Cystic Disease of the Groin Presenting as Compression of a Femoral Vessel

In this study, we describe our diagnosis and treatment of two patients who presented with femoral vessel compression caused by a cystic lesion in the groin. One case was diagnosed as adventitial cystic disease (ACD) of the common femoral artery resulting in leg claudication and the other was diagnosed as a ganglion cyst (GC) causing femoral vein compression and unilateral leg swelling. The operative findings differed between these two cases with respect to the dissection of the cyst and femoral vessel, but the postoperative histological examination results were similar. The pathogenesis of ACD and GC is not fully understood, and further investigation is needed to delineate the exact pathology of these uncommon conditions.

Osteoclasts: Crucial in Rheumatoid Arthritis

Osteoclasts are a major component of bone metabolism in physiologic condition and in rheumatoid arthritis (RA). RA is a chronic, autoimmune, inflammatory disease primarily affecting the joints. Joint inflammation leads to cartilage and bone destruction by osteoclast activation. This osteoclast activation leads to typical RA symptoms and is the therapeutic target. Several kinds of drugs are used for preventing bone loss by osteoclasts in RA patients. However, the bone destructive action of osteoclasts is not the only mechanism in RA pathogenesis. Recent research suggests that the osteoclasts regulate hematopoietic stem cell niches and invoke immune responses in bone. Osteoclasts are derived from bone marrow hematopoietic stem cells, and maintain the hematopoietic stem cell niches contract with osteoblasts. Osteoclasts secret several cytokines to regulate inflammation and T cell differentiation, and present antigen to T cells via major histocompatibility complex class I and class II molecules. Osteoclast concepts in both origins and functions are under major reconsideration and research. In this review, we will discuss these new insights.

Quality of Life in Patients with Osteochondromatosis / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to help predict the prognosis of multiple osteochondromatosis patients with the investigation of social function, pain, physical function and quality of life of patients. MATERIALS AND METHODS: Forty-five cases were diagnosed as multiple osteochondromatosis from March 1993 to June 2014. We performed a survey on pain, daily life, school or work life assessment of research and development-36. Forty-five people who responded to the survey completely were enrolled. Variable factors, including physical functioning, role limitations due to physical health, role limitations due to emotional problems, energy/fatigue, emotional well-being, social functioning, pain, and general health state were considered as elements related to quality of life. In addition, we investigated significant factors for multiple osteochondromatosis patients, and analyzed the survey by scoring. Related factors included age (over 18 years and under 18 years), gender, body mass index, operation, joint deformity, recurrence of disease, family history, the number of involved joints and the location of tumor. Statistical analyses were performed using SAS ver. 9.3 (SAS Inc., Cary, NC, USA). p-values of <0.05 were deemed statistically significant. RESULTS: Patients with a family history of multiple osteochondromatosis showed a significantly decreased result of assessment, physical function, vitality of life, social activities, and health state. In addition, there was a tendency of a poor influence in pain, emotional wellbeing, and general health. CONCLUSION: The results suggest that family history is a significant factor influencing and predicting the quality of life. In other words, the developed patients in the household including patients with severe enough for the rest of the family to know have poor prognosis. Through this study multiple osteochondromatosis is a chronic disease having a profound impact on quality of life.

Comparison of Results between Hook Plate Fixation and Ligament Reconstruction for Acute Unstable Acromioclavicular Joint Dislocation

BACKGROUND: In the present study, we aimed to compare clinical and radiographic outcomes between hook plate fixation and coracoclavicular (CC) ligament reconstruction for the treatment of acute unstable acromioclavicular (AC) joint dislocation. METHODS: Forty-two patients who underwent surgery for an unstable acute dislocation of the AC joint were included. We divided them into two groups according to the treatment modality: internal fixation with a hook plate (group I, 24 cases) or CC ligament reconstruction (group II, 18 cases). We evaluated the clinical outcomes using a visual analog scale (VAS) for pain and Constant-Murley score, and assessed the radiographic outcomes based on the reduction and loss of CC distance on preoperative, postoperative, and final follow-up plain radiographs. RESULTS: The mean VAS scores at the final follow-up were 1.6 +/- 1.5 and 1.3 +/- 1.3 in groups I and II, respectively, which were not significantly different. The mean Constant-Murley scores were 90.2 +/- 9.9 and 89.2 +/- 3.5 in groups I and II, respectively, which were also not significantly different. The AC joints were well reduced in both groups, whereas CC distance improved from a mean of 215.7% +/- 50.9% preoperatively to 106.1% +/- 10.2% at the final follow-up in group I, and from 239.9% +/- 59.2% preoperatively to 133.6% +/- 36.7% at the final follow-up in group II. The improvement in group I was significantly superior to that in group II (p < 0.001). Furthermore, subluxation was not observed in any case in group I, but was noted in six cases (33%) in group II. Erosions of the acromion undersurface were observed in 9 cases in group I. CONCLUSIONS: In cases of acute unstable AC joint dislocation, hook plate fixation and CC ligament reconstruction yield comparable satisfactory clinical outcomes. However, radiographic outcomes based on the maintenance of reduction indicate that hook plate fixation is a better treatment option.

The Result of Bone Grafting for Fibrous Dysplasia / 대한골관절종양학회지

PURPOSE: Fibrous dysplasia is related to the mutation of gene encoding the alpha-subunit of a signal-transducing G-protein and has variable clinical course. Operation can be performed to prevent functional disorder or structural deformity. After curettage, autologous bone graft were used to fill the defects after curettage. The aim of this study is to compare the result of autogenous cancellous bone grafting and allogenic bone grafting for fibrous dysplasia. MATERIALS AND METHODS: Among the patients who visit our hospital during the period of April, 1997 to October, 2013, we selected 34 patients who diagnosed fibrous dysplasia and visited our clinic over 1 year. There were 13 males and 21 females. Average age was 26.4 (range 2 to 57) years old. Autogenous bone graft (group I) in 5 cases, Non-autogenous bone graft (group II) in 30 cases. Iliac bone is used in all cases of autogenous bone graft. There were no significant difference in age, follow-up period, preoperational laboratory finding between two groups. Radiographic image was done to evaluate the recurrence of fibrous dysplasia or secondary degeneration. RESULTS: There were four cases in recurrence (group I: 1 case, group II: 3 cases, p=0.554). In all recurrent cases, reoperations were done using curettage and autogenous iliac bone graft. There was no re-recurrence after reoperation. One case of secondary aneurysmal bone cyst was confirmed (group II) and 1 cases of pathologic fractures had developed (group I: 0 case, group II: 1 cases, p=0.559). No malignant change occurred. CONCLUSION: There were no significant difference between autogenous bone graft group and non-autogenous bone graft group. Our result suggested that autogenous bone graft seems to be good method to treat fibrous dysplasia, in the case of small volume of tumor lesion or non-weight bearing portion.

The Failure of Polyethylene Lock of MUTARS(R) Distal Femur Tumor Endoprostheses: A Case Report / 대한골관절종양학회지

The guidelines for the treatment of massive bone defects caused by bone resection due to tumors have changed from amputation to limb salvaging surgery. Limb salvaging surgery using endoprotheses is a well-established procedure. However, Aseptic loosening, infection, and mechanical defect remain significant problems. Among them, we experienced the case with a breakage of polyethylene lock of MUTARS(R) distal femur tumor Endoprostheses.

The effect of ketamine on the separation anxiety and emergence agitation in children undergoing brief ophthalmic surgery under desflurane general anesthesia / 대한마취과학회지

BACKGROUND: Emergence agitation (EA) frequently occurs after desflurane anesthesia in children. Ketamine, because of its sedative and analgesic properties, might be useful for the management of separation anxiety and EA. We investigated the preventive effect of ketamine on separation anxiety and EA after desflurane anesthesia in children for brief ophthalmic surgery. METHODS: Sixty children, ranging in age from 2-8 years old, undergoing brief ophthalmic surgery were randomly allocated to one of the 3 groups: group C received normal saline, group K1.0 received ketamine 1.0 mg/kg intravenously before entering the operating room, or group K0.5 received ketamine 0.5 mg/kg 10 min before the end of the surgery. Before induction, the separation anxiety score was evaluated. Extubation time, post-anesthesia care unit stay time, postoperative nausea and vomiting, emergence agitation, and pain were assessed. RESULTS: The group K1.0 had a lower separation anxiety score compared with groups K0.5 and C. Extubation time in group K0.5 was significantly prolonged compared with groups K1.0 and C. The incidence of EA and the modified Children's Hospital of Eastern Ontario Pain Scale were significantly lower in group K1.0 and group K0.5 compared to group C, but there was no significant difference between groups K1.0 and K0.5. CONCLUSIONS: In children undergoing brief ophthalmic surgery with desflurane anesthesia, ketamine 1.0 mg/kg administered before entering the operating room reduced separation anxiety, postoperative pain, and incidence of EA without delay in recovery.

What Do the Patients Want and Worry in Korean Patients Who Undergo Arthroscopic Rotator Cuff Surgery?

BACKGROUND: To specify what patients want and worry preoperatively is important in orthopedic practice. The aim of the current study was to analyze the patient characteristics of rotator cuff disease in Korean population who were willing to undergo arthroscopic surgery, and to evaluate the differences in expectations and concerns by age and gender. METHODS: We prospectively enrolled 303 patients who underwent rotator cuff surgery between April 2004 and August 2008. Three questionnaires were completed before surgery: the first one addressing preoperative patient's expectation, the second one focusing on concerns by covering 64 items using a visual analogue scale, and the third one evaluating patient's demographic characteristics. The characteristics of preoperative expectation, concern, and demographic data were evaluated according to gender and age group. RESULTS: Female patients had lower level of sports activity (p = 0.007) and lower levels of information (p = 0.028). Gender specific worries are about a caregiver during hospital stay, operating on the working side, fear about ugly scars, postoperative pain, applying makeup or combing hair. The older group responded that they can't be willing to change activities of daily living (p = 0.001), are not living with a spouse (p = 0.002), had previous shoulder operation history (p = 0.008), and had a lower level of information (p = 0.007). They especially worried about medical bills, worried about the physician being too young and inexperienced, postoperative pain, loss of arm function, and hospital food. CONCLUSIONS: Our data showed what Korean patients wanted and were concerned about prior to rotator cuff surgery. This can empower patients to formulate realistic expectations and make informed decisions. We feel that we can achieve higher levels of postoperative satisfaction by analyzing expectations and concerns in depth and addressing these proactively.

Effect of ketamine on intravenous patient-controlled analgesia using hydromorphone and ketorolac after the Nuss surgery in pediatric patients / 대한마취과학회지

BACKGROUND: Nuss surgery is preferred in pectus excavatum repair because this procedure produces excellent cosmetic results and prevents postoperative distressed pulmonary function. However, the procedure causes severe pain due to thoracic expansion. This study was designed to investigate the analgesic effect of small doses of ketamine on an intravenous patient-controlled analgesia (IV-PCA) using hydromorphone and ketorolac for pain control after Nuss surgery. METHODS: Forty-four patients undergoing elective Nuss surgery were randomly assigned to receive hydromorphone 3 microg/kg/hr, ketorolac 0.05 mg/kg/hr and ondansetron 0.1 mg/kg/day (Group HO, n = 22) or hydromorphone 3 microg/kg/hr, ketorolac 0.05 mg/kg/hr, ondansetron 0.1 mg/kg/day and ketamine 0.15 mg/kg/hr (Group HK, n = 22) via an IV-PCA pump after surgery. A blind observer evaluated each patient using the Modified Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) for the assessment of pain control. The total administered PCA volume, side effects and parents satisfaction with pain control were assessed at postoperative 1, 4, 8, 12, 24, and 48 hours. RESULTS: There were no significant differences in Modified CHEOPS between the groups during postoperative 48 hours. The total PCA volume in group HK was significantly lower than that in group HO (P < 0.05). The side effects in both groups did not significantly differ except for pruritus. The levels of satisfaction from the parents were not significantly different between the groups. CONCLUSIONS: A small dose of ketamine on IV-PCA reduced the total administered dose of IV-PCA with hydromorphone and ketorolac and reduced the incidence of pruritus after the Nuss procedure in pediatric patients.

An Atypical Subtrochanteric Femoral Fracture in a Patient with Multiple Myeloma Received Zoledronic Acid: A Case Report / 대한골관절종양학회지

Little literature exists about the risk of atypical femoral fracture in patients received zoledronic acid for prevention of skeletal metastasis. We report an atypical subtrochanteric femoral fracture in a patient with multiple myeloma received zoledronic acid. The patient was treated by closed reduction and internal fixation with cephalomedullary nailing.

Reliability of Triggered EMG for Prediction of Safety during Pedicle Screw Placement in Adolescent Idiopathic Scoliosis Surgery

STUDY DESIGN: We performed a prospective study to evaluate the reliability of using triggered electromyography (EMG) for predicting pedicle wall breakthrough during the placement of pedicle screw in adolescent idiopathic scoliosis surgery. PURPOSE: We wanted to correlate pedicle wall breakthrough with the triggered EMG threshold of stimulation and the postoperative computed tomography (CT) findings. OVERVIEW OF LITERATURE: Pedicle wall breakthrough has been reported to be difficult to evaluate by radiographs. Triggered EMG had been found to be a more sensitive test to detect this breakthrough. METHODS: Seven patients who underwent the insertion of 103 pedicle screws were evaluated. The triggered EMG activity was recorded from several muscles depending on the level of screw placement. The postoperative CT scans were read by a spine surgeon who was a senior fellow in orthopedics, and a musculoskeletal radiologist. RESULTS: The mean age at surgery was 12.6 years (range, 11 to 17 years). The preoperative mean Cobb angle was 54.7degrees (range, 45 to 65degrees). There were 80 thoracic screws and 23 lumbar screws. All the screws had stimulation thresholds of > or = 6 mA, except 3 screws with the stimulation threshold of or = 6 mA were safe, with 90.3% reliability, as was assessed on the postoperative CT scans.

Anaphylaxis with angioedema by rocuronium during induction of general anesthesia: A case report / 대한마취과학회지

Perioperative anaphylaxis is characterized by severe respiratory and cardiovascular manifestations. Correct management of anaphylaxis during anaesthesia requires a multidisciplinary approach with prompt recognition and treatment of the acute event by the attending anesthesiologist. A 34-year-old woman was scheduled to undergo endo venous laser therapy of varicose veins. She had no history of allergies and had never undergone general anesthesia. General anesthesia was induced with propofol and rocuronium bromide. Approximately three minutes after rocuronium administration, hypotension and tachycardia developed and angioedema around the eyelids and skin rashes and urticaria appeared. The patient received ephedrine and hydrocortisone with hydration. After achieving stable vital signs and symptom relief, surgery was performed without complications. A postoperative skin dermal test performed to identify the agent responsible revealed a positive skin test for rocuronium.

Staged Minimally Invasive Plate Osteosynthesis of Distal Tibial Fractures

PURPOSE: To assess the result of staged minimally invasive plate osteosynthesis (MIPO) for distal tibial fracture with an open wound or injured soft tissue. MATERIALS AND METHODS: In 20 patients (mean age, 47.8 year-old) with distal tibial fractures, there were 4 type A fractures and 16 type C fractures based on the AO classification system. Eight of the 20 patients had open fractures. MIPO was performed on average 23.9 days after bridging external fixation. At the final follow-up, we assessed the radiological results of bone union and alignment. Functional results were also evaluated by measuring the degrees of ankle motion and the American Orthopedic Foot & Ankle Society (AOFAS) scores. RESULTS: Seventeen of 20 cases (85%) achieved primary union at an average of 21.3 weeks. There were 3 cases of nonunion requiring a bone graft. The mean AOFAS score was 88.5 (range, 67~92) and the average range of ankle motion was 49.2degrees (plantarflexion: 37.4degrees, dorsiflexion: 11.8degrees). Complication included 2 cases of minor mal-alignment, 1 case of claw toe and 1 case of peroneal neuropathy. Patients over the age of 60 had lower functional results. Additional factors did not affect the final results. CONCLUSION: Staged MIPO may achieve satisfactory results in distal tibial fractures with soft tissue compromise, decreasing deep infections and soft tissue complications.

Management of Complex Regional Pain Syndrome Type 1 With Total Spinal Block

Complex regional pain syndrome (CRPS) is a painful and disabling disorder that can affect one or more extremities. Unfortunately, the knowledge concerning its natural history and mechanism is very limited and many current rationales in treatment of CRPS are mainly dependent on efficacy originated in other common conditions of neuropathic pain. Therefore, in this study, we present a case using a total spinal block (TSB) for the refractory pain management of a 16-year-old male CRPS patient, who suffered from constant stabbing and squeezing pain, with severe touch allodynia in the left upper extremity following an operation of chondroblastoma. After the TSB, the patient's continuous and spontaneous pain became mild and the allodynia disappeared and maintained decreased for 1 month.

Evaluation of Anterior Knee Pain

Anterior knee pain is an enigmatic entity with multiple causes, and so the patients, who present with diverse symptoms, require different treatments. A combination of variables, including abnormal lower limb biomechanics, soft-tissue tightness, muscle weakness and excessive exercise, may result in increased cartilage and subchondral bone stress, patellofemoral pain and subtle or more overt patellar maltracking. Because of the multiple forces affecting the patellofemoral joint, the clinical evaluation and treatment of this disorder is quite a challenge. Our extensive search of the literature revealed no single gold-standard test/maneuver to diagnose this disorder, and the reliability of the maneuvers described was generally low or untested. Making a specific and accurate diagnosis of the etiology, based on a thorough physical exam and imaging studies, is essential to create an effective therapeutic approach for the patient's successful return to proper knee function.