Validation of Electronic Foot Function Index in Patients with Foot and Ankle Disease: A Randomized, Prospective Multicenter Study / 대한족부족관절학회지

PURPOSE: To evaluate the efficiency of the electronic foot function index (eFFI) through a prospective, random based, multi-institutional study. MATERIALS AND METHODS: The study included 227 patients ranging in age from 20 to 79 years, visited for surgery in different 15 institutes, and agreed to volunteer. The patients were assigned randomly into a paper-based evaluated group (n=113) and tablet-based evaluated group (n=114). The evaluation was done on the day of hospital admission and the method was changed on the second day of surgery and re-evaluated. PADAS 2.0 (https://www.proscore.kr) was used as an electronic evaluation program. RESULTS: There were no differences in age and sex in both groups. The intraclass correlation coefficient (ICC) evaluation revealed an eFFI ICC of 0.924, showing that both results were similar. The evaluation time was shorter in the tablet-based group than the paper-based group (paper vs tablet, 3.7±3.8 vs 2.3±1.3 minutes). Thirty-nine patients (17.2%) preferred to use paper and 131 patients (57.7%) preferred the tablet. Fifty-seven patients (25.1%) found both ways to be acceptable. CONCLUSION: eFFI through tablet devices appears to be more constant than the paper-based program. In addition, it required a shorter amount of time and the patients tended to prefer the tablet-based program. Overall, tablet and cloud system can be beneficial to a clinical study.

The Methods for Foot Function Index and Foot and Ankle Outcome Score Measurement: A Comparison between Paper-and-Pencil Method and Electronic Method / 대한족부족관절학회지

PURPOSE: The patient-reported outcome measure (PROM) is used to quantify the subjective state of patients before and after the treatment. The electronic method was recently developed and used for the completion of PROM, in addition to the conventional paper and pencil method. This study identified whether the results of Foot Function Index (FFI) and Foot and Ankle Outcome Score (FAOS) using the paper and pencil method was different from those using the electronic method. MATERIALS AND METHODS: Between May 2016 and August 2016, 42 patients who were admitted to the Seoul Foot and Ankle Center two days before surgery were included for evaluation. The mean age was 46 years (range, 21~72 years). There were 29 males and 13 females. To use the electronic method, the PADAS software (PADAS, Seoul, Korea) was implemented using a touch pad. The primary trial of FFI and FAOS was performed using either the paper-and-pencil method or the electronic method. At 24 hours after the primary test, a secondary trial of FFI and FAOS was performed using the other method. Then, we identified the reliability of FFI and FAOS between the two methods by calculating the intraclass coefficient. RESULTS: Twenty-two patients underwent the first trial using the paper-and-pencil method, and 20 patients underwent the first trial using the electronic method. Of the 42 patients, 8 patients were excluded from this study and only 34 patients were included in this study. The reliability of FFI was excellent with an intraclass coefficient of 0.957, and the reliability of FAOS was also excellent with an intraclass coefficient of 0.840. CONCLUSION: The paper-and-pencil method and the electronic method have the same result for the completion of FFI and FAOS in this study. Therefore, it is commonly considered that the completion of FFI and FAOS using the electronic method can be applied in practice.

Demineralized Bone Matrix Injection in Consolidation Phase Enhances Bone Regeneration in Distraction Osteogenesis via Endochondral Bone Formation

BACKGROUND: Distraction osteogenesis (DO) is a promising tool for bone and tissue regeneration. However, prolonged healing time remains a major problem. Various materials including cells, cytokines, and growth factors have been used in an attempt to enhance bone formation. We examined the effect of percutaneous injection of demineralized bone matrix (DBM) during the consolidation phase on bone regeneration after distraction. METHODS: The immature rabbit tibial DO model (20 mm length-gain) was used. Twenty-eight animals received DBM 100 mg percutaneously at the end of distraction. Another 22 animals were left without further procedure (control). Plain radiographs were taken every week. Postmortem bone dual-energy X-ray absorptiometry and micro-computed tomography (micro-CT) studies were performed at the third and sixth weeks of the consolidation period and histological analysis was performed. RESULTS: The regenerate bone mineral density was higher in the DBM group when compared with that in the saline injection control group at the third week postdistraction. Quantitative analysis using micro-CT revealed larger trabecular bone volume, higher trabecular number, and less trabecular separation in the DBM group than in the saline injection control group. Cross-sectional area and cortical thickness at the sixth week postdistraction, assessed using micro-CT, were greater in the regenerates of the DBM group compared with the control group. Histological evaluation revealed higher trabecular bone volume and trabecular number in the regenerate of the DBM group. New bone formation was apparently enhanced, via endochondral ossification, at the site and in the vicinity of the injected DBM. DBM was absorbed slowly, but it remained until the sixth postoperative week after injection. CONCLUSIONS: DBM administration into the distraction gap at the end of the distraction period resulted in a significantly greater regenerate bone area, trabecular number, and cortical thickness in the rabbit tibial DO model. These data suggest that percutaneous DBM administration at the end of the distraction period or in the early consolidation period may stimulate regenerate bone formation and consolidation in a clinical situation with delayed bone healing during DO.

Foot Drop of Contralateral Limb after Deformity Correction in a Polio Patient: A Case Report / 대한족부족관절학회지

Postpoliomyelitis syndrome is a common neurological disorder that occurs in patients who have experienced paralytic poliomyelitis. Recently, as a result of vaccination against poliovirus, incidence of poliomyelitis is exceedingly low. However, many patients with postpolio syndrome may encounter anesthesia when undergoing surgery, such as for correction of foot deformity and other operations. We report on a 45-year-old woman who experienced paralysis of her contralateral limb after operation on the left foot under spinal anesthesia. Postoperative electromyography/nerve conduction study (EMG/NCS) was performed in order to determine the cause of paralysis. Motor power of the sequelae involved leg showed improvement with time and recovered fully to the preoperative level at six months after the index operation. A precise evaluation, including a physical examination and EMG/NCS, should be performed preoperatively when spinal anesthesia is planned for postpolio syndrome patients.

Electrical Stimulation Therapy in Chronic Functional Constipation: Five Years' Experience in Patients Refractory to Biofeedback Therapy and With Rectal Hyposensitivity

BACKGROUND/AIMS: Biofeedback therapy (BFT) can be unsuccessful in constipated patients, even those with pelvic floor dysfunction. Electrical stimulation therapy (EST) has been introduced as a novel therapeutic modality in patients with chronic constipation, especially those who have rectal hyposensitivity. We evaluated the efficacy of EST based on five years' clinical experience. METHODS: From January 2002 to February 2007, 159 patients underwent EST. After exclusion of 12 drop-outs, 147 (M:F = 61:86, 49 +/- 17 years) finished all treatment sessions. Among them, 88 (M:F = 29:59, 49 +/- 17 years) were refractory to BFT without rectal hyposensitivity (RH), and 59 (M:F = 32:27, 54 +/- 17 years) were those with RH. RESULTS: The overall response to EST was 59.2% (87/147) by per-protocol analysis. In the EST-responsive group, overall satisfaction improved significantly (from 7.3 +/- 3.0 to 4.3 +/- 2.5, P < 0.05). Subgroup analysis showed that the response rate was 64.8% (57/88) in patients refractory to BFT without RH, and 50.8% (30/59) in those with RH. CONCLUSIONS: EST may have additional therapeutic efficacy in patients who are refractory to BFT. EST may also be effective in patients with RH, including restoration of rectal sensation. Therefore, EST could be considered as an alternative choice in patients refractory to BFT and with or without RH.

Negative-pressure wound therapy induces endothelial progenitor cell mobilization in diabetic patients with foot infection or skin defects

Non healing chronic wounds are difficult to treat in patients with diabetes and can result in severe medical problems for these patients and for society. Negative-pressure wound therapy (NPWT) has been adopted to treat intractable chronic wounds and has been reported to be effective. However, the mechanisms underlying the effects of this treatment have not been elucidated. To assess the vasculogenic effect of NPWT, we evaluated the systemic mobilization of endothelial progenitor cells (EPCs) during NPWT. Twenty-two of 29 consecutive patients who presented at the clinic of Seoul National Universty Hospital between December 2009 and November 2010 who underwent NPWT for diabetic foot infections or skin ulcers were included in this study. Peripheral blood samples were taken before NPWT (pre-NPWT) and 7-14 days after the initiation of NPWT (during-NPWT). Fluorescence-activated cell sorting (FACS) analysis showed that the number of cells in EPC-enriched fractions increased after NPWT, and the numbers of EPC colony forming units (CFUs) significantly increased during NPWT. We believe that NPWT is useful for treating patients with diabetic foot infections and skin ulcers, especially when these conditions are accompanied by peripheral arterial insufficiency. The systemic mobilization of EPCs during NPWT may be a mechanism for healing intractable wounds in diabetic patients with foot infections or skin defects via the formation of increased granulation tissue with numerous small blood vessels.

A Case of Cronkhite-Canada Syndrome Showing Spontaneous Remission

Cronkhite-Canada syndrome (CCS) is a rare, noninherited gastrointestinal polyposis syndrome associated with ectodermal changes such as alopecia, nail dystrophy, and cutaneous hyperpigmentation. The etiology and pathogenesis of CCS are not known, but diarrhea, malnutrition, gastrointestinal bleeding, and infection may occur in the affected patient; moreover, this condition could be fatal. However, previous reports have described several cases of spontaneous remission. We report a 60-year-old man who was incidentally found to have colonic polyposis, alopecia, and hypogeusia and was diagnosed to have CCS. However, this patient experienced spontaneous remission, including regrowth of body hair and alleviation of bowel inflammation, without any specific medications such as steroids, antibiotics, or proton pump inhibitors.

A Case of Tuberculous Optochiasmatic Arachnoiditis / 대한내과학회지

Tuberculous optochiasmatic arachnoiditis (OCA) is a rare complication of tuberculous meningitis. We describe a 47-year-old female with tuberculous OCA confused with ethambutol-associated optic neuropathy. She was on anti-tuberculous treatment (i.e., isoniazid, rifampin, ethambutol, and pyrazinamide) for two months due to tuberculous meningitis. Visual impairment occurred during treatment, and ethambutol was changed to levofloxacin because of concern for ethambutol-associated optic neuropathy. Her visual impairment did not improve three months after anti-tuberculous treatment that excluded ethambutol, and she was referred to our hospital. Brain MRI showed enhancement of the optic chiasm and bilateral optic tract, and fundoscopy revealed bilateral optic nerve atrophy, suggesting tuberculous OCA. Her visual acuity was partially improved after anti-tuberculous treatment. Tuberculous OCA should be considered in addition to ethambutol-associated optic neuropathy for a patient with tuberculous meningitis who presents with visual impairment.

A Case of Lactic Acidosis Caused by Linezolid Treatment of Persistent Methicillin-Resistant Staphylococcus Aureus Bacteremia / 대한내과학회지

Linezolid is an antibiotic in the oxazolidinone family that works as a bacterial protein synthesis inhibitor. It is used for the treatment of Gram-positive, multidrug-resistant bacteria. Adverse effects of linezolid include bone marrow suppression, peripheral or optic neuropathy, and, less commonly, lactic acidosis. Lactic acidosis usually occurs as a result of cardiopulmonary failure or sepsis, but it is sometimes caused by drugs, such as linezolid, and treatment of such lactic acidosis involves cessation of the drug. We report a case of lactic acidosis caused by the use of linezolid for the treatment of persistent methicillin-resistant Staphylococcus aureus bacteremia, which occurred after endoscopic sclerotherapy of gastic varices.

Normal Range of the Inflammation Related Laboratory Findings and Predictors of the Postoperative Infection in Spinal Posterior Fusion Surgery

BACKGROUND: Inflammation related hematological parameters vary greatly depending on patients. It is not well known how much increase of which parameter warrants suspicion of postoperative infection. This study proposes to identify the normal range and the predictive factors for postoperative infection by conducting a time series analysis of the hematological parameters of patients after the spinal posterior fusion. METHODS: A retrospective study was done with 608 patients who underwent spinal posterior fusion with pedicle screw fixation. Laboratory assessment including the leucocyte, neutrophil, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) of patients for 2 weeks after operation. The patients were divided into the one-level fusion group (group I), the two-level fusion group (group II), the three or multi-level fusion or reoperation group (group III), and the postoperative infection group (group IV). Blood was drawn before breakfast prior to the operation, and then 2-3 days, 4-7 days, 8-11 days, and 12-14 days after the operation. The leucocyte count, neutrophil count, CRP, and ESR were measured. RESULTS: From 4-7 days after the operation, the CRP and neutrophil count of group IV were significantly higher than those of group I and II, and from 8-11 days after operation, the CRP and neutrophil counts were significantly higher than those of all groups. Twelve to fourteen days after the operation, the neutrophil count of group IV was significantly higher than that of group I and II, while the neutrophil count of group III was also higher than that of group I. The lower limit of the 95% confidence interval (CI) of the CRP and neutrophil count group IV was greater than the upper limit of the 95% CI of group I and II. The ESR of group IV was significantly higher than that of group I and III. CONCLUSIONS: If the postoperative CRP and neutrophil counts are high, or if the CRP begins to rise again 8 days after the operation, the likelihood of infection increases, but caution must be exercised in interpreting the results. If the hematological parameters are higher than the lower limit of the 95% CI of the postoperative infection group, infection must be strongly suspected.

A Case of Tuberculous Optochiasmatic Arachnoiditis / 대한내과학회지

Tuberculous optochiasmatic arachnoiditis (OCA) is a rare complication of tuberculous meningitis. We describe a 47-year-old female with tuberculous OCA confused with ethambutol-associated optic neuropathy. She was on anti-tuberculous treatment (i.e., isoniazid, rifampin, ethambutol, and pyrazinamide) for two months due to tuberculous meningitis. Visual impairment occurred during treatment, and ethambutol was changed to levofloxacin because of concern for ethambutol-associated optic neuropathy. Her visual impairment did not improve three months after anti-tuberculous treatment that excluded ethambutol, and she was referred to our hospital. Brain MRI showed enhancement of the optic chiasm and bilateral optic tract, and fundoscopy revealed bilateral optic nerve atrophy, suggesting tuberculous OCA. Her visual acuity was partially improved after anti-tuberculous treatment. Tuberculous OCA should be considered in addition to ethambutol-associated optic neuropathy for a patient with tuberculous meningitis who presents with visual impairment.

A Case of Lactic Acidosis Caused by Linezolid Treatment of Persistent Methicillin-Resistant Staphylococcus Aureus Bacteremia / 대한내과학회지

Linezolid is an antibiotic in the oxazolidinone family that works as a bacterial protein synthesis inhibitor. It is used for the treatment of Gram-positive, multidrug-resistant bacteria. Adverse effects of linezolid include bone marrow suppression, peripheral or optic neuropathy, and, less commonly, lactic acidosis. Lactic acidosis usually occurs as a result of cardiopulmonary failure or sepsis, but it is sometimes caused by drugs, such as linezolid, and treatment of such lactic acidosis involves cessation of the drug. We report a case of lactic acidosis caused by the use of linezolid for the treatment of persistent methicillin-resistant Staphylococcus aureus bacteremia, which occurred after endoscopic sclerotherapy of gastic varices.

Concurrent hepatic adenomatoid tumor and hepatic hemangioma: a case report

A 45-year-old male with alleged asymptomatic hepatic hemangioma of 4 years duration had right upper-quadrant pain and was referred to a tertiary hospital. Computed tomography and magnetic resonance imaging scans revealed a hypervascular mass of about 7 cm containing intratumoral multilobulated cysts. A preoperative liver biopsy was performed, but this failed to provide a definitive diagnosis. The patient underwent a partial hepatectomy of segments IV and VIII. The histologic findings revealed multifocal proliferation of flattened or cuboidal epithelioid cells and a highly vascular edematous stroma. Immunohistochemistry findings demonstrated that the epithelioid tumor cells were positive for cytokeratin (AE1/AE3), vimentin, calretinin, and cytokeratin 5/6, and were focally positive for CD10, and negative for WT1 and CD34, all of which support their mesothelial origin. Immunohistochemistry for a mesothelial marker should be performed for determining the presence of an adenomatoid tumor when benign epithelioid cells are seen.

A Case of Cytomegalovirus Colitis in Chronic Adult T-Cell Leukemia/Lymphoma / 영남의대학술지

Adult T-cell leukemia/lymphoma (ATLL) is a malignancy of mature T-cells caused by the human T-cell lymphotrophic virus type I (HTLV-I). HTLV-I is endemic in some areas in Japan, the Caribbean basin, and Africa but has low prevalence in South Korea. Patients with ATLL are susceptible to opportunistic infections such as cytomegalovirus (CMV) infection, but CMV infection in chronic ATLL is uncommon. Reported herein is a case involving a 44-year-old woman with chronic ATLL who presented the symptoms of fever and diarrhea. She was suspected to have acute-type ATLL but was later diagnosed with CMV colitis.

Acromial Morphology in Different MR Oblique Sagittal Slices: Correlation with Rotator Cuff Disorder

PURPOSE: On the hypothesis that the acromion morphology is changed according to the its site, we identified the morphology of the acromion on the oblique slices of MRI and we investigated the association of the acromial shape with the clinical stages of rotator cuff disorder on the magnetic resonance (MR) images. In addition, we compared the acromion morphology on MRI and simple X-rays. MATERIAL AND METHODS: The MR images of seventy one patients with rotator cuff disorder and who underwent arthroscopic surgery were compared with that of a control group of sixteen patients who didn't have rotator cuff disorder on MRI. On three subsequent oblique sagittal slices from the lateral edge of the acromion (S1, S2 and S3), each acromion morphology on the MRI slices was classified according to Epstein et al: flat, curved or hooked. We investigated the changing parttern of the acromion shape and we compared the acromion shape on MRI and that on simple X-rays. We classified the rotator cuff tear by the severity: bursitis, partial thickness tear or full thickness tear. We investigated which acromial type on the MRI oblique slice was associated with the severity of rotator cuff disease. RESULTS: Changes of the acromial shape occurred in 54 patients (76.1%). The most frequent pattern was that the types are same on S1 and S2 and different on S3 (22 cases, 31.0%). The acromial type on S1 and S2 was significantly associated with the severity of rotator cuff disorder (p=0.001 and 0.022), respectively. There was no reliability of the acromial shape on MRI and roentgenography (p>0.05). CONCLUSION: The type of acromion changed from lateral to medial. Among the three positions, the shape of the acromion on S1 and S2 had meaningful correlation with the clinical stage of rotator cuff disorder. There was no statistical correlation of the acromial shape between MRI and simple X-ray.

Early Results of Hemicondylar Hamate Replacement Arthroplasty in Proximal Interphalangeal Fracture-Dislocation Injury

PURPOSE: We assessed early clinical and radiological results of hemicondylar hamate replacement arthroplasty in fracture-dislocation injury of the proximal interphalangeal joint. MATERIALS AND METHODS: From March 2007 to February 2008, four patients who had suffered from comminuted unstable fracture-dislocation of the proximal interphalangeal joint were treated by hemicondylar hamate replacement arthroplasty. All patients were male, and average age at operation was 21.5(range, 14~27) years. All cases showed subluxation of the proximal interphalangeal joint, and mean articular surface involvement was 50.8(range, 42.1~62.5)%. We clinically measured ROM, grip strength, pain of donor & recipient site, and radiologically assessed whether or not union, malalignment, or step-off occurred. RESULTS: Average follow-up period was 9.5(range, 6~14) months. Mean flexion contracture was 12.5 (range, 10~15)degrees in affected side and 0degrees in unaffected side. Mean further flexion was 92.5 (range, 85~100)degrees in affected side and 95.0 (range, 90~100)degrees in unaffected side. Mean VAS pain scores was 1.75 (range, 1~3) in recipient site and 1.25 (range, 0~2) in donor site. Mean grip strength was 11 (range, 8~15) lb in affected side and 14 (range, 10~17) lb in unaffected side. Union without malalignment was achieved in all cases. CONCLUSIONS: Early results of hemicondylar hamate replacement arthroplasty in the treatment of fracture-dislocation of the proximal interphalangeal joint showed satisfactory functional and radiological outcome.