Diagnosis and treatment of patellofemoral joint instability

Patellofemoral instability, by definition, is a condition where the patella bone pathologically disarticulates out from the patellofemoral joint, either through subluxation or complete dislocation. The overall incidence of patellofemoral instability ranges between 5.8 and 29 per 100,000. Over time, patients with patellar instability can have debilitating pain, limitations in basic function, and long-term arthritis.Current Concepts: Risk factors for patellofemoral instability include trochlear dysplasia, patella alta, increased tibial tubercle-to-trochlear groove distance, abnormal patella lateral tilt, and coronal and torsional malalignment. The proper treatment is often debatable. Conservative treatment is suitable for acute dislocation but has a high failure rate for chronic instability, which usually necessitates surgical treatment. Today’s common surgical treatments focus on fixing anatomical defects, relieving symptoms of instability, and allowing patients to return to a suitable level of activity.Discussion and Conclusion: In this review, we summarize the relevant pathophysiology, categorization, clinical features, physical examination, imaging, and treatment options for patellofemoral instability.

Three-Dimensional Evaluation of Similarity of Right and Left Knee Joints

PURPOSE: The purpose of this study was to evaluate the anatomical similarity of three-dimensional (3D) morphometric parameters between right and left knees. MATERIALS AND METHODS: Ten fresh-frozen paired cadaveric knees were tested. Following dissection, footprint areas of the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) were measured. Surface scanning was performed using a 3D scanner. Scanned data were reproduced and morphometric parameters were measured on specialized software. After making mirror models, we compared footprint center positions of the ACL and PCL of both sides and calculated the average deviation of 3D alignment between the right- and left-side models. RESULTS: No significant side-to-side differences were found in any morphometric parameters. Bony shapes displayed a side-to-side difference of < 1 mm. Distal femoral and proximal tibial volumes did not present side-to-side differences, either; the average 3D deviations of alignment between the right and left sides were 0.8±0.4/1.1±0.6 mm (distal femur/proximal tibia). Center-to-center distances between the right and left ACL footprints were 2.6/2.7 mm (femur/tibia) for the anteromedial bundle and 2.4/2.8 mm for the posterolateral bundle. They were 1.9/1.5 mm for the anterolateral bundle and 2.2/1.8 mm for the posteromedial bundle of the PCL. CONCLUSIONS: There was a remarkable 3D morphometric similarity between right and left knees. Our results might support the concept of obtaining morphologic reference data from the uninvolved contralateral knee.

Endoscopic Nasobiliary Drainage for Bile Leak Caused by Injury to the Ducts of Luschka / 대한소화기학회지

A 51-year-old man underwent laparoscopic cholecystectomy for gallbladder stones. He had developed fever, chills, and abdominal pain four days after the procedure. In the drain tube, bile was persistently observed. An endoscopic retrograde cholangiopancreatography (ERCP) showed a leakage from the small duct into the right intrahepatic duct. We determined that the bile leak was caused by an injury to the ducts of Luschka. An endoscopic sphincterotomy (ES) using a 5-F nasobiliary tube (NBT) was performed, and the leak was resolved in five days. Herein, we report a bile leak caused by an injury to the ducts of Luschka after laparoscopic cholecystectomy. The leak was treated with ES using 5-F NBT, and the resolution of the leak was confirmed without repeated endoscopy.

Clinical impact of the early alanine amininotransferase flare during tenofovir monotherapy in treatment-naïve patients with chronic hepatitis B

BACKGROUND/AIMS: Little is known about the effect of early flares on response during first-line tenofovir disoproxil fumarate (TDF) treatment for chronic hepatitis B (CHB). The aim of this study was to investigate the incidence and outcome of early alanine aminotransferase (ALT) flare in treatment-naive patients with CHB during long-term TDF monotherapy. METHODS: One hundred eighty-one treatment-naive CHB patients were treated with a 300-mg once-daily dose of TDF for more than 12 weeks. Virological markers of hepatitis B virus (HBV) and biochemical data were measured at baseline and every 4-12 weeks during the therapy. The proportion of patients with undetectable HBV DNA level (5 × upper limit of the normal range) occurred in seven patients (3%) without viral breakthrough within the first 8 weeks after the start of TDF monotherapy. Among them, six patients were HBeAg-positive and one patient was HBeAg-negative. All cases of early ALT flares resolved within 4 weeks and virologic response was observed in all patients without interruption or discontinuation of treatment. CONCLUSIONS: Continuous TDF monotherapy was effective and safe in treatment-naive patients with CHB who experienced early ALT flares followed by a decrease in HBV DNA level.

Interposition of the Posterior Cruciate Ligament into the Medial Compartment of the Knee Joint on Coronal Magnetic Resonance Imaging

OBJECTIVE: The purpose of our study was to evaluate the overall prevalence and clinical significance of interposition of the posterior cruciate ligament (PCL) into the medial compartment of the knee joint in coronal magnetic resonance imaging (MRI). MATERIALS AND METHODS: We retrospectively reviewed 317 consecutive patients referred for knee MRI at our institution between October 2009 and December 2009. Interposition of the PCL into the medial compartment of the knee joint on proton coronal MRI was evaluated dichotomously (i.e., present or absent). We analyzed the interposition according to its prevalence as well as its relationship with right-left sidedness, gender, age, and disease categories (osteoarthritis, anterior cruciate ligament tear, and medial meniscus tear). RESULTS: Prevalence of interposition of PCL into the medial compartment of the knee joint was 47.0% (149/317). There was no right (50.0%, 83/166) to left (43.7%, 66/151) or male (50.3%, 87/173) to female (43.1%, 62/144) differences in the prevalence. There was no significant association between the prevalence and age, or the disease categories. CONCLUSION: Interposition of the PCL into the medial compartment of the knee joint is observed in almost half of patients on proton coronal MRI of the knee. Its presence is not associated with any particular factors including knee pathology and may be regarded as a normal MR finding.

Dynamic Three-Dimensional Analysis of Lachman Test for Anterior Cruciate Ligament Insufficiency: Analysis of Anteroposterior Motion of the Medial and Lateral Femoral Epicondyles

PURPOSE: To evaluate dynamic three-dimensional (3D) kinematic properties of the anterior cruciate ligament (ACL)-insufficient knees and healthy contralateral knees in awake patients during the Lachman test using biplane fluoroscopy. MATERIALS AND METHODS: Ten patients with unilateral ACL-insufficient knees and healthy contralateral knees were enrolled in this study. Each patient underwent the Lachman test three times in the awake state. The knee joint motions were captured using biplane fluoroscopy. After manual registration of 3D surface data from 3D-computed tomography to biplane images, dynamic 3D kinematic data were analyzed. RESULTS: The average anteroposterior (AP) translation of the medial femoral epicondyle of the ACL-insufficient knees (11.5+/-4.2 mm) was significantly greater than that of the contralateral knees (7.7+/-3.5 mm) (p<0.05). However, there was no statistically significant side-to-side difference in the average AP translation of the lateral femoral epicondyle. During the Lachman test, the distal femur was more externally rotated than the proximal tibia, which showed significant difference between both sides. CONCLUSIONS: During the Lachman test, the medial femoral epicondyle of the ACL-insufficient knee exhibited greater AP motion than that of the contralateral knee, whereas there was no significant side-to-side difference with regard to the AP motion of the lateral femoral epicondyle.

Bone Tunnel Diameter Measured with CT after Anterior Cruciate Ligament Reconstruction Using Double-Bundle Auto-Hamstring Tendons: Clinical Implications

OBJECTIVE: To evaluate the correlation between bone tunnel diameter after anterior cruciate ligament (ACL) reconstruction measured by computed tomography (CT) using multiplanar reconstruction (MPR) and stability or clinical scores. MATERIALS AND METHODS: Forty-seven patients (41 men and 6 women, mean age: 34 years) who had undergone ACL reconstruction with the double bundle technique using auto-hamstring graft and had subsequently received CT scans immediately after the surgery (T1: range, 1-4 days, mean, 2.5 days) and at a later time (T2: range, 297-644 days, mean, 410.4 days) were enrolled in this study. The diameter of each tunnel (two femoral and two tibial) at both T1 and T2 were independently measured using MPR technique by two radiologists. Stability and clinical scores were evaluated with a KT-2000 arthrometer, International Knee Documentation Committee objective scores, and the Lysholm score. Statistical analysis of the correlation between the diameter at T2 or the interval diameter change ratio ([T2 - T1] / T1) and clinical scores or stability was investigated. RESULTS: The tibial bone tunnels for the anteromedial bundles were significantly widened at T2 compared with T1 (observer 1, 0.578 mm to 0.698 mm, p value of 0.8) for both observers. Interobserver agreement for measurement was excellent (> 0.8) except for the most distal portion of the femoral bone tunnel for anterior medial bundle in immediate postoperative CT, which showed moderate agreement (concordance correlation coefficient = 0.6311). CONCLUSION: Neither the diameter nor its change ratio during interval follow-up is correlated with stability or clinical scores.

Primary Anorectal Malignant Melanoma Treated With Endoscopic Mucosal Resection

Anorectal melanoma is a rare neoplasm that accounts for less than 1-4% of anorectal malignant tumors. The main therapeutic modality for anorectal melanoma is surgical treatment, with abdominoperineal resection or wide local excision being the most common approaches. A 77-year-old male with a history of cerebral infarction and hypertension presented with anal bleeding. Here, we report a case of anorectal melanoma treated by endoscopic mucosal resection with adjuvant interferon therapy rather than surgical resection. The patient has been disease-free for 5 years after endoscopic treatment.

Volume and Contact Surface Area Analysis of Bony Tunnels in Single and Double Bundle Anterior Cruciate Ligament Reconstruction Using Autograft Tendons: In Vivo Three-Dimensional Imaging Analysis

BACKGROUND: Regarding reconstruction surgery of the anterior cruciate ligament (ACL), there is still a debate whether to perform a single bundle (SB) or double bundle (DB) reconstruction. The purpose of this study was to analyze and compare the volume and surface area of femoral and tibial tunnels during transtibial SB versus transportal DB ACL reconstruction. METHODS: A consecutive series of 26 patients who underwent trantibial SB ACL reconstruction and 27 patients with transportal DB ACL reconstruction using hamstring autograft from January 2010 to October 2010 were included in this study. Three-dimensional computed tomography (3D-CT) was taken within one week after operation. The CT bone images were segmented with use of Mimics software v14.0. The obtained digital images were then imported in the commercial package Geomagic Studio v10.0 and SketchUp Pro v8.0 for processing. The femoral and tibial tunnel lengths, diameters, volumes and surface areas were evaluated. A comparison between the two groups was performed using the independent-samples t-test. A p-value less than the significance value of 5% (p < 0.05) was considered statistically significant. RESULTS: Regarding femur tunnels, a significant difference was not found between the tunnel volume for SB technique (1,496.51 +/- 396.72 mm3) and the total tunnel volume for DB technique (1,593.81 +/- 469.42 mm3; p = 0.366). However, the total surface area for femoral tunnels was larger in DB technique (919.65 +/- 201.79 mm2) compared to SB technique (810.02 +/- 117.98 mm2; p = 0.004). For tibia tunnels, there was a significant difference between tunnel volume for the SB technique (2,070.43 +/- 565.07 mm3) and the total tunnel volume for the DB technique (2,681.93 +/- 668.09 mm3; p < or = 0.001). The tibial tunnel surface area for the SB technique (958.84 +/- 147.50 mm2) was smaller than the total tunnel surface area for the DB technique (1,493.31 +/- 220.79 mm2; p < or = 0.001). CONCLUSIONS: Although the total femoral tunnel volume was similar between two techniques, the total surface area was larger in the DB technique. For the tibia, both total tunnel volume and the surface area were larger in DB technique.

In Vivo Three-Dimensional Imaging Analysis of Femoral and Tibial Tunnel Locations in Single and Double Bundle Anterior Cruciate Ligament Reconstructions

BACKGROUND: Anatomic footprint restoration of anterior cruciate ligament (ACL) is recommended during reconstruction surgery. The purpose of this study was to compare and analyze the femoral and tibial tunnel positions of transtibial single bundle (SB) and transportal double bundle (DB) ACL reconstruction using three-dimensional computed tomography (3D-CT). METHODS: In this study, 26 patients who underwent transtibial SB ACL reconstruction and 27 patients with transportal DB ACL reconstruction using hamstring autograft. 3D-CTs were taken within 1 week after the operation. The obtained digital images were then imported into the commercial package Geomagic Studio v10.0. The femoral tunnel positions were evaluated using the quadrant method. The mean, standard deviation, standard error, minimum, maximum, and 95% confidence interval values were determined for each measurement. RESULTS: The femoral tunnel for the SB technique was located 35.07% +/- 5.33% in depth and 16.62% +/- 4.99% in height. The anteromedial (AM) and posterolateral (PL) tunnel of DB technique was located 30.48% +/- 5.02% in depth, 17.12% +/- 5.84% in height and 34.76% +/- 5.87% in depth, 45.55% +/- 6.88% in height, respectively. The tibial tunnel with the SB technique was located 45.43% +/- 4.81% from the anterior margin and 47.62% +/- 2.51% from the medial tibial articular margin. The AM and PL tunnel of the DB technique was located 33.76% +/- 7.83% from the anterior margin, 45.56% +/- 2.71% from the medial tibial articular margin and 53.19% +/- 3.74% from the anterior margin, 46.00% +/- 2.48% from the medial tibial articular margin, respectively. The tibial tunnel position with the transtibial SB technique was located between the AM and PL tunnel positions formed with the transportal DB technique. CONCLUSIONS: Using the 3D-CT measuring method, the location of the tibia tunnel was between the AM and PL footprints, but the center of the femoral tunnel was at more shallow position from the AM bundle footprint when ACL reconstruction was performed by the transtibial SB technique.

Pill-induced Intramural Hematoma of the Esophagus

Intramural hematoma of the esophagus is a rare cause of chest pain. Varying degrees of submucosal dissection and rupture of the esophagus can induce intramural hematoma of the esophagus. It is viewed as a complication of endoscopic sclerotherapy of esophageal varices, and is likely caused by an elevation in intraesophageal pressure due to factors such as blood coagulation abnormality, drugs, trauma or vomiting. We describe one case of pill-induced spontaneous intramural hematoma that was successfully managed by conservative treatment and discuss the case with a review of the literature.

Endoscopic Management for Colocutaneous Fistula as a Complication of Percutaneous Endoscopic Gastrostomy

Percutaneous endoscopic gastrostomy (PEG) has become a safe and effective technique for enteral feeding. Colocutaneous fistula, which is a rare complication of PEG, is thought to be formed during insertion of the original PEG tube when the colon becomes interposed between the stomach and the abdominal wall. We present a patient who developed colocutaneous fistula after PEG tube exchange. Three years ago, a PEG tube for enteral feeding was placed in a 27-year-old male with cerebral palsy and severe scoliosis. Two months after PEG tube exchange, he was admitted to our hospital because fecal material was observed in the tube and exit site. The diagnosis of colocutaneous fistula was made after injection of gastrografin in the fistula opening of the abdominal wall. Endoscopic management for the fistula opening of the colon was successfully performed using metal-clips and we were able to avoid surgical therapy for the fistula.

Hemorrhagic cholecystitis presenting as obstructive jaundice

No abstract available.

What Symptoms Are More Important for Korean Patients in Knee Osteoarthritis? Development and Validation of the Korean Knee Score

PURPOSE: The purpose of this study was to develop and validate a novel knee evaluation instrument, the Korean Knee Score (KKS), to reflect a floor life style with high knee flexion. In addition, we aimed to assess the importance of high knee flexion activity for Korean patients. MATERIALS AND METHODS: The KKS was developed following the guidelines of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine. During development step, generated items were asked to 50 patients to determine importance and obtain an impact score for each item. A total of 634 patients were included in the validation survey. RESULTS: Forty one items were generated and impact scores of each item about floor life style were higher than other items. The KKS exhibited excellent reliability (intraclass correlation coefficient=0.931) and strong internal consistency (Cronbach's alpha=0.973). The content validity was good, with no ceiling or floor effect. The construct, convergent, and divergent validities were good. Moderate responsiveness was evident, with a standardized response mean of 0.74. CONCLUSIONS: The KKS, has good validity, reliability, and responsiveness. The KKS includes items for floor life style, which are thought more important for Korean patients. The KKS can be used as a good evaluation questionnaire for Korean knee osteoarthritis patients.

Anatomical versus Non-Anatomical Single Bundle Anterior Cruciate Ligament Reconstruction: A Cadaveric Study of Comparison of Knee Stability

BACKGROUND: The purpose of this study was to compare the initial stability of anatomical and non-anatomical single bundle anterior cruciate ligament (ACL) reconstruction and to determine which would better restore intact knee kinematics. Our hypothesis was that the initial stability of anatomical single bundle ACL reconstruction would be superior to that of non-anatomical single bundle ACL reconstruction. METHODS: Anterior tibial translation (ATT) and internal rotation of the tibia were measured with a computer navigation system in seven pairs of fresh-frozen cadaveric knees under two testing conditions (manual maximum anterior force, and a manual maximum anterior force combined with an internal rotational force). Tests were performed at 0, 30, 60, and 90 degrees of flexion with the ACL intact, the ACL transected, and after reconstruction of one side of a pair with either anatomical or non-anatomical single bundle ACL reconstruction. RESULTS: Under manual maximal anterior force, both reconstruction techniques showed no significant difference of ATT when compared to ACL intact knee state at 30degrees of knee flexion (p > 0.05). Under the combined anterior and internal rotatory force, non-anatomical single-bundle ACL reconstruction showed significant difference of ATT compared to those in ACL intact group (p 0.05). Internal rotation of the tibia showed no significant difference in the ACL intact, the ACL transected, non-anatomical reconstructed and anatomical reconstructed knees. CONCLUSIONS: Anatomical single bundle ACL reconstruction restored the initial stability closer to the native ACL under combined anterior and internal rotational forces when compared to non-anatomical ACL single bundle reconstruction.

Orthopedic disease and sports medicine related to lower limbs

In this study, the cause, diagnosis, and treatment of common lower limb injuries during the sports activities were presented. Sports injuries of the lower limbs are the most common injuries in the sports medicine field due to the high level of use of the lower limbs during sports activities. The common causes of leg injuries in athletes are traumatic force over the critical limit of normal tissue, repetitive microtrauma, and overuse. Common hip and pelvis problems encountered by the authors include trochanteric bursitis, snapping hip syndrome, and labral tears. The anterior and posterior cruciate ligaments, medial and lateral collateral ligaments, and meniscus have been most frequently involved in sports injuries affecting the knees. Lateral ankle sprain represents one of common injuries in the athletic population. Common overuse injuries are tendinopathies, stress fractures, chronic exertional compartment syndrome, and shin splints. Athletic activity provides a variety of positive benefits to participants' health. To safely continue those activities, an injury prevention program focusing on injuries that may occur in specific sports activities is recommended for participants. Early diagnosis and proper treatment are also important in promoting prompt recovery and preventing secondary injuries.

Two Cases of Postintubation Tracheoesophageal Fistula in Patients with a History of Tracheostomy: Case Report / 대한구급학회지

Common causes of acquired tracheoesophageal (T-E) fistula are blunt trauma on the neck or chest, malignancy, long-term mechanical ventilation, and post-intubation injury. Most of the cases are fatal due to severe respiratory infection. We experienced two cases of post-intubation T-E fistula in patients with a history of tracheostomy that developed earlier than usual. One case was caused by excessive cuff pressure and the other by avulsion injury during endotracheal intubation. We can get instructions from these cases that how to prevent T-E fistula because it is hard to treat and causes severe outcomes.

Four cases of toxic liver injury associated with Dictamnus dasycarpus / 대한간학회지

We report four cases of toxic hepatitis that occurred after taking a decoction made by boiling down the root of Dictamnus dasycarpus. The four patients had a median age of 60 years, common symptoms of jaundice and general weakness, and stated that they had not consumed alcohol for at least 5 years. The markers of hepatitis A, B, and C were all negative in the patients. Abdominal ultrasonography revealed common bile ducts with normal diameters. Two of the cases were a mother and daughter, and the other two were sporadic. All of them had consumed a decoction made by boiling down the root of Dictamnus dasycarpus five or six times daily until several days before admission. Dictamnus dasycarpus induced liver injury presenting with a benign course lasting less than 1 month after cessation of the causative agent. We suggest that this natural product can cause acute hepatitis in rural areas.

Multiple Cavernous Hemangiomas of the Glans Penis, Penis, and Scrotum / 대한비뇨기과학회지

Although a hemangioma is usually found in childhood, a cavernous hemangioma of the genitalia is rarely found. Urologists often face difficulty when making the decision for surgery to treat a genital cavernous hemangioma. We report here on a case of a cavernous hemangioma that extended into the glans penis, penile shaft and scrotum. Immediately after surgical excision of the hemangiomas in the penile shaft and scrotum, the worm-like lesions subsided. The protruding lesions of the glans penis were naturally relieved after 12 months follow up.

Treatment of Intertrochanteric Fracture: Comparison of Proximal Femoral Nail and Proximal Femoral Nail A

PURPOSE: To evaluate the results of fracture fixation between using Proximal Femoral Nail and using Proximal Femoral Nail A and to analyze the effectiveness of proximal femoral nail A. MATERIALS AND METHODS: We reviewed 32 patients who suffered from intertrochanteric fracture in our hospital, which were 19 cases of PFN and 13 cases of PFNA. Retrospectively we evaluated mean operation time, amount of bleeding, beginning of ambulation, average union period, changes of neck shaft angle and complication on set of telephone interview and OPD. We also evaluated postoperative capability of function and mobility using 'Social function score' and 'Mobility score'. RESULTS: PFNA showed shorter mean operation time, less bleeding, shorter average union period, earlier ambulation and less change of neck shaft angle than PFN. Although they didn't show statistical difference, postoperative capability of function and mobility showed statistical and mathematical difference on each group. CONCLUSION: PFNA showed better results of postoperative function and mobility and less complications than PFN. So treatment using PFNA is better method than that of PFN.