Arthroscopic Transosseous Suture Repair for Bankart Lesion with a Flexible Drill Device: An Experimental and Preliminary Clinical Report

PURPOSE: Too develop a flexible drill device that can be inserted into the shoulder joint so that arthroscopic transosseous suture repair for Bankart lesion is possible. MATERIALS AND METHODS: We created a device composed of a flexible drill unit and a guide pipe unit. The flexible drill unit was made of flexible multifilament wires (1.2 mm in diameter) that was twisted into one cord so that it can flex in any direction and a drill bit (1.2 mm in diameter) that is attached onto one end of the flexible wire. The guide pipe unit was a 150 mm long metal pipe (2.0 mm in inner diameter and 3.0 mm in outer diameter), with one end bent to 30 degrees. The flexible drill set was inserted into the shoulder joint through the posterior portal of the joint. The guide pipe component was placed onto the medial wall of the glenoid so that the pipe was placed 5 mm posterior to the margin of the anterior glenoid rim. The flexible drill was driven through the glenoid by the power drill so that holes were made in the glenoid. A non-absorbable suture was passed through the hole. Tying of a sliding knot tying was accomplished over the capsule and labrum after making a stitch through the capsule and labrum with a suture hook loaded with suture passer. The same procedures were done at the 2 and 4 O'Clock positions of the glenoid. RESULTS: Five cases with Bankart lesion received arthroscopic transosseous repair with our flexible drill device. There were no intraoperative problems. Neither redislocation nor subluxation was reported at final follow-up. CONCLUSION: Arthroscopic transosseous suture repair without suture anchors and easy tying of a sliding knot are possible with a flexible drill set.

Treatment of Old Achilles Tendon Rupture using Modified Flexor Hallucis Longus Tendon Transfer / 대한족부족관절학회지

PURPOSE: The purpose of this study was to evaluate the clinical results of the old Achilles tendon rupture treated with modified flexor hallucis longus (FHL) tendon transfer. MATERIALS AND METHODS: Seventeen patients with old Achilles tendon rupture treated with modified FHL tendon transfer between March 2004 and February 2008 were enrolled in this study. Technically FHL was pass through the distal portion of the ruptured tendon instead of the drilled hole made on the calcaneus. The mean age of the patients was 37 years (range, 22~67 years), mean follow-up period was 28 months (range, 12~30 months). Patients' subjective satisfaction, calf circumferential diameter, range of motion of ankle and AOFAS ankle-hind foot score and Arner-Lidholm score was evaluated. RESULTS: The average gap between the ruptured tendon was 52 mm (range, 47~56 mm). The AOFAS score improved from 47 pre-operatively to 91 points at the last follow-up. Sixteen patients were satisfied with the result free from discomfort, a patient had mild discomfort who had DM. fourteen patients had decreased range of motion less than 5 degrees while 2 patients had more than 7 degrees decrease compared to the intact side but had no discomfort in daily activities. Nine patients had less than 1 cm calf circumferential diameter difference and 7 patients had 1 to 3 cm diameter difference compared to the intact side. One who had more than 3 cm diameter difference had deteriorated muscle strength. CONCLUSION: Modified FHL tendon transfer can be a useful technique for the treatment of old Achilles tendon rupture when the gap is with large gap placed too proximal.

Catastrophic Catecholamine-Induced Cardiomyopathy Mimicking Acute Myocardial Infarction, Rescued by Extracorporeal Membrane Oxygenation (ECMO) in Pheochromocytoma

Pheochromocytoma is a rare disorder and functioning tumor composed of chromaffin cells that secrete catecholamines. Patients with a pheochromocytoma 'crisis' have a high mortality in spite of aggressive therapy. We present a case with a severe acute catecholamine cardiomyopathy presenting ST segment elevation with cardiogenic shock after hemorrhage into a left suprarenal tumor. Intra-aortic balloon pump (IABP) support, combined with inotropic therapy, was performed. However, the patient deteriorated rapidly and was unresponsive to a full dose of inotropics and IABP. We decided to apply extracorporeal membrane oxygenation (ECMO) device for the patient. His clinical state began to improve 3 days after ECMO. After achieving hemodynamic stabilization, he underwent successful laparoscopic left adrenalectomy. He needed no further cardiac medication after discharge.

The Usefulness of 2-Dimensional Longitudinal Strain for Prediction of the Postoperative Left Ventricular Systolic Function in Patients with Valvular Heart Disease Causing Volume Overloading

BACKGROUND AND OBJECTIVES: Prediction of the postoperative left ventricular (LV) function in valvular heart disease that will cause LV volume overloading, such as chronic mitral regurgitation (MR) and aortic regurgitation (AR), remains elusive. We sought to test if 2-dimensional peak negative longitudinal strain (LS2D) was useful for prediction of the postoperative LV function in relation to this disease entity. SUBJECTS AND METHODS: Newly developed speckle tracking imaging was performed preoperatively to measure the LS2D in 26 and 22 patients with MR and AR, respectively. A favorable response after the operation (FR) was defined according to the change in the LV ejection fraction (EF): 1) a LVEF > or =55% both pre- and post-operation, 2) a postoperative LVEF > or =55% with a pre-operative LVEF between or =45%, or 3) an increase in the LVEF >10% with a pre-operative LVEF <45%. RESULTS: Follow-up echocardiography was performed at an average of 6.7+/-2.3 months after the operation. FR was confirmed in 36 patients (LVEF from 55.4+/-10.1 to 58.3+/-5.0%, p=0.06), with the remaining 12 showing an unfavorable response (LVEF from 52.5+/-7.6 to 45.1+/-5.4%, p<0.01). There was no significant difference in the baseline characteristics, including underlying etiologies, operation techniques, and cardiopulmonary bypass time, and LV volumes and EF between the two groups. The only difference was the LS2D, which was significantly larger in the FR group (-19.8+/-3.9 versus -16.2+/-2.9%, p<0.01). An LS2D of -18.3% could predict an unfavorable response of the LVEF following an operation, with a sensitivity and specificity of 75 and 75%, respectively. CONCLUSION: The preoperative LS2D is a useful predictor of the postoperative left ventricular function in AR and MR.

A Case of Intraductal Papillary Mucinous Tumor Arising from the Accessory Pancreatic Duct / 대한소화기내시경학회지

Mucin-producing tumors of the pancreas were first reported by Ohhashi and Takagi in 1980. Since then, many cases of intraductal papillary mucinous tumor (IPMT) of the pancreas, which is almost homonymous to mucin-producing tumors of the pancreas, have been reported. IPMTs are generally regarded as tumors with a favorable prognosis. Some IPMTs have invasiveness and this is always associated with a poor prognosis. Most IPMTs arise from the main pancreatic duct and IPMTs arising from the accessory pancreatic duct are relatively rare. Only 6 cases have been reported in the literature so far. Our patient was a 43-year old man who was admitted to the hospital due to recurrent pancreatitis. An endoscopic retrograde pancreatography revealed a patulous minor papilla orifice extruding mucin and a cystic lesion in a branch of the accessory duct. A pancreaticoduodenectomy was performed and a pathologic examination of the resected specimen showed intraductal papaillary mucinous neoplasm, low grade malignancy, in the accessory pancreatic duct and its branch. We herein report this interesting case with a review of the literature.

A Case Report of Percutaneous Fenestration of the Intimal Flap for Limb Ischemia in the Aortic Dissection

The residual tense false lumen following surgical repair of aortic dissection remains one of the most difficult and challenging postsurgical problems. Percutaneous fenestration of the dissecting membrane under the guidance of intravascular ultrasound has been recently introduced to depressurize the tense false lumen. A 63-year-old woman who underwent repair of acute type I dissection was readmitted because of claudication and numbness of the left lower extremity. Angiography, computed tomography, and magnetic resonance imaging clearly showed a dissection flap starting from the thoracic aorta distal to the left subclavian artery. Compressed true lumen by the markedly enlarged tense false lumen was also noted in the double-channeled descending thoracoabdominal aorta. Under intravascular ultrasound guidance, the intimal flap was punctured with a Brockenbrough needle advanced to the true lumen through a femoral artery, and then, a balloon catheter was introduced over the guidewire which was placed across the dissection flap. Desired fenestration was obtained successfully by inflation of the balloon without complications. After procedure, symptoms resolved promptly and she is currently(clinical follow-up of 12 months postfenestration) ambulating without claudication. In conclusion, percutaneous fenestration of the intimal flap is a technically feasible and an effective alternative procedure to surgical repair for restoration of perfusion to an ischemic extremity in selected patients complicated with aortic dissection.

Temporal Changes of Left Ventricular Contractile Function after Corrective Surgery in Mitral Regurgitation: Difference according to the Type of Surgery and Its Clinical Significance

BACKGROUND AND OBJECTIVES: Although it is well known that postoperative left ventricular contractile function is an important prognostic factor in mitral regurgitation, temporal changes of left ventricular contractile function could not be evaluated due to lack of follow-up studies and the difference according to the type of surgery was not established. We addressed these issues by analyzing the data of serial echocardiographic studies and sought to determine factors associated with mortality and cardiovascular events during follow-up. MATERIALS AND METHOD: Retrospective analysis of echocardiographic data and medical records was done in patients who underwent corrective surgery for significant mitral regurgitation at the Asan Medical Center from January 1990 to December 1997. Patients who underwent echocardiography before and immediately after the surgery, and follow-up study at least 6 months later were selected for the analysis. RESULTS: Of 199 patients who underwent mitral valve surgery for mitral regurgitation during that period, 164 patients were included in this study. Among them, 89 patients underwent valve repair and 75 valve replacement. Immediately after surgery, ejection fraction decreased significantly in all patients (62+/-9% vs. 50+/-10%, p<0.01). At the average of 32 months after surgery, ejection fraction was significantly higher in the repair group than in the replacement group (57+/-10% vs. 52+/-11%, p=0.01). During follow-up (mean 32+/-24 months), there were 53 cardiovascular events in 33 patients (heart failure in 14, cardiac death in 11, stroke in 11, reoperation in 11, hemorrhage in 4, thromboembolism in 1 and endocarditis in 1). Cardiovascular events were significantly more frequent in valve replacement group than in valve repair group (23/75 vs. 10/89, p=0.002). Multivariate analysis showed that the independent predictors of all cardiovascular events were immediate postoperative end-systolic volume (p=0.006, hazard risk=1.026, 95% CI=1.01~1.05) and age (p=0.04, hazard risk=1.07, 95% CI=1.001-1.14). The overall survival rate was 85+/-6% at 7 years. Multivariate analysis revealed an independent beneficial effect of valve repair on overall survival (p=0.0058, hazard ratio=0.046, 95% CI=0.005-0.411). CONCLUSION: After surgery, ejection fraction decreased significantly in both groups. However, patients with repair showed progressive improvement of left ventricular contractility and revealed higher ejection fraction at the follow-up study than those with replacement, which might contribute to higher survival rate in this group.