based on our case study, prompt investigation of risk factors associated with MTX toxicity is required for all patients receiving MTX therapy. MTX treatment, even at a low dose, should be discontinued in patients with advanced CKD.

Subtalar Distraction Arthrodesis Using Frozen Allobone Graft by Interpositional Structural / 대한족부족관절학회지

PURPOSE: Subtalar distraction arthrodesis is useful treatment option for restore hindfoot alignment. but, using structural autograft have high risk of donor site morbidity. Recently, by replacing the structural allograft has been reported satisfactory clinical results. Therefore, the authors reviewed the results of subtalar distraction arthrodesis using a structural allograft, retrospectively. MATERIALS AND METHODS: From January 2008 to May 2010, 12 patients (12 feets; 9 male, 3 female) underwent subtalar distraction arthrodesis using frozen structural allograft. 9 cases were calcaneal malunion, 2 were nonunion or malunion after subtalar arthrodesis, 1 was other cause. Mean age was 38.9 (12~66) years old and follow up period was 16.5 (12~36) months. Surgical was performed with posterolateral approach and tricortical allobone block of frozen femoral neck was used. Analysis was done with retorspective manner to evaluate preoperative, postoperative, and final follow up radiologic measurement and AOFAS ankle-hindfoot scale. RESULTS: There was statistically significant increase (p<0.05) of ankle-hindfoot scale from preoperative 27.5 points to postoperative 72.5 points, talocalcaneal height by 6.62 mm, calcaneal pitch angle by 5.73 degrees, lateral talocalcaneal angle by 6.38 degrees and significant decrease (p<0.05) of tali-1st metatarsal angle by 5.23 degrees. 11 feet (91.7%) acquired bony union and it takes average 5.1 months. Final post-operative result revealed talocalcaneal height changed by 2.57 mm, calcaneal pitch anble, lateral talocalcaneal angle, talar-1st metatarsal angle were changed by 2.63 degrees, 1.62 degrees, 1.18 degrees, respectively (p<0.05). 3 cases of partial osteonecrosis of posterior facet of calcaneus were observed in operation field, 4 cases of complication were developed (1 case of nonunion, 1 collapse of allobone graft, 1 screw loosening, 1 superficial skin necrosis). CONCLUSION: Subtalar distraction arthrodesis using frozen structural allobone graft is useful alternative treatment method of arthrodesis with structural autobone graft.

Intraneural Ganglion Cyst in Foot and Ankle / 대한족부족관절학회지

PURPOSE: Pathogenesis of intraneural ganglion is controversial, however, the synovial theory that the intraarticular region is the origination of disease has come into the spotlight nowadays. But there are a few researches about intraneural ganglion in foot and ankle. We studied 7cases of intraneural ganglion. We are going to prove the synovial theory by indentifying articular branch of intraneural ganglion. MATERIALS AND METHODS: From August 2003 to May 2011, we evaluated 7 ouf of 8 patients diagnosed as a intraneural ganglion in foot and ankle. The gender ratio were 4 male and 3 female, and the mean age at the time of surgery was 52.9 years. Clinically, we checked pre and post operative symptom, muscle tone and whether loss of muscle tone and sensation exists. We analyzed surgical records and preoperative MRI and compared those with intra-operative finding. RESULTS: In MRI analysis of 7cases, the connection around the joints were confirmed, and 1 case was confirmed in the retrospective analysis of MRI. Intraneural ganglions occurred in medial plantar nerve 3 cases, lateral plantar nerve 1 case, superficial peroneal nerve 1 case and sural nerve 1 case. We could not found recurrence during the follow up periods. Most patients relieved pain after operation, but recovery of sensation was unsatisfactory. We could find some cases pathological finding of the nerve intraoperatively, and clinical result of that cases was poor. CONCLUSION: Intraneural ganglion can occur in various parts in foot and ankle. We concluded that the intranneural ganglion originated from joint by identifying the artichlar branch of ganglion. Due to its small size, it is difficult to find articular branch in operation field. But we do our best to find and remove articular branch. Currently, considering the small amount of research in foot and ankle, more research about articular brach is needed.

The Treatment of Subtrochanteric Fracture with Cephallomedually Nail: Minimal Incision and Lowman Clamp Assisted Reduction

PURPOSE: To evaluate the radiographic results of patients with subtrochanteric femoral fracture using minimal incision and cephalomedullary nail technique. MATERIALS AND METHODS: This study was performed on 54 patients, 54 cases of hip, recruited among patients who underwent minimal incision and Cephalomedullary nail from September 2005 to August 2008 and were available for 1-year or longer follow up. The gender ratio was 37 males and 17 females, and the mean age at the time of surgery was 57.4 years (range; 16~81 years). According to injury mechanism, traffic accident was 29 cases, fall down form high height was 18 cases, slip down was 7 cases. In classification by Seinsheimer, type II was 23 cases (m/c), type III was 18 cases, type IV was 13 cases. Average follow up period was 14 months (12~18). Radiographic evaluation was performed for time taking union, mal-union and complication. RESULTS: 53 of the 54 cases united. 39 of 54 reductions were anatomic. 19 fractures had a monir varus deformity of proximal fragment (between 2degrees and 5degrees). There was no varus deformity of more than 5degrees. 1 case that had been treated with PFN had nail breakage without trauma. There were no other complications. CONCLUSION: Surgical treatment of subtrochanteric fractures with minimal incision and Cephalomedullary nail technique can reslut in excellent reduction without complications including inflammation & malunion. Careful attention to detail for using Lowman clamp is demanding to decrease soft tissue injury.

Narrow Band Imaging and White Light Colonoscopy for Detection of Polyps / 대한소화기내시경학회지

BACKGROUND/AIMS: Narrow band imaging (NBI) is a new technique that is expected to improve the detection rate of colorectal polyps, but results have been inconsistent. The aim of this study was to compare the polyp miss rate and the characteristics of missed colorectal polyps using white light (WL) and NBI. METHODS: 62 patients were randomized into two groups. In the first group (NBI first, NBIF), a colonoscopic examination of each segment (cecum-ascending, transverse, descending, and rectosigmoid colons) was performed first with NBI followed by a re-examination of the same segment using WL. An opposite sequence was applied for the other group (white light first, WLF). RESULTS: 67 polyps were found in the first examination, and 31 polyps were found on the re-examination, resulting in a polyp miss rate of 31.6%. The polyp miss rate was 39% for WLF and 23% for NBIF (p>0.05). Seventy-four small polyps (<5 mm) were found, and miss rates for NBIF and WLF were 20% and 46%, respectively (p=0.01). The polyp miss rate at the rectosigmoid was 11% for NBIF and 54% for WLF (p=0.01). CONCLUSIONS: The polyp miss rate was not significantly different between NBI or WL when a colonoscopy was performed. NBI resulted in a lower polyp miss rate for small (<5 mm) and rectosigmoid polyps than WL.

Ceramic on Ceramic Total Hip Arthroplasty: The Results of a Minimum 10-Years Follow up

PURPOSE: We wanted to evaluate the clinical and radiographic results of ceramic on ceramic bearing cementless total hip arthroplasty with a minimum of 10-years follow up. MATERIALS AND METHODS: This study was performed on 44 patients and 51 hips, and the patients were recruited among the patients who underwent ceramic-ceramic type cementless total hip arthroplasty from August 1998 to February 2000 and they were available for 10-years or longer follow up. The gender ratio was 28 males and 16 females, and the mean age at the time of surgery was 49 years (range: 26~77 years). Regarding the causality of disease, osteonecrosis was noted in 36 cases, degenerative arthritis was noted in 4 cases, acetabular dysplasia was noted in 4 cases and septic or tuberculous hip sequelae was noted in 7 cases. The clinical evaluation was performed according to the Harris hip score, and for the radiological evaluation of the femoral component, we assessed the degree of subsidence and the presence of periprosthetic osteolysis, endosteal new bone formation and cortical hypertrophy, and the final fixation state of the implant. In the cases with an acetabular cup osteoscleostic line in the vicinity of the acetabular cup, endosteal new bone formation, acetabular osteolysis and the vertical migration as well as the horizontal migration of the acetubular cup were assessed. RESULTS: Regarding the clinical outcomes, the Harris hip score was improved from an average 59 points to 93 points at the final follow up. For the radiological results, osteolysis was not detected in the acetabular and femoral components, the subsidence of femoral stem was not beyond 2 mm on average and significant subsidence was not detected. In regard to complications, linear fracture during surgery was noted in 6 cases and postoperative hip dislocation was noted in 1 case. A ceramic head fracture occurred in one case and a ceramic liner fracture occurred in 2 cases. CONCLUSION: This type of articulation is a promising option at a minimum of 10-years follow up of 51 hips that underwent ceramic-ceramic bearing cementless total hip arthroplasty. However, our results demonstrated that surgeons should be aware of the potential risks of ceramic fracture when using ceramic-on-ceramic bearing surfaces. Additional longer-term follow-up is necessary.

Pain Control after Total Hip Replacement Arthroplasty Using Periarticular Multimodal Drug Injection

PURPOSE: This study attempted to evaluate the pattern of change of the pain after total hip arthroplasty (THA) and to confirm the effect of periarticular multimodal drug injection (PMDI) on controlling the early postoperative pain. MATERIALS AND METHODS: Of the total patients who underwent primary THA at our hospital because of osteonecrosis of the femoral head from March to October 2008, 60 patients were enrolled in this study. The subjects were divided into three groups. Groups 1 & 2 received periarticular injection. Group 1 included the patients who were injected with a combination of opioid, long-acting local anesthetics, a non-steroidal anti-inflammatory drug and epinephrine. Group 2 received a combination of morphine and ropivacaine and group 3 was not injected with any analgesics. The visual analogue scale (VAS) at 4 hours, 8 hours, 12 hours, 24 hours, 2 days, 3 days, 5 days, 14 days and 1 month after surgery, the frequency that patients pushed the self-controlled pain medication machine for 2 days after surgery and the amount of clonac that was injected according to the needs of the patients were used as objective measures. RESULTS: The VAS score at postoperative 4 hours to 3 days among the groups showed a significant difference (P0.05). The frequency of pushing the self-controlled pain medication machine among the groups and the amount of clonac according to the needs of the patients among the groups showed that there were significant decreases at the operation day, the postoperative 1, 2 day and the 3 days (P<0.05). CONCLUSION: PMDI has a significant effect on controlling the early postoperative pain after THA.