Comparison of the Size of the Posterior Malleolar Fragment in Trimalleolar Ankle Fractures Measured Using Lateral Plain Radiography and Three-Dimensional Computed Tomography

Purpose@#This study aimed to evaluate and compare the accuracy of the size of the posterior malleolar fragment measured using lateral plain radiography and three-dimensional computed tomography (3DCT) in patients with ankle trimalleolar fractures. @*Materials and Methods@#This study enrolled 80 patients (80 ankles) with ankle trimalleolar fractures and analyzed the size of the posterior malleolar fragments using plain radiography and 3D-CT. The articular involvement of the posterior malleolar fragments was measured as a percentage of the articular surface in the sagittal length of the tibial plafond using lateral plain radiography, and the articular surface area was directly measured using 3D-CT. In addition, we classified the patients into three groups based on the morphology of the posterior malleolar fracture, according to the Haraguchi classification method, and evaluated and compared the accuracy of the size of the posterior malleolar fragments. @*Results@#The mean articular involvement of the posterior malleolar fragments on plain radiography was 27.6% (range, 6.0%-53.1%), which was significantly higher than the mean of 21.9% (range, 4.7%-47.1%) measured using 3D-CT (p=0.004). In the analysis, according to the fracture morphology, the mean difference between the two methods was the largest for type I fractures at 9.1% (range, 1.8%-19.5%) and the smallest for type II fractures at 1.1% (range, –7.7% to 8.8%). @*Conclusion@#The articular involvement of posterior malleolar fragments measured using plain radiography showed low accuracy and significantly higher values than the actual articular involvement. Therefore, careful evaluation using 3D-CT is crucial for accurate analysis and optimal treatment in patients with ankle trimalleolar fractures.

Wedge-Shaped Resection for Massive Xanthomatosis of Achilles Tendon / 대한정형외과학회잡지

Purpose@#Xanthomatosis of the Achilles tendons is rare. In some patients, however, the lesions in the Achilles tendon need to be removed, which may be painful and disfiguring. While studies of successful surgical outcomes for the total resection and reconstruction of the Achilles tendon have been reported, reconstruction surgery has a technical challenge, and extended surgical exposures are required. This study analyzed five cases of bilateral xanthoma of the Achilles tendon, which was treated surgically using a wedge-shaped tendon-sparing approach to eliminate the need for tendon reconstruction. @*Materials and Methods@#From July 2010 to May 2018, five patients with xanthomatosis in both Achilles tendons underwent wedgeshaped tendon preserving surgery. The average age was 49 years (range, 40–55 years), and the follow-up period was 21.4 months (range, 12–31 months). The patients consisted of three males and two females. Complications related to surgery were recorded. The outcome measures included the range of motion of the ankle joint, American Orthopaedic Foot and ankle Society (AOFAS) ankle/hindfoot score, and visual analogue scale (VAS) for overall satisfaction at the last follow-up. The availability of a single-limb heel raise and returning time to work were also measured. @*Results@#Wound dehiscence that did not require secondary surgery was noted in one patient. At the last follow-up, the range of motion of the ankle joint was normal in all patients. The mean AOFAS ankle/hindfoot score was 91 (range, 85–96) and the VAS for the overall satisfaction ranged from 8 to 10. The average time between surgery and return to work was 27.6 days (range, 17–58 days) and all patients could perform a single-limb heel raise test. @*Conclusion@#The tendon-sparing technique, which can preserve the anatomical functioning of the Achilles tendon, could be an excellent surgical approach because it has very promising functional and cosmetic surgical outcomes in patients with Achilles tendon xanthomatosis.

Non-surgical treatment of hemorrhagic shock caused by rupture of iatrogenic pseudoaneurysm / 영남의대학술지

Iatrogenic femoral artery pseudoaneurysm is a complication in patients undergoing catheterization. The risk increased when large-bore sheaths, concomitant anticoagulation therapy, and antiplatelet therapy are used during the intervention. Ultrasound-guided thrombin injection has become the treatment of choice. Rapid expansion, rupture, infection, and mass effect resulting in distal or cutaneous ischaemia or peripheral neuropathy, as well as failure of other treatment options are all indications for surgery. We report a 48-year-old man who developed hemorrhagic shock due to femoral pseudoaneurysm rupture after coronary angiography, and successfully treated by ultrasound-guided thrombin injection.

Exercise-Induced Intrapulmonary Arteriovenous Shunt in a Patient Complaining of Dyspnea during Strenuous Exercise

A 51-year-old highly fit man presented for dyspnea with strenuous aerobic exercise. The patient was asymptomatic and all tests were normal at rest. With increasing exercise intensity, he suddenly complained of dyspnea and showed a severe exercise-induced hypoxemia with an excessive alveolar-arterial oxygen tension difference. In agitated saline contrast echocardiography at peak exercise, a large amount of left to right shunt was identified after > 5 cardiac cycles, which suggests the presence of exercise-induced intrapulmonary arteriovenous shunt in this patient.

A Case of Vertebral Osteomyelitis and Spinal Epidural Abscess Caused by Haemophilus aphrophilus / 대한내과학회지

Haemophilus aphrophilus is an aerobic, gram-negative oropharyngeal bacterium, commonly isolated from cases of HACEK endocarditis. In addition, H. aphrophilus has also been shown to cause invasive bone and joint infections. Although multiple cases of H. aphrophilus endocarditis have been described, no cases of invasive bone and joint infections caused by H. aphrophilus have been reported in Korea. Here we report the case of a 69-year old woman with a diagnosis of vertebral osteomyelitis and spinal epidural abscess with compressive myelopathy caused by H. aphrophilus, in which there was no objective evidence of infective endocarditis. She was successfully treated with intravenous administration of cefotaxime and drainage of the epidural abscess by laminectomy of the T3-7 vertebrae.

Comparison Korean National Health Insurance Reimbursement and Other Guidelines for TNF-alpha Blocker in Rheumatoid Arthritis

OBJECTIVE: The aim of this study was to examine how many Korean rheumatoid arthritis (RA) patients fulfilling the 2008 American College of Rheumatology (ACR) recommendation, 2007 British Society for Rheumatology (BSR) guideline and 2010 Japan College of Rheumatology (JCR) guideline for TNF-alpha blocker, meet the Korean National Health Insurance reimbursement criteria and to evaluate the reasons for failing the Korean National Health Insurance reimbursement criteria. METHODS: Data were obtained from a registry of RA patients who visited rheumatology clinics of Hallym university affiliated hospitals. Patients who were previously prescribed with methotrexate or leflunomide for more than 3 months and had at least one DAS28 examination were included in the present study. RESULTS: Of 642 patients included, 118 episodes meeting ACR guideline for using TNF-alpha blocker were identified in 88 patients (13.7%). In addition, 19 episodes meeting BSR guideline in 17 patients (2.6%) and 21 episodes meeting JCR guideline in 21 patients (6.2%) were identified. Four episodes (4.8%) meeting ACR recommendation, 0 episodes meeting BSR criteria and 5 episodes (12%) meeting JCR criteria, respectively, were eligible for TNF-alpha blocker according to the Korean National Health Insurance reimbursement guideline. The most common reason for failing the Korean National Health Insurance reimbursement criteria was the number of active joint counts (92.6%). CONCLUSION: Our results show that the majority of RA patients satisfying the ACR guideline, BSR and JCR guideline for use of the TNF-alpha blocker did not meet the Korean National Health Insurance reimbursement criteria. Patients most often failed due to active joint count criteria.

Non-invasive Monitoring of Oxygen and Carbon Dioxide Tension: Accuracy of Transcutaneous O2 and CO2 and Endtidal CO2

PURPOSE: To determine the concordance of transcutaneous CO2 (PtcCO2) versus arterial CO2 (PaCO2), end-tidal CO2 (PetCO2) versus PaCO2, and transcutaneous O2 (PtcO2) versus arterial O2 (PaCO2) among healthy adult volunteers, and to determine the normal values of the PtcCO2/PtcO2 and PtcO2/PaO2 that will be used as early signs of shock or as prognostic factors for critically ill patients. METHODS: We measured the PtcO2, PtcCO2, PetCO2, PaO2, and PaCO2 from 11 healthy volunteers while breathing room air or O2 at a flow rate of 6 L/min via nasal cannula. The PtcO2 and PtcCO2 were measured using a Radiometer's transcutaneous sensor that interfaced with the Solar 8000 patient monitor system. The PetCO2 was measured using a side stream capnometer that sampled air from a nasal catheter. The PaO2 and PaCO2 were measured from arterial blood samples. The concordances of the PtcCO2 versus the PaCO2, the PtcO2 versus the PaO2, and the PetCO2 versus the PaCO2 were analyzed using a Bland-Altman plot. We defined the normal values of the P(a-tc)CO2, PtcO2/PaO2, and PtcCO2/PtcO2. RESULTS: Twenty-two pairs of the PtcCO2 versus PaCO2, PtcO2 versus PaO2, and PetCO2 versus PaCO2 were obtained. The mean (+/-SD) values of the P(a-tc)CO2, P(atc) O2, and P(a-et)CO2 were 0(+/-2.2) mmHg, 35.4(+/-24.1) mmHg, and 1.4(+/-1.3) mmHg, respectively (p=0.947, p<0.001, and p<0.001 by paired t-test, respectively). The P(a-tc)CO2 and P(a-et)CO2 showed a high concordance of 95.5% within a range of +/-4 mmHg. The median (25~75%) values of the PtcCO2/PtcO2 and PtcO2/PaO2 at room air were 54.8%(46.8%~62.7%), respectively. CONCLUSION: The PtcCO2 and PetCO2 had a reliable concordance with the PaCO2. However, the PtcO2 was discordant with the PaO2 and this discordance was increased when inspiring O2. Therefore, the absolute values of the PtcO2 cannot be used as a surrogate measurement of the PaO2. However, because the O2 supply did not increase the PtcCO2, but rather the PtcO2, we can use the trend in the change in the PtcCO2/PtcO2 or PtcO2/PaO2 in shock patients.