Salvage with Reverse Total Shoulder Arthroplasty after the Failure of Proximal Humeral Tumor Treatment / 대한정형외과학회잡지

PURPOSE: Many reconstruction methods have been attempted after an en-bloc resection of the proximal humerus. In particular, the introduction of reverse shoulder arthroplasty (RSA) has made a breakthrough in the functional recovery of the shoulder. Nevertheless, RSA has limitations when the humeral bone stock loss is significant. In addition, it is unclear if RSA is effective in patients showing failure with non-operative treatment of a proximal humeral tumor. MATERIALS AND METHODS: A reconstruction was performed using an overlapping allograft-RSA composite for 11 patients with a failed proximal humeral construct. Delayed RSA was performed on 6 patients with failed non-operative treatment. The pre- and postoperative Musculoskeletal Tumor Society (MSTS) score and the complications were addressed. RESULTS: Overlapping allograft-RSA composite afforded a stable construct in 11 failed proximal humeral reconstructions and the patient's chief complaints were resolved. The mean time to the union of overlapped allograft-host junction was 5.5 months. Average preoperative MSTS score of 20.3 point increased to 25.7 point, postoperatively. Four of the six patients who had RSA within 4 years from the index operation showed arm elevation of more than 90° whereas the remaining 5 patients showed some disability. The complications include one case each of dislocation and aseptic infection, which were resolved by changing the polyethylene liner and scar revision, respectively. None of the 6 patients who underwent delayed RSA after the failure of non-operative treatment showed arm elevation more than 90°. CONCLUSION: An overlapping allograft-RSA composite is a simple and reliable reconstructive modality in patients with massive bone loss. In patients with metastatic cancer necessitating a surgical resection at presentation, early conversion to RSA is recommended to secure functional recovery.

Surgical and Oncological Outcome of Pelvis Bone Tumor Patients with Type III Internal Hemipelvectomy / 대한정형외과학회잡지

PURPOSE: It is generally accepted that bony reconstruction after type III (pubic) internal pelvectomy is not necessary. However, technical problems in type III resection, functional outcome according to the extent of resection, and the usefulness of synthetic material to decrease the risk of hernia has not been well addressed. MATERIALS AND METHODS: Fifteen patients who underwent type III internal pelvectomy were extracted and the pathologic diagnosis, Enneking's stage, location of tumor and size, operation time, amount of transfusion, surgical margin, local recurrence, distant metastasis, and functional outcomes were analyzed according to the extent of resection. RESULTS: Pathologic diagnosis was chondrosarcoma in 9, Ewing's sarcoma in 3, metastatic carcinoma in 2, and osteosarcoma in 1 patient. There were 4 patients with local recurrence and one with concomitant lung metastasis. Average Musculoskeletal Tumor Society functional score was 26.7. According to the extent of resection, functional score of 7 cases with unilateral both rami (6) or ischium (1) resection was 26, 4 cases with unilateral both rami and partial contralateral pubic ramus resection was 25, and 4 cases with unilateral both rami including ischium was 24. Two patients had tumor related complication. One patient with a huge intrapelvic tumor aroused at the symphysis pubis showed urethral invasion at presentation, therefore, urethral resection and permanent suprapubic cystostomy was inevitable. The other patient with bilateral pubic ramus involvement by tumor showed caudal displacement of the uterus after pregnancy (4 years after primary resection). She underwent Caesearian section for delivery. CONCLUSION: Regardless of the extent of pubic bone resection, functional outcome was similar. The risk of abdominal or pelvic organ hernia was minimal even without the use of artificial material for soft tissue reconstruction; however, when the extent of resection crosses the symphysis pubis, selective application of an additional procedure to reinforce the pelvic floor may be considered.

Giant Cell-Rich Osteosarcoma: A Tumor Simulating Borderline Lesion / 대한정형외과학회잡지

PURPOSE: Giantcell-rich osteosarcoma (GCRO) is a rare subtype of osteosarcoma. We reviewed; 1) radiological finding of GCRO and clinical impression-related diagnostic workup at referral center, 2) diagnostic delay until a proper diagnosis is made, 3) impact of diagnostic delay on the oncologic outcome. MATERIALS AND METHODS: We reviewed 17 patients with GCRO. We investigated the plain radiographic finding, tumor size and location, presence of pathologic fracture, clinical impression and pathological diagnosis at referral center, diagnostic delay, definitive treatment, local recurrence, metastasis, and survival rate. RESULTS: Eleven cases (64.7%) showed a plain radiographically, purely osteolytic pattern while 6 cases (35.3%) showed mixed osteolytic and sclerotic lesion. Diagnosis at primary center was osteosarcoma in 7 (41.2%), giant cell tumor in 7 (41.2%), and benign bone tumor in 3 (17.6%). Six patients (35.3%) experienced diagnostic delay. Mean diagnostic delay was 3.1 months (1 to 8). At final follow-up 5-year actuarial survival rate of 17 patients was 65%+/-25%. Although 11 patients without diagnostic delay showed a tendency of high survival over 6 patients with diagnostic problem, there was no statistical significance (p=0.14). CONCLUSION: GCRO is a rare subtype of osteosarcoma simulating giant cell tumor both pathologically and radiologically. Careful diagnostic approach is required in order not to misdiagnose this malignant tumor.

Post-traumatic Back Pain Revealed as Tuberculous Spondylitis: A Case Report

Tuberculous spondylitis is a very rare disease, but it can result in bone destruction, kyphotic deformity, spinal instability, and neurologic complications unless early diagnosis and proper management are done. Because the most common symptom of tuberculous spondylitis is back pain, it can often be misdiagnosed. Atypical tuberculous spondylitis can be presented as a metastatic cancer or a primary vertebral tumor. We must make a differential diagnosis through adequate biopsy. A 30-year-old man visited our clinic due to back and chest pain after a recent traffic accident. About 1 year ago, he had successfully recovered from tuberculous pleurisy after taking anti-tuberculosis medication. We performed epidural and intercostal blocks but the pain was not relieved. For the further evaluation, several imaging and laboratory tests were done. Finally, we confirmed tuberculous spondylitis diagnosis with the biopsy results.

Shade comparative analysis of natural tooth measured by visual and spectrophotometric methods / 대한치과보철학회지

STATEMENT OF PROBLEM: A clinically successful color match is one of the important factor to get an esthetic dental restoration. Dental shade guides are commonly used to evaluate tooth color in restorative procedure. But numerous reports have indicated that common shade guides do not provide sufficient spectral coverage of the natural tooth colors. To address issues associated with the shade guide, distinct avenues have been pursued objective spectrophotometric / colorimetric assessment. PURPOSE: This study compared the accuracy of tooth color selection of spectrophotometer with that of human visual determination. Three main factors were investigated, namely, the effect of light, the individual variation and the experience of the observer. MATERIAL AND METHODS: At the first experiment, on ten patients, one operator independently selected the best matching shade to the unrestored maxillary central incisor, using a Vita Classical Shade Guide in the morning, at noon and in the afternoon. The same teeth were measured by means of a reflectance spectrophotometer. At the second experiment, on ten patients, ten operators (5 experts, 5 novices) selected and measured by the same method above at noon. At the third experiment, the results of the second experiment were divided into two groups, expert and novice, and analyzed. RESULTS: 1. There was significant difference between visual and spectrophotometric assessment (mean delta E values) in experiment 1, 2, 3 (p < .05). 2. There was no significant difference between experts and novices group, when comparing with each visual and spectrophotometric assessment (mean delta E values). CONCLUSION: Spectrophotometer could be used to analyze the shade of natural tooth objectively. Thereby, this method offers the potential tominimize considerably the need for corrections or even remakesafter intraoral try-in of restoration. Furthermore, to achieve its advantage, both the shade-matching environment and communication between dentist and technician should be optimized with use of visual and instrumental shade-matching systems.

Effects of Steroid Administration on the Blood Glucose Level during Spine Surgery in Patients with Metabolic Syndrome

BACKGROUND: The risk of steroid-induced hyperglycemia is debated, and methylprednisolone is still used during spinal surgery. We have compared the blood glucose level in patients with metabolic syndrome treated with or without methylprednisolone. METHODS: This study was conducted in 68 adult patients who underwent elective spine surgery. Patients were classified into the following groups: methylprednisolone group (n = 39, group M), placebo group (n = 29, group P), group M patients with metabolic syndrome (n = 17, group MM), and group P patients without metabolic syndrome (n = 21, group NMP). Before and after injection of either 125 mg methylprednisolone or a placebo, we consecutively checked the blood glucose level every 30 minutes up to 4 hours. RESULTS: The blood glucose level was significantly increased in group M patients as compared to group P patients. The blood glucose level was more significantly increased in group MM as compared to group NMP patients. The increased blood glucose levels over 4 hours were 50 mg/dl in group MM and 35 mg/dl in group NMP patients. CONCLUSIONS: We recommend that close monitoring of the blood glucose level up to several hours after injection of a steroid should be seriously considered during spine surgery, particularly in patients with metabolic syndrome.

Minimally Invasive Surgical Technique in Uvulopalatopharyngoplasty: Palatoglossal Line / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Uvulopalatopharyngoplasty remains the most common surgical procedure performed as a treatment for obstructive sleep apnea syndrome. But, the authors believe that the surgical technique has some of the following limitations: a relatively low success rate, possible complications and the lack of a consensus on the palatal resection margin. In this study, we present a modified surgical technique and its clinical experiences. SUBJECTS AND METHOD: Twelve patients with snoring and obstructive sleep apnea/hypopnea were included in this study between September 2004 and April 2005. We divided the patients into two groups according to the resection margin of the uvula. And we defined the palatal incision margin as a palatoglossal line and tried a suture remodeling of the neopharynx. RESULTS: Abnormal breathing cessation (apnea/hypopnea) during sleep disappeared in all patients. There was no residual snoring in 10 patients (83.3%) but 2 patients (16.7%) complained of some residual snoring. The group with less than half resection of the uvula during surgery had a neouvula formed and could maintain a naturally shaped velopharynx. These patients had low incidence of postoperative complications such as severe scar formation and globus sensation. CONCLUSION: We recommend the palatoglossal line as an ideal incision margin for the uvulopalatopharyngoplasty and the preservation of the neouvula.

Blood Eosinophilia in Patients Undergoing Continous Ambulatory Peritoneal Dialysis / 대한신장학회잡지

PURPOSE: The prevalence of blood eosinophilia in patients who are maintained on regular hemodialysis has been well established. Blood eosinophilia in patients initiating peritoneal dialysis has been mentioned, but its prevalence and etiologic factors have not been well delineated. Therefore, we performed this retrospective study to find out prevalence and possible etiologic factors of blood eosinophilia in patients undergoing continuous ambulatory peritoneal dialysis. METHODS: Between May 2001 to May 2004, the patients who began continuous ambulatory peritoneal dialysis at one renal center were included in this study. Patients with allergic history or allergic reaction during observed period were excluded. The routine peripheral WBC counts of 47 patients were reviewed and possible predisposing factors of eosinophilia were investigated. RESULTS: Blood eosinophilia was observed in 17 of 47 patients (35% of all patients). In most patients with blood eosinophilia, the time in which the eosinophil count began to be rise was within 40 days, and duration of eosinophilia was variable (mean+/-SD;74+/-67 days). The mean of the peak eosinophil count was 750+/-257/mm3 (mean+/-SD). Possible predisposing factors included recent parenteral iron therapy, but not statistically significant (p=0.09). CONCLUSION: Our retrospective study showed that the eosinophil counts in patients with end stage renal disease on continuous ambulatory peritoneal dialysis were frequently elevated. Predisposing factors for this eosinophilia were not clear, suggesting that immunologic disturbance by uremia or dialysis itself might have influence on eosinophil homeostasis.

Open Lock of the Jaw on Induction of Anesthesia: A case report / 대한마취과학회지

The temporomandibular joint can be dislocated during anesthesia as a result of excessive oral opening and direct laryngoscope handling. Occasionally, yawning can be observed during the induction of anesthesia with propofol. The forceful and voluntary yawning after a propofol injection can lead to a dislocation of the temporomandibular joint. We report a case of an anterior dislocation of the temporomandibular joint upon induction with propofol, which caused difficulties in mask ventilation and endotracheal intubation. Although intubation had been carried out successfully in this case, an unanticipated difficult airway can be confronted at anytime. Therefore, anesthesiologists should be aware of the management of a difficult airway and practice various methods according to a difficult airway algorithm.

Clinical Implications of Pulse Pressure in Chronic Kidney Disease / 대한신장학회잡지

BACKGROUND: Arterial hypertension is one of the major factors for progression to end stage renal disease (ESRD) in chronic kidney disease (CKD). Pulse pressure, which stands for arterial stiffness, is a well known risk factor for cardiovascular disease, especially in old patients. A few reports showed that increased arterial stiffness is associated with decreased glomerular filtration rate (GFR). The aim of this study is to investigate the effects of pulse pressure on renal outcome in CKD patients. METHODS: Total 153 patients were included who visited our institution for the first time between January 2000 and December 2000. Patients' medical records were reviewed retrospectively. CKD was defined as GFR by MDRD equation less than 60 mL/ min/1.73 m2. Patients with CKD 5 were excluded. The primary end point of this study for progression of renal disease was doubling serum creatinine. RESULTS: On multivariate analysis based on baseline clinical and laboratory data, pulse pressure was an independent risk factor for progression of CKD. Antihypertensive treatment for 1 year (since the first visit) decreased both systolic and diastolic blood pressure (BP) significantly, and pulse pressure as well. At the end of follow up of 3.7 years (mean), while systolic BP tended to increase slightly, diastolic BP was persistently decreased. Consequently, pulse pressure was further widened compared to that of 1 year. Pulse pressure was positively correlated with age, fasting glucose, and calcium phosphorus product (CPP) whereas it was negatively correlated with hemoglobin and GFR. CONCLUSION: This study shows that pulse pressure is a good predictor for renal outcome in CKD. Besides age and hypertension, anemia, fasting glucose, CPP and uremia can adversely affect pulse pressure in CKD. Therefore, BP control and correction of those factors are recommended to attenuate the progression of CKD.

Anesthetic Management of a Patient with Pheochromocytoma in Pregnancy: A case report / 대한마취과학회지

Pheochromocytoma with pregnancy is very uncommon but it is associated with very high maternal and fetal morbidity and mortality. Antepartum diagnosis and proper management can prevent mother and fetus from potentially lethal outcome. Since pheochromocytoma produces and secretes catecholamines, hemodynamic instability can be brought. The aim of anesthetic management is the avoidance of drugs and episodes that will result in hypertensive crisis, and the selection of safe anesthetic measures and anesthetics to mother and fetus. We report a case of pheochromocytoma with pregnancy managed with combined anesthetic technique-epidural anesthesia for cesarean section and general anesthesia for resection of pheochromocytoma 3 weeks after cesarean section. ?

Risk Factors for Development of Acute Renal Failure after Liver Transplantation / 대한이식학회지

PURPOSE: Acute renal failure (ARF) is one of the common complications after liver transplantation (LT) and could be fatal unless promptly treated. Identification of risk factors is needed to prevent ARF and to attenuate the unfavorable outcomes of ARF after LT. The aim of this study was to analyze risk factors for development of postoperative ARF (between day 0 and day 30 after LT). METHODS: Total 72 LTs were performed between 1996 and 2005. Sixty six patients' records, excluding 6 patients with preoperative serum creatinine level more than 2.5 mg/dl, were reviewed retrospectively for preoperative, intraoperative, and postoperative variables to compare patients presenting ARF with the remaining patients. RESULTS: Postoperative ARF occurred in 36 transplants (54.5%) after LT. Preoperative serum sodium, bilirubin and BUN, creatinine level were higher in ARF group. ARF group had more child-pugh class C, and more episodes of preoperative hepatic encephalopathy. During intraoperative period, anhepatic time was longer and total doses of intraoperative furosemide was larger in ARF group. Also, postoperative blood immunosuppressant level was higher, and postoperative episodes of bleeding and hypotension were more common in ARF group. In multivariate analysis, preoperative child-pugh class C (P=0.041), preoperative serum creatinine level (> or =1.0 mg/dL, P=0.032), and postoperative episodes of hypotension and bleeding (P=0.045, P=0.03 respectively) were identified as risk factors for postoperative ARF. CONCLUSION: This study showed that preoperative renal and liver function, and postoperative hemodynamic condition were independent risk factors for development of ARF after LT.

Coronary Angiographic Findings and Risk Factors for Coronary Artery Occlusive Disease in Renal Transplant Patients with Clinically Suspected Ischemic Heart Disease / 대한이식학회지

PURPOSE: Cardiovascular disease is a substantial health problem in renal transplant patients, and ischemic heart disease is a leading cause of death in these patients. Renal transplant patients have many conventional risk factors for atherosclerotic coronary artery diaese, including hypertension, hyperlipidemia, and posttransplant diabetes mellitus. This study were to evaluate the prevalence of angiographically-determined coronary artery occlusive disease (CAOD) in renal transplant patients, and to identify the risk factors for significant coronary artery disease. METHODS: The retrospective study were performed in 36 patients with renal transplantation who underwent coronary angiography to diagnose ischemic heart disease. RESULTS: A total of 36 recipients (27 males, 9 females) were studied and the mean age was 51.5 years. Significant CAOD was identified in 69% of patients (1-vessel: 19%, 2: 25, 3: 25). By univariate and multivariate logistic regression analysis, the association of clinical variables with CAOD was assessed. The interval between the diagnosis of end-stage renl disease and renaltransplantation was an independent risk factor (P<0.05). The variables such as old age, acute rejection episodes, cholesterol level, as well as the presence of obesity, and D.M,. were not associated. CONCLUSION: The prevalence of angiographically-determined CAOD in renal transplant recipients is 69%. The risk of CAOD seems to be increased in recipients with long duration of dialysis before transplantation. The early or preemptive transplantation could be recommended for preventing CAOD in renal transplantation candidates.