Intramedullary Screw Fixation for Clavicle Shaft Fractures: Comparison of the Anterograde versus the Retrograde Technique

BACKGROUND: The purpose of this study was to investigate the difference between two nailing approaches of intramedullary screw fixation, the retrograde nailing versus the anterograde nailing, on the radiological and clinical outcomes in patients with clavicle shaft fractures. METHODS: From April 2002 to August 2014, we enrolled a total of 22 patients with clavicle shaft fractures to participate in this study. Twelve patients received retrograde intramedullary nailing and 10 received anterograde nailing. The average duration of follow-up was 12 months. In all the patients, we took follow-up radiographs of the anteroposterior and the axial views to assess the postoperative radiological outcomes. We measured the visual analogue scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score, and the range of motion (ROM). RESULTS: Clinically, we did not find a statistically significant difference in the retrograde group and the anterograde group in terms of the duration to bone union, the VAS score the ASES score and the ROMs. Radiologically, we found that the difference in the clavicle shortening of the affected arm and the unaffected arm did not show a statistically significant difference at the immediate postoperative assessment. we found that the difference in the clavicle shortening of the affected arm between the immediate postoperative and the final follow-up value did not show a statistically significant difference. CONCLUSIONS: We found that both the retrograde nailing and the anterograde nailing gave a favorable outcome for clavicle shaft fractures. Although we saw evidence of clavicle shortening after intramedullary screw fixation, this was not a factor that influenced clinical outcome.

Intramedullary Screw Fixation for Clavicle Shaft Fractures: Comparison of the Anterograde versus the Retrograde Technique

BACKGROUND: The purpose of this study was to investigate the difference between two nailing approaches of intramedullary screw fixation, the retrograde nailing versus the anterograde nailing, on the radiological and clinical outcomes in patients with clavicle shaft fractures. METHODS: From April 2002 to August 2014, we enrolled a total of 22 patients with clavicle shaft fractures to participate in this study. Twelve patients received retrograde intramedullary nailing and 10 received anterograde nailing. The average duration of follow-up was 12 months. In all the patients, we took follow-up radiographs of the anteroposterior and the axial views to assess the postoperative radiological outcomes. We measured the visual analogue scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score, and the range of motion (ROM). RESULTS: Clinically, we did not find a statistically significant difference in the retrograde group and the anterograde group in terms of the duration to bone union, the VAS score the ASES score and the ROMs. Radiologically, we found that the difference in the clavicle shortening of the affected arm and the unaffected arm did not show a statistically significant difference at the immediate postoperative assessment. we found that the difference in the clavicle shortening of the affected arm between the immediate postoperative and the final follow-up value did not show a statistically significant difference. CONCLUSIONS: We found that both the retrograde nailing and the anterograde nailing gave a favorable outcome for clavicle shaft fractures. Although we saw evidence of clavicle shortening after intramedullary screw fixation, this was not a factor that influenced clinical outcome.

Rotator Cuff Repair in Patients over 75 Years of Age: Clinical Outcome and Repair Integrity

BACKGROUND: Some studies have shown significant functional improvement after rotator cuff (RC) repair in elderly patients. However, few studies have reported the healing potential of RC tears in elderly patients. METHODS: Twenty-five patients aged ≥ 75 years who underwent RC repair were enrolled. The mean age at the time of surgery was 78.3 years (range, 75 to 88 years) while the mean follow-up was 36.3 months (range, 18 to 114 months). We evaluated clinical and structural outcomes after RC repair in the retear and healed groups. RESULTS: Of 25 patients, 16 (64%) had healed RC lesions and 9 (36%) had retorn cuff lesions. The retear rate increased significantly with increasing initial tear size (small to medium, 13%; large, 60%; massive, 80%; p = 0.024) but not with increasing age (p = 0.072). The mean visual analog scale (VAS), University of California Los Angeles (UCLA), and Constant scores significantly improved from 5.2, 15.8, and 49.3 preoperatively to 1.4, 31.1, and 71.9 in the healed group and from 6.0, 14.4, and 39.5 preoperatively to 2.4, 28.3, and 63.6 in the retear group at the final follow-up (p < 0.05, respectively). There were no significant differences in clinical outcomes between the 2 groups at the final follow-up. Retear was significantly correlated with initial tear size (p = 0.001; odds ratio [OR], 2.771; 95% confidence interval [CI], 1.394 to 5.509 for large to massive tears) (p = 0.001; OR, 0.183; 95% CI, 0.048 to 0.692 for small to medium tears). CONCLUSIONS: There were significant improvements in clinical outcomes after RC repair in patients ≥ 75 years. Structural integrity after cuff repair did not affect the final clinical outcome. Even in elderly patients aged ≥ 75 years, healing of repaired RC can be expected in cases of small to medium tears. Although the retear rate was relatively high for large to massive tears, clinical outcomes still showed significant improvement.

Shoulder Arthrodesis in Brachial Plexus Injury Patient

PURPOSE: To analyze the clinical and radiologic results of the shoulder arthrodesis in brachial plexus injury patients with flail upper extremity. MATERIAL AND METHOD: From Aug 1978 to April 2008, 29 shoulders in 29 patients with brachial plexus injury with shoulder fusion, we evaluated 20 shoulders in 20 patients, more than 1 year follow up. The average follow-up period was 6.45years (range: 1year~24years). There were 13 men and 7 women, and the mean age at the time of trauma was 32.0years(2~65 years). The type of injury was a motorcycle accident in 11 patients, in car accident in 5, pedestrian accident in 3, and fall from a height in 1. The lesion of injury was root and trunk in 1 patient, trunk and cord in 1, trunk in 18. Surgery was performed on the whole arm type paralysis in 12 patients, lower arm type paralysis in 8 patients. The preoperative visual analog scale score was 8.7(7~10). When the trapezius and serratus anterior muscle were in function, operation was performed. 18 patients were processed to the additional operation. Gracilis free flap in 6 patients, neurotization in 3, Steindler flexor plasty in 6, and tendon transfer in 3 were performed. Fixation was conducted with cancellous screws in 13 patients, Knoles pins in 5, and cancellous screws and Knoles pins in 2. The position of the arthrodesis at operation was 28.5degrees(20~45degrees) in abduction, 30.3degrees(20~45degrees) in flexion, and 30.8degrees(20~40degrees) in internal rotation. RESULT: The follow up visual analog scale score was 3.4(0~7). Postoperatively, shoulder spica cast was applied for 15.3weeks(8-20weeks). The median time to bony union was 17.7weeks(9~28weeks). Average range of motion was 32.0degrees(15~40degrees) of abduction, 24.0degrees(10~40degrees) of flexion, and 18.5degrees(10~30degrees)of internal rotation. CONCLUSION: The shoulder fusion in brachial plexus injury patients is one of the good methods to relieve pain, improve the function and stabilize the flail shoulder joint.

Soft Tissue Reconstruction of the Thumb with the First Dorsal Metacarpal Artery Island Flap

PURPOSE: The aim of this study was to report the efficacy of the first dorsal metacarpal artery island flap for soft tissue defect of the thumb. MATERIAL AND METHODS: We performed the first dorsal metacarpal artery island flap for soft tissue defect of the thumb in 14 cases since 1992 to 2008. There were dorsal defect in 9 cases, volar defect in 2 cases and lateral defect in 3 cases. The cases are limited by defect size under 2.5 cm in width. We checked a vessel diameter in the flap pedicle, a mobile pedicle length in operative field. Evaluation results was based on flap quality, donor site quality, two-point sensory discrimination, scar contractures, total active movement of the thumb and donor digit. RESULTS: The flap quality was well vascularized and survived in 12 cases (success rate : 86%). Diameter of vessels in flap was estimated within 0.5 mm by operational findings. Dorsal vein was irregular and complicated. Average of the pedicle length was 3.2 cm. Sensory function were preserved in all cases after long term follow up, but the cases we could measure two-point discrimination were 9 cases and average was 5.3 mm. Donor sites were dermatized using skin graft and 2 cases were complained limitation of motion at joints of index finger. CONCLUSION: The failure rate of flap were about 14%. We considered that it need to prepare under operational microscopy because vessels distributed into flap are small and complex. Problems of donor site are not negligible. However it was regarded as a useful island flap which could preserve sensory function in case of soft tissue defect of thumb when it applied to appropriate cases and operated by skilled procedure.

One-stage Reverse Lateral Supramalleolar Adipofascial flap for Soft Tissue Reconstruction of the Foot and Ankle Joint

PURPOSE: To report the clinical results and efficacies of one stage reverse lateral supramalleolar adipofascial flap for soft tissue reconstruction of the foot and ankle joint. MATERIAL AND METHODS: We performed 5 cases of one stage reverse lateral supramalleolar adipofascial flap from Jan 2005 to Sept 2005. All patients were males and mean age was 50(36~59) years old. The causes of soft tissue defects were 1 diabetic foot, 2 crushing injuries of the foot, 1 open fracture of the calcaneus, and 1 chronic osteomyelitis of the medial cuneiform bone. Average size of the flap was 3.6(3~4)x4.6(4~6) cm. All flaps were harvested as adipofascial flap and were performed with the split-thickness skin grafts (STSG) above the flaps simultaneously. RESULTS: All flap survived completely and good taking of STSG on the flap was achieved in all cases. There were no venous congestion and marginal necrosis of the flap. In diabetic foot case, wound was healed at 4 weeks after surgery due to wound infection. There was no contracture on the grafted sites. Ankle and toe motion were not restricted at last follow up. All patients did not have difficulty in wearing shoes. CONCLUSION: The reverse lateral supramalleolar adipofascial flap and STSG offers a valuable option for repair of exposure of the tendon and bone around the ankle and foot. Also one stage procedure with STSG can give more advantages than second stage with FTSG, such as good and fast take-up, early ambulation and physical therapy, and good functional result.

Total Elbow Arthroplasty after Failed Surgical Treatment for Elbow Fracture or Dislocation

PURPOSE: The current study reports the clinical results of total elbow arthroplasties (TEA) which were Performed on patients with poor clinical and radiological results after initial surgeries for elbow fractures or dislocations. MATERIALS AND METHODS: The clinical outcomes of twelve consecutive patients who underwent TEA after failed surgeries for elbow fractures or dislocations from january, 1995 to December, 2005 were evaluated. The initial diagnoses were distal humeral fractures in 8 cases and fracture-dislocations in 4 cases. The Mean period from the initial operations to the TEAs was 12 months. The mean folloow up period after TEA was 43 months. RESULTS: The mean range of motion, in terms of active extension, activeflexion, supination, and pronation, improved from 14.2degrees, 96.7degrees, 50.8degrees and 53.3degrees to 5.4degrees, 122.1degrees, 63.3degrees and 67.5degrees, respectively (p<0.05).RAdiolucent lines were found in 3 cases, which were 1 case of type 3, and 2 cases of type 4. All three loosening cases underwent revision TEAs. The mean postoperative Mayo elvow performance score was 79 point. There were 6 cases of excellent, 2 cases of good, and 4 cases in poor. CONCLUSION: Good clinical results were obtained after TEA performed in failed surgeries for elbow fractures of dislocations.

Clinical Features and Adequate Indication of CRRT in Severely Burned Patients

PURPOSE: Acute renal failure is not a rare event in severe burns and the prognosis of a burn patient becomes remarkably unfavorable with the onset of renal insufficiency. Several studies have reported that the incidence of ARF in severe burns is 0.5 ~ 30% and the mortality rate is 73 ~ 90%. This study analyzed the clinical features of severe burns requiring continuous renal replacement therapy (CRRT) to determine the adequate indication for CRRT. METHODS: Thirty-nine patients requiring CRRT out of 492 burned patients who were admitted to the burn intensive care unit in the Burn center, Hangang Sacred Heart Hospital from January 2003 to December 2004, were reviewed. CRRT was indicated when azotemia, fluid overload, acidosis, or hyperkalemia were observed. The APACHE II score, BUN, creatinine, creatine kinase, bicarbonate and base excess were analyzed at admission and at the initiation of CRRT for the survival group and non-survival group. RESULTS: The incidence of ARF requiring CRRT in severely burned patients was 7.9%. The average of burn area was 51.1%. The mean delay in initiating CRRT was 16.6 days and the mean duration of CRRT was 7.0 days. There was no difference between the survival group and the non- survival group in the data obtained upon admission, but there was a significant difference in the BUN level at the initiation CRRT. Therefore, the BUN level at the initiation CRRT has corelation with the mortality. CONCLUSION: CRRT is helpful for treating severely burned patients who have ARF, particularly those with accompanying with hemodynamic instability. This study showed that the BUN level at the initiation of CRRT associated with mortality. Therefore, the BUN level is an important criterion for initiating CRRT in these patients. However, a prospective randomized control study will be needed to accurately define BUN level.

Clinical Practice Using Allograft Skin in the Treatment of Massive Burns

PURPOSE: The most common cause of death in massive burn patients is burn wound sepsis. Therefore we have been using allograft skin for preventing burn wound sepsis. METHODS: Included in this study were 71 subjects who had sustained extensive burns from December 2003 through February 2006. 1. Early selective Escharectomy was performed for full thickness burn areas. 2. Allograft skins were grafted on excision area. 3. An autograft was performed for areas with a formation of granulation tissue after the allograft skin had come away. 4. A modified sandwich grafting technique (1 : 4 ~ 6 meshed autograft with Cultured Epithelial Autografts) was performed in large sized burns. 5. Acellular dermal substitute was concurrently used to prevent burn scar contraction on joint areas. RESULTS: Seventy one subjects were included (Fresh allograft: 9 cases, Cryo-preserved allograft: 42 cases, Glycerol preserved allograft: 20 cases). The average burn area was 41.8 (20 ~ 92) %TBSA (Total Body Surface Area). The mean area of the allograft skin used was 26.9 (8 ~ 70) %TBSA. The grafted allograft skins usually came away 3 weeks later. Four cases of initial take failure were occurred. All of these cases were pediatric patients using cadaver skin. Nine patients were dead from heart failure, severe inhalation, respiratory failure, pneumonia in old age, renal failure etc. There was no definite wound sepsis. Cultured Epithelial Autografts (CEAs) were used in fourteen cases. In twenty- five cases, acellular dermal substitute was simultaneously used. CONCLUSION: Early selective escharectomy, allograft skin coverage, acellular dermal substitutes and wide meshed autograft with CEA application would be immensely helpful techniques in patients with extensive burns.

Comparison of left ventricular hypertrophy between hypertensives and chronic renal disease patients: Echocardiographic Study / 대한내과학회지

OBJECTIVES: Left ventricular hypertrophy (LVH) is one of the most common echocardiographic findings and an important prognostic factor for cardiovascular mortality in hypertensives and chronic renal failure patients. To evaluate the prevalence and the types of LVH, and left ventricular systolic and diastolic functions as worsening of renal function, and to elucidate the risk factors for LVH, we performed this study retrospectively in normal populations, hypertensives, and renal failure with or without hemodialysis. METHODS AND SUBJECTS: We recruited the study population among the patients who had taken echocardiography at Pun-Dang CHA Hospital from July, 1995 to June, 1997. They are consisted of 54 patients for normal control, 53 patients of hypertensives, 31 patients of mild renal failure with less than 4.5 mg/dl of serum creatinine (Group I), 29 patients of moderate renal failure with more than 4.5 mg/dl of serum creatinine (Group II), and 47 patients of end stage renal disease with hemodialysis (Group III). The echocardiography was performed with all standard strategies including 2 dimension, M mode, and Doppler signals. RESULTS: 1) Among the baseline characteristics, the body mass index only significantly increased in hypertensives compared with group II and III.2) The prevalences of LVH in each groups were 5.6% in control group, 49.1% in hypertensives, 83.8% in group I, 89.7% in group II, and 100% in group III respectively. And the pevalences of concentric LVH were 5.6%, 43.3%, 41.9%, 34.5%, and 25.5% and those of the eccentric hypertrophy were 0.0%, 5.7%, 41.9%, 55.2%, and 74.5% respectively. The prevalence of eccentric hypertrophy increased according to deterioration of renal function.3) The left ventricular mass index was significantly higher in hypertensives, Group I, Group II, and Group III than normal control and the left ventricular volume index was greater in all renal failure patients compared with controls and hypertensives.4) In pre-hemodialysis renal failure patients, the types of LVH were consisted of 8 of normal heart (Group A), 23 of concentric LVH (Group B), and 29 of eccentric LVH (Group C). The systolic blood pressure and mean arterial pressure were significantly higher in group C than group A but there was no significant difference between group C and B. The RBC volume was significantly decreased in group B and C compared with group A. The echocardiographic end diastolic interventricular septal thickness and posterior wall thickness were significantly thicker in group B than others but end diastolic LV dimension, LV mass index, and LV volume index were significantly increased in group C than group B and A. The LV ejection fraction and fractional shortening as markers of LV systolic function in group C revealed the lowest level among three groups. The E velocity among the Doppler study profiles was significantly higher in group C than others.5) In hemodialysis group, all the patients had any types of LV hypertrophic changes. The concentric LVH group (group B) had significantly higher systolic blood pressure and mean arterial pressure than eccentric LVH (group C) but there was no difference in diastolic blood pressure between two groups. The echocardiographic interventricular septum and posterior wall were thicker in group B than group C but end diastolic LV dimension and LV volume were significantly higher in group C than group B.6) The LV mass index in pre-hemodialysis group had positive relationship with blood pressure and serum urea nitrogen level and the LV volume index was positively correlated with systolic blood pressure and mean blood pressure.7) The LV mass index in hemodialysis group had positive relationship with age and systolic blood pressure and LV volume index was positively correlated with serum urea nitrogen level but negatively correlated with blood pressure. CONCLUSION: The prevalence of LVH was much higher in renal failure group than hypertenssives and the proportion of eccentric LVH was increased with worsening of renal function. Although the arterial hypertension is the most important risk factor for LVH, this finding suggested existence of other contributing risk factors for LVH in chronic renal failure, which included uremia, anemia, and age.

Bone Mineral Density and Markers of Bone Turnover in Patients with End-Stage Renal Failure on Starting Hemodialysis / 대한신장학회잡지

Renal osteodystrophy is well recognized complication of end stage renal disease(ESRD) and is associated with a marked morbidity. To evaluate bone loss in renal osteodystrophy, we measured bone mineral density(BMD) in distal radius by quantitative computed tomography in 43 ESRD patients on starting hemodialysis(HD) and in 84 healthy controls matched for age and sex. We also measured intact parathyroid hormone(iPTH), serum total alkaline phosphatase(T-ALP), osteocalcin(OC) and urine deoxypyridinoline(U-DPD) as bone turn-over markers. 1) The mean age of ESRD patients and control groups were 49.8 and 49.7 years. M:F ratio were 1:1.1 and 1:1.3 on each groups. There was no significant differences on each groups. 2) Serum T-ALP and OC were 263.9+/-264.5U/L, 43.5+/-27.6ng/mL in ESRD patients and 167.4+/-46.6U/ L, 8.8+/-3.9ng/mL in control groups. These were significantly higher in ESRD patients(P<0.001, P< 0.001), while U-DPD were not significant difference on each groups(5.3+/-4.1 vs 5.4+/-1.9nM/mM. Cr.). 3) Serum iPTH and aluminum were 296.8+/-263.4pg/mL, 10.1+/-11.6ng/mL in ESRD patients. 4) Total density, trabecular density and cortical density were 340.4+/-83.6, 172.9+/-48.4, 477.2+/-123.5mg/ cm3 in ESRD patients and 393.2+/-49.1, 210.6+/-32.9, 541.3+/-76.2mg/cm3 in control groups. BMD was statistically significantly reduced in ESRD patients (P<0.001, P<0.001, P<0.001, respectively). Z score of total density and trabecular density were -0.62+/-1.12, -0.91+/-0.95 in ESRD patients and 0.19+/-0.68, 0.06+/-0.59 in control groups. It was significantly reduced in ESRD patients(P<0.001, P<0.001, P<0.001, respectively). 5) In ESRD patients, serum T-ALP, iPTH, OC, U-DPD were not correlated with BMD and Z score. But in control groups, serum OC was correlated inversly with BMD, and U-DPD was only correlated inversely with trabecular density. 6) In ESRD patients(n=22) who were having iPTH above 300pg/mL, serum OC and U-DPD were significantly higher than in ESRD patients(n=21) who were having iPTH below 300pg/mL(52.6+/-28.8ng/ mL, 6.8+/-5.1nM/mM.Cr. vs. 33.9+/-23.3ng/mL, 3.7+/-1.9 nM/mM.Cr. P<0.05, P<0.05 repectively). But serum aluminum, and T-ALP were not significant difference on each groups. BMD and Z score were also not difference on each groups. 7) In ESRD patients who were having iPTH above 300pg/mL, iPTH and serum OC were inversely correlated with BMD but U-DPD were only inversely correlated with trabecular density. In ESRD patients who were having iPTH below 300pg/mL, bone turn-over markers were not correlated with BMD. In ESRD patients on starting HD, BMD were significantly reduced, but serum T-ALP, OC, iPTH and U-DPD were not correlated with BMD. In ESRD patients who were having iPTH above 300 pg/mL, BMD were significantly inversely correlated with serum OC, iPTH.

Rahnella Aquatilis Bacteremia in a Hemodialysis Patient / 대한신장학회잡지

Rahnella aquatilis, an infrequently isolated gram-negative rod, is the only species of the genus Rahnella within the Enterobacteriaceae family. The organism's natural habitat is water, from which most isolates have been recoverd. Infecions in humans have only occasionally been reported, especially in immunocompromised patients. We reort a case of bacteremia caused by this organism in a hemodialysis patient.