Results of Iliac Bone Graft with Kirschner Wire Fixation for Scaphoid Nonunions

PURPOSE: To determine clinical and radiographic results of iliac bone grafting with Kirschner wire fixation for treatment of scaphoid nonunions. METHODS: A total of 13 patients who had scaphoid nonunion treated with iliac bone grafting and Kirschner wire fixation between October 2007 and January 2016 were enrolled as subjects of this study. Their clinical results were evaluated, including range of motion of the wrist joint and modified Mayo wrist score. Radiographic results including lateral intrascaphoid angle and scapholunate angle were also assessed. RESULTS: Bony union was achieved in 11 (84.6%) of 13 cases. Modified Mayo wrist score was improved from 64.0 preoperatively to 87.5 postoperatively. Average intrascaphoid angle was improved from 39.5° preoperatively to 27.2° postoperatively while scapholunate angle was improved from 66.0° preoperatively to 55.1° postoperatively. CONCLUSION: Iliac bone graft with Kirschner wire fixation provided good clinical and radiographic results. Therefore, iliac bone graft with Kirschner wire fixation can be considered as a good treatment option for scaphoid nonunion.

New Fixation Method Using Two Crossing Screws and Locking Plate for Cubitus Varus Deformity in Young Adult Elbow: Case Report

Many types of osteotomy have been proposed for the treatment of cubitus varus deformity of the elbow, and various methods for fixation of the osteotomy site have also been described. However, no method has been perfect. We treated two cases of cubitus varus elbow deformity with step-cut osteotomy using a new fixation method with two crossing screws and an anatomically designed locking plate. Active assisted elbow range of motion (ROM) exercise was permitted at postoperative 3 days, after removal of the drainage. Preoperative and postoperative humerus-elbow-wrist angles and ranges of motion of the two patients were compared. At 3 months follow-up, each patient had recovered the preoperative elbow ROM, and achieved the complete bony union of the osteotomy site and proper correction of the cubitus varus deformity. In addition, the appropriate remodeling of the lateral bony protrusion was observed. Therefore, we introduce a new fixation method for achievement of stable fixation allowing immediate postoperative elbow motion after corrective osteotomy for cubitus varus deformity in young adults.

The Role of Lunate Morphology on Scapholunate Instability and Fracture Location in Patients Treated for Scaphoid Nonunion

BACKGROUND: To determine the association between lunate morphology and the scapholunate instability using radiographic images, and investigate the association between lunate morphology and scaphoid fracture location. METHODS: Between January 2003 and December 2011, we retrospectively evaluated the plain radiographs and computed tomography (CT) images of 70 patients who underwent surgical intervention for a scaphoid nonunion, in order to determine the association between lunate type (I or II) and scapholunate instability or scaphoid fracture location. We determined the scaphoid fracture location using the fragment ratio and measured the radiolunate angle and capitate-triquetrum (C-T) distance. RESULTS: A type II lunate was present in 68.6% (48 of 70 cases). Mean fragment ratio of fracture location was 50.6% in the type II lunate group and 56.2% in the type I lunate group (p = 0.032). Sixteen of the 70 patients had dorsal intercalated segmental instability (DISI) deformities. Nine of 22 cases showed DISI deformity in type I lunate and 7 of 48 cases showed DISI deformity in type II lunate (p = 0.029). However, there were no significant differences between the presence of DISI deformity and fracture location (p = 0.15). Morphologic comparisons by both plain radiography and CT indicated a mean C-T distance in the type I lunate group (22 cases) of 2.3 mm and 5.0 mm in the type II lunate group (48 cases). The C-T distances were significantly correlated with lunate morphology (p = 0.001). CONCLUSIONS: A type II lunate was associated with low incidence of DISI deformity and proximal location of fracture in patients presenting with a scaphoid nonunion.

The Role of Lunate Morphology on Scapholunate Instability and Fracture Location in Patients Treated for Scaphoid Nonunion

BACKGROUND: To determine the association between lunate morphology and the scapholunate instability using radiographic images, and investigate the association between lunate morphology and scaphoid fracture location. METHODS: Between January 2003 and December 2011, we retrospectively evaluated the plain radiographs and computed tomography (CT) images of 70 patients who underwent surgical intervention for a scaphoid nonunion, in order to determine the association between lunate type (I or II) and scapholunate instability or scaphoid fracture location. We determined the scaphoid fracture location using the fragment ratio and measured the radiolunate angle and capitate-triquetrum (C-T) distance. RESULTS: A type II lunate was present in 68.6% (48 of 70 cases). Mean fragment ratio of fracture location was 50.6% in the type II lunate group and 56.2% in the type I lunate group (p = 0.032). Sixteen of the 70 patients had dorsal intercalated segmental instability (DISI) deformities. Nine of 22 cases showed DISI deformity in type I lunate and 7 of 48 cases showed DISI deformity in type II lunate (p = 0.029). However, there were no significant differences between the presence of DISI deformity and fracture location (p = 0.15). Morphologic comparisons by both plain radiography and CT indicated a mean C-T distance in the type I lunate group (22 cases) of 2.3 mm and 5.0 mm in the type II lunate group (48 cases). The C-T distances were significantly correlated with lunate morphology (p = 0.001). CONCLUSIONS: A type II lunate was associated with low incidence of DISI deformity and proximal location of fracture in patients presenting with a scaphoid nonunion.

New Fixation Method Using Two Crossing Screws and Locking Plate for Cubitus Varus Deformity in Young Adult Elbow: Case Report

Many types of osteotomy have been proposed for the treatment of cubitus varus deformity of the elbow, and various methods for fixation of the osteotomy site have also been described. However, no method has been perfect. We treated two cases of cubitus varus elbow deformity with step-cut osteotomy using a new fixation method with two crossing screws and an anatomically designed locking plate. Active assisted elbow range of motion (ROM) exercise was permitted at postoperative 3 days, after removal of the drainage. Preoperative and postoperative humerus-elbow-wrist angles and ranges of motion of the two patients were compared. At 3 months follow-up, each patient had recovered the preoperative elbow ROM, and achieved the complete bony union of the osteotomy site and proper correction of the cubitus varus deformity. In addition, the appropriate remodeling of the lateral bony protrusion was observed. Therefore, we introduce a new fixation method for achievement of stable fixation allowing immediate postoperative elbow motion after corrective osteotomy for cubitus varus deformity in young adults.

Distribution of Glomus Tumors in Fingers

PURPOSE: Glomus tumor has known as smaller than 1 cm, hard to palpate, therefore patients often suffer from chronic pain. Based on our experiences about glomus tumors, we would like to evaluate their distributions. MATERIALS AND METHODS: This study includes 24 cases that underwent surgery for clinically diagnosed glomus tumor from January, 2001 to May, 2009. Clinical symptoms were firstly evaluated and ultrasonography in 8 cases and Magnetic Resonance Imaging (MRI) in 5 cases were performed for more accurate diagnosis and localization. Complete resection with biopsy was done in all cases. RESULTS: According to pathologic findings, 20 out of 24 cases were reported as glomus tumor, and the other 4 cases were 2 fibrous tumor with chronic inflammation, 1 hemangioma, and 1 neuroma. Twenty glomus tumors at dorsal side under the nail were distributed to proximal radial in 11 cases, proximal ulnar in 6 cases, distal radial in 2 cases and distal ulnar in 1 case. Tumors were more frequently found at proximal in 17 cases(85%) and at radial side in 13 cases(65%). CONCLUSIONS: Glomus tumors tend to occur under nail of proximal and radial part. We think that accurate diagnosis and location of glomus tumors are needed to complete surgical resection.

The Radiologic and Clinical Changes after Open Complete Repair of Massive Rotator Cuff Tears

PURPOSE: This study evaluated the preoperative and postoperative radiologic findings of patients with complete repairs after massive rotator cuff tears along with the incidence of re-tear and the clinical outcomes. MATERIALS AND METHODS: This study evaluated 33 cases who had open complete repairs for massive rotator cuff tears and these patients were followed up for more than 24 months. The clinical evaluation was performed according to the shoulder joint function test of the American Shoulder and Elbow Surgeons (ASES), and the degree of arthritis related to the massive rotator cuff tears was evaluated using the Hamada classification. RESULTS: The ASES scores improved from 37.6 preoperatively to 85.6 postoperatively. The mean preoperative acromio-humeral interval (AHI) score was 6.5 mm, which increased to 9.3 mm immediately after surgery, and there was a decreased to 6.5 mm noted at the last follow up. The lower radiology stages of arthritis according to the classification showed better preoperative and postoperative results. CONCLUSION: An open complete repair as the surgical treatment for a massive rotator cuff tear showed satisfactory results for pain relief and an improvement in the shoulder joint function though re-tear after surgery.

The Clinical Phenotype of Thyroid-Associated Orbitopathy related to Underlying Thyroid Status

PURPOSE: Thyroid-Associated Orbitopathy (TAO) presents with highly variable clinical characteristics. We hypothesize that the underlying thyroid status predisposes a patient to different clinical characteristics of TAO. METHODS: We retrospectively studied the clinical data of 385 patients from the New York area who were referred to our clinic and diagnosed with TAO from Jan 1990 to Dec 2000. We divided the 385 patients into three groups: Graves' hyperthyroid, euthyroid, and hypothyroid, and analyzed them statistically. RESULTS: Three hundred thirty-one (86%) patients were hyperthyroid, 25 (6.5%) were euthyroid, and 29 (7.5%) were hypothyroid. The average age of TAO presentation in each group was 46.7, 46.1, and 49.9 years, respectively. The female-male ratio in each group was 5.25, 3.17, 13.5:1, respectively (p>0.05). The average time from thyroid disease to TAO in the hyperthyroid and hypothyroid groups was 16.6 and 38 months, respectively (p<0.05). The hyperthyroid group had more proptosis (76.1 vs. 41.4%, p=0.0001<0.05) than the hypothyroid group. CONCLUSIONS: TAO has different clinical characteristics depending on thyroid status. The hyperthyroid group has a short disease interval and more severe clinical course of TAO than the hypothyroid group.

The Risk Factors for Severe Thyroid-Associated Orbitopathy

PURPOSE: To determine risk factors for severe Thyroid-Associated Orbitopathy (TAO). METHODS: We retrospectively studied the clinical data of 385 patients of the New York City area diagnosed with TAO from January 1990 to December 2000. We reviewed clinical characteristics and tried to identify several risk factors. The statistical analysis was applied to the collected data. RESULTS: Men more frequently had proptosis, restrictive myopathy, and optic neuropathy than women. Patients older than 50 years presented more frequently with proptosis, restrictive myopathy, and optic neuropathy than younger than 50 years. Patients with a family history of thyroid disease had similar clinical characteristics compare to those without family history. Smokers more often had proptosis, restrictive myopathy, and compressive optic neuropathy than nonsmokers. Patients who had received radioactive iodine (RAI) treatment were older, and were more frequently smokers. If patients were smokers and treated with radioactive iodine treatment, they were more likely to have proptosis, restrictive myopathy, and compressive optic neuropathy than if not treated with radioactive iodine. However, the RAI treatment did not seem to be associated with severe characteristics of TAO in non-smokers. CONCLUSIONS: The risk factors for severe TAO are: male, age older than 50, smoking, treated with RAI in smokers.

The Epidemiologic and Clinical Characteristics of Thyroid-Associated Orbitopathy

PURPOSE: To determine the epidemiologic and clinical characteristics of thyroid-associated orbitopathy (TAO). METHODS: We retrospectively studied the clinical data of 385 patients from the New York City area diagnosed with TAO from January 1990 to December 2000. The total cases were divided into male and female groups and age-adjusted relative incidence rates were obtained to plot the incidence curve and clinical characteristics. Statistical analysis was applied to the collected data. RESULTS: The average age of patients with TAO was 46.3 years for females and 50.1 years for males. The female-male ratio was 5.31:1. In 23.3% of patients, the diagnosis of TAO was made simultaneously with their thyroid disease. In 75% of cases, the diagnosis was made within 18 months of the presentation of thyroid disease. Soft tissue involvement was noted most frequently in 311 (80.8%), eyelid retraction in 306 (79.5%), proptosis in 278 (72.2%), restrictive myopathy in 234 (60.8%), and compressive optic neuropathy in 43 (11.2%) of 385 patients. CONCLUSIONS: TAO has variable and different epidemiologic and clinical characteristics according to sex and age.

Thyroid Associated Orbitopathy following Periocular Surgery

PURPOSE: To descirbe a series of patients in which Thyroid Associated Orbitopathy (TAO) occurred after periocular surgery. METHODS: A retrospective case review of patients who developed TAO in close temporal association with periocular surgical interventions and presented at the orbital clinic from 1997 to 2004. History of previous thyroid abnormality and the lack of TAO signs and symptoms before surgery were reviewed and analyzed. RESULTS: Nine patients that developed TAO in association with periocular surgery were identified. All were women with an average age of 59.3years. (range: 45-75 years). The patients divided into two groups. Group 1 consisted of four patients who had previously been diagnosed with Graves' hyperthyroidism (GH). They ranged in age from 48 to 75 years (average: 58.8 years). The diagnosis of GH had been made an average of 50.5 months (range: 12-96 months) before presentation with TAO. Group 2 consisted of five patients who had no previous history of thyroid abnormality. They ranged in age from 45 to 74 years (average: 60.2 years). No patients had any signs or symptoms of TAO before their recent presentation. CONCLUSIONS: Periocular surgery may lead to local inflammatory events that may contribute to the instigation of TAO in predisposed individuals.

Cases of Complications after the Use of Punctal Plugs

PURPOSE: To report cases of complications after using punctual plugs with a literature review. METHODS: We studied 3 complicated cases after the use of punctual plugs: a 46-year-old female with recurrent mucopurulent discharge, a 42-year-old male with a pinkish mass over the punctum, and a 29-year-old female with recurrent epiphora. RESULTS: The 46-year-old female was diagnosed with canaliculitis caused by actinomyces, the 42-year-old male with chronic pyogenic granuloma, and the 29-year-old female with canalicular obstruction. All 3 cases improved after proper treatments. CONCLUSIONS: Complications after the use of punctal plugs are not common but they can be significant. They have to be used carefully after through evaluation and obtained proper informed consents from the patient.

Bilateral Episcleral Osseous Choristoma

PURPOSE: To report the symmetric masses developed in both eyes, which were diagnosed with bilateral osseous choristoma and surgically excised. METHODS: A 6-year-old female was noted by her parents to have a mass under the conjunctiva of her left eye. The mass was white and firmly attached to the globe. The same lesion was present in the right eye. CT scan showed that the masses were high bone-density and did not invade the sclera deeply. Therefore, excisional biopsy of the lesions were performed. RESULTS: Histopathologic examination showed that the masses were episcleral osseous choristoma. There was no complication of recurrence or adhesion after surgery. CONCLUSIONS: In case of a hard mass under the conjunctiva, which is diagnosed with osseous choristoma by CT scanning, it is helpful to determine the accurate location and adhesion of the massfor successful surgery.

Sarcoidosis, Presented as Recurrent Eyelid Masses

PURPOSE: Sarcoidosis is a granulomatous inflammation that can affect all organs, and the initial manifestation is sometimes ophthalmologic disease. The purpose of this article is to report the diagnosis of ocular sarcoidosis for a patient whose chief complaint was recurrent eyelid mass without any other ophthalmologic symptoms or signs. METHODS: A 43-year-old female had an 8-month history of bilateral upper eyelid swelling, right upper eyelid mass, and right ptosis. She had received localized steroid injection at a local dermatologic clinic. On physical examination, there were hard and fixed eyelid masses and mechanical ptosis due to an eyelid mass in the right upper eyelid. Mass excision and biopsy were performed, and a pulmonology specialist was consulted to evaluate the nodule on chest X-ray RESULTS: The patient's condition had been diagnosed with multiple chalazia at the first pathologic reading, but it was diagnosed with sarcoidosis at the second pathologic reading, which was requested because of recurrence. The diagnosis of sarcoidosis was based on chest PA, and chest CT, and was confirmed by lung biopsy specimen. CONCLUSIONS: In the case of recurrent eyelid mass, sarcoidosis should first be ruled out.

Two Cases of Intraorbital Wooden Foreign Bodies

PURPOSE: To report two cases of acute and chronic intraorbital wooden foreign bodies. METHODS: We sutured an 11-year-old boy who had sustained forehead laceration with a pencil (Case 1) and sutured a 43-year-old man who had sustained lower eyelid laceration due to a wooden splinter embedded in the eyelid 1 month before (Case 2). We confirmed the presence of intraorbital wooden foreign bodies in both cases using radiological examinations and removed them. RESULTS: In Case 1, a pencil from the primary wound, and the patient obtained good visual acuity and full extraocular motility for six months. In Case 2, granulated wooden foreign bodies were removed and had limited extraocular motility and diplopia at post-operative three months. CONCLUSIONS: Unremoved intraorbital foreign bodies may lead to many ophthalmologic sequelae. If intraorbital foreign bodies intrude into the adjacent central nervous system, it may lead to fatal complications. The actual presence of intraorbital wooden foreign bodies should require radiological examinations; when confirmed, they should be removed surgically.

Management with Radical Excision in Squamous Cell Carcinoma of the Lacrimal Sac

PURPOSE: Squamous cell carcinoma of the lacrimal sac is rare and there is high rate of recurrence after dacryocystectomy. We report successful radical excision of the tumor for the purpose of reducing the recurrence and improving the survival rate. METHODS: A 48-year-old man who had a history of epiphora and medial canthal mass for one year was referred to our clinic. CT scan showed a mass on the lacrimal fossa but there was no evidence of bony destruction or local invasion. We confirmed that the excised mass was squamous cell carcinoma of the lacrimal sac by frozen section. So, radical excision including bony and mucous nasolacrimal duct (NLD), inferior turbinate, and medial maxilla was performed through lateral rhinotomy. RESULTS: Ten months later, there was skin defect and medial canthal deformity. So we corrected the deformity with a forehead free flap and the result was cosmetically acceptable. There was no evidence of recurrence or distant metastasis for one- year follow- up period. CONCLUSIONS: Despite its high recurrence rate, we can reduce the recurrence and mortality rate of squamous cell carcinoma of the lacrimal sac with radical excision including bony and mucous NLD, inferior turbinate, and medial maxilla.

A case of traumatic eyeball extrusion with complex, comminuted fractures

PURPOSE: Traumatic extrusion of the eyeball is rare. We experienced and successfully reconstructed a case of the eyeball extrusion with complete avulsion of the optic nerve, and complex, comminuted fractures of medial and inferior orbital walls. METHODS: A 27-year-old man presented with the ocular pain and eyeball extrusion of the right eye after the trauma. There were multiple lacerations of the eyelid and the conjunctiva of the right eye, the complete avulsion of the optic nerve and the avulsion of extraocular muscles except the lateral rectus muscle, and the eyeball extrusion of the right eye. We performed the enucleation with Medpor(R) sphere implantation and the reconstruction of the inferior and medial walls with Medpor(R) one channel and sheet implant. RESULTS: At one-year follow-up, there were no implant exposure and infection, and good cosmetic result was seen without enophthalmos. CONCLUSIONS: In a case of eyeball extrusion with complex, comminuted fractures after trauma, we could reconstruct these successfully with enucleation with Medpor(R) sphere implantation, and repair of fractures with Medpor(R) channel and sheet implant.

Surgical Treatment of a Capillary Hemangioma with Preoperative Embolization

PURPOSE: To assess the effect of surgical excision of a capillary hemangioma with preoperative embolization. METHODS: An 8-month-old girl with large upper eyelid capillary hemangioma obscuring the visual axis which did not show any decrease in size of tumor mass after two steroid injections was referred to us. We treated this patient with preoperative embolization and surgical excision of the mass. RESULTS: We treated this patient successfully with preoperative embolization and surgical excision of the mass without considerable blood loss. No recurrences have been noted. CONCLUSIONS: Surgical excision of capillary hemangiomas with preoperative embolization should be considered a treatment option in large capillary hemangiomas that fail to respond to local corticosteroid injections.

Medpor(r) Enophthalmos Wedge Implants in Enophthalmos Correction

PURPOSE: We assessed the effect of Medpor(r) enophthalmos wedge implant on the correction enophthalmos. METHODS: Authors operated on 12 patients with enophthalmos using Medpor(r) enophthalmos wedge implant. RESULTS: Among 12 cases, 5 were men and 7 were women. Average age was 37.2 years. Average followup period was 8.1 months. There were posttraumatic enophthalmos in 8 patients and anophthalmic enophthalmos in 4 patients. We used 27 implants to correct enophthalmos (mean 2.3 implants). Among 8 orbital fracture cases, ocular motility disturbance and diplopia were improved in 7 cases. The amount of enophthalmos corrected was between 1 and 5 mm (mean 3.1 mm). We experienced improvement of inferior dystopia (mean 2.1 mm) in 11 cases and medial dystopia (mean 0.8 mm) in 5 cases. There was no case of visual loss, implant infection, migration, or exposure. CONCLUSIONS: Our results showed that Medpor(r) enophthalmos wedge implant effectively corrected enophthalmos without significant complications.

Porous Polyethylene (Medpor(R)) Channel Implants in Orbital Fracture Repairs

PURPOSE: A porous polyethylene channel implant(PPCI) has internal channels that accept mini- or microplates, using fixation to bone in the large, complex orbital fractures. We assessed the effects of this implants in orbital fracture repairs. METHODS: We assessed the effects of PPCIs in 15 orbital fracture patients of minimal 3 months follow-up. RESULTS: Among 15 cases, 9 were men and 6 were women. Average age was 35.7 years. Average followup period was 8.1 months. The surgery was performed less than two weeks after injury in 5 patients and more than two weeks after injury(delayed) in 10 patients. Among these, 13 cases had combined medial and inferior wall fractures, 2 cases had large, posterior inferior wall fractures. Excellent results were obtained in all 13 patients with ocular motility disturbance and diplopia. The mean correction of enophthalmos was 3.1mm. We obtained marked improvement of inferior and medial dystopia in 9 cases. There were no cases of visual loss, implant infection, migration, or exposure. CONCLUSIONS: A PPCI has malleability that permits easy shaping and contouring, and semirigid structures provide structural stability. PPCIs are suited for reconstruction of large fractures(greater than 50%) or posterior fractures which cannot secure fixation without significant complications.