A Case of Severe Aortic Stenosis Patient With High Operative Risk Treated by Transcatheter Aortic-Valve Implantation

Aortic stenosis is the most frequent type of valvular heart disease in adult. Approximately 2-7% of the population over the age of 65 suffer from aortic valve stenosis. Due to the increasing average life expectancy in Korea, degenerative aortic stenosis is increasing and becoming a troublesome health problem in older population. Because older patients with severe degenerative aortic stenosis have many other medical conditions so they are not suitable candidate for surgery. Recently, transcatheter aortic-valve implantation (TAVI) has been suggested as a less invasive treatment for patients with high perioperative risk. We report a successful TAVI case in severe aortic stenosis patient with high perioperative risk.

A Newly Developed Pericardial Tuberculoma During Antituberculous Therapy

Tuberculosis generally affects the respiratory tract. In developing nations, the pericardium is the most common location of extrapulmonary tuberculosis; however, tuberculous pericarditis rarely appears as a localized mass or tuberculoma. We present here a case of a 62-year-old woman with pericardial tuberculoma. She had a history of effusive tuberculous pericarditis and drainage. Because she had taken regular medication over a period of six months, the pericardial mass with an adjacent lung nodule newly detected on the chest radiogram was initially suspected of being invasive lung cancer. Prior to pathologic confirmation, precise information from imaging tests, including computed tomography, magnetic resonance imaging, and positron emission tomography-computed tomography are helpful when making decisions regarding which methods should be used for surgical approach and treatment. Through imaging, our case showed typical features of pericardial tuberculoma and a favorable clinical course after two months with a change in antituberculous therapy.

Deglutition Syncope Associated With Ventricular Asystole in a Patient With Permanent Atrial Fibrillation

Deglutition syncope is a situational syncope that is diagnosed only by a detailed history. We report deglutition syncope in a 62-year-old man, who had permanent atrial fibrillation. The patient had no structural or functional abnormalities of the esophagus. During syncopal attacks, his electrocardiography showed ventricular asystole that was sustained for 12 seconds. The patient was successfully treated by implantation of a permanent pacemaker.

Flash Pulmonary Edema in a Patient With Unilateral Renal Artery Stenosis and Bilateral Functioning Kidneys

Flash pulmonary edema typically exhibits sudden onset and resolves rapidly. It generally is associated with bilateral renal artery stenosis or unilateral stenosis in conjunction with a single functional kidney. We describe a patient who presented with flash pulmonary edema treated by percutaneous therapy with stent implantation. Our case is unique in that the flash pulmonary edema occurred in the setting of unilateral renal artery stenosis with bilateral functioning kidneys.

Intravascular Ultrasound-Guided Troubleshooting in a Large Hematoma Treated With Fenestration Using a Cutting Balloon

Intramural hematoma formation is not a well-studied complication of percutaneous coronary intervention. We describe a patient with stable angina who developed an intramural hematoma during elective percutaneous coronary intervention (PCI) in the right coronary artery (RCA). Total occlusion with dense dye staining developed a long way from the distal RCA, near the posterior descending artery bifurcation site. The true lumen was compressed by the enlarged, tense, false lumen. The patient was successfully treating with intravascular ultrasound-guided fenestration using a cutting balloon, and a stent was implanted in the distal RCA.

The Occurrence of a Branchial Cleft Cyst in the Anterior Mediastinum: A Case Report

Branchial cleft cysts and branchial anomalies develop from the branchial cleft apparatus that persists after fetal development. The most common anatomical site for the occurrence of branchial cleft cysts is in the cervical area, generally anterior to the sternomastoid muscle in the upper or middle portion of the neck. A mediastinal branchial cleft cyst is extremely rare and few cases have been reported. We report the case of branchial cleft cyst found in the anterior mediastinum with literature review.

Accuracy of Intramedullary versus Extramedullary Tibial Alignment Guides: A Randomized, Prospective Study in Bilateral Total Knee Arthroplasty

PURPOSE: To determine which one is more accurate tibial cutting system for total knee arthroplasty between intramedullary and extramedullary alignment guides in Korean osteoarthritis patient. MATERIALS AND METHODS: A prospective study of 80 consecutive total knee arthroplasties in 40 patients with bilateral osteoarthritis of knee was carried out. All patients were undertaken the total knee arthroplasty with intramedullary cutting system in randomly assigned side of the knee, and with extramedullary cutting system in the other side. A standing antero-posterior radiograph of whole lower extremity was performed at six months after operation, and tibia component angle(TCA) which represents the angle between the mechanical axis of tibia and transverse axis of the prosthetic knee joint was measured. The optimal values for TCA was defined as 90+/-4 degrees. RESULTS: The mean values for the TCA in all cases was 89.3+/-1.9 degrees(82~ 96 degrees) and 93% of all patients were included in the optimal range. The TCA fell into the optimal range in 36 cases of 40 cases(90%) with extramedullary cutting system, while 38 cases of 40 cases(95%) with intramedullary cutting system. These differences were not statistically significant. CONCLUSION: Both extramedullary and intramedullary alignment cutting systems are effective methods for Korean. In order to reduce the risk of malalignment, proper proximal tibia cutting method should be carefully selected according to the individual characteristics of the knee, and preoperative evaluation for alignment using radiograph is mandatory.

A case of acute myocardial infarction caused by a septic coronary embolism and treated with embolectomy / 대한내과학회지

An acute myocardial infarction caused by a septic coronary embolism is a known complication of infective endocarditis and usually carries a fatal prognosis. We experienced a case of a 27-year-old man with an acute myocardial infarction caused by a coronary embolism due to bacterial endocarditis. An echocardiogram demonstrated mitral valve regurgitation with highly mobile multiple vegetations. Because of the high risk of systemic embolization and congestive heart failure, the patient underwent emergency surgery. Mitral valve replacement and an embolectomy were performed successfully without any surgical complications.

Acromegaly improved with sandostatin LAR treatment / 대한내과학회지

Cardiovascular disease is the most frequent cause of death in patients with acromegaly. Recently, long-term treatment with a somatostatin analogue (Sandostatin LAR) has been shown to be effective in controlling growth hormone (GH) and insulin like growth factor-1 (IGF-1) hypersecretion in most patients with acromegaly. Along with the effectiveness in the hormone profile, Sandostatin LAR has been reported to be effective for tumor mass shrinkage and clinical symptom improvement. We have encountered a female acromeglic patient with severe dilated cardiomyopathy and the patient was treated with Sandostatin LAR After treatment for 12 months, as seen by follow up echocardiography, the overall cardiac function was significantly improved. We report the case with a review of the literature.

A Case of Smoking Induced Acute Eosinophilic Pneumonia / 결핵및호흡기질환

Acute eosinophilic pneumonia (AEP) has been described as an idiopathic febrile illness with a duration of less than seven days with severe hypoxemia, pulmonary infiltrates, and no history of asthma. It has been reported that AEP is associated with smoking. Although the pathogenesis of smoking induced AEP is being actively studied, there is no direct histological evidence that smoking actually induces AEP. Recently, we encountered a case of AEP that may have been caused by smoking. We performed a cigarette smoking challenge test to verify that smoking was indeed the cause of AEP in this patient. Smoking induced an increase the proportion of eosinophils in the bronchoalveolar lavage fluid without any respiratory symptoms or abnormal radiological findings. This result suggests that smoking was the cause of AEP in this patient.

The Comparision of the Midvastus and Paramedian Approaches for Total Knee Arthroplasty

PURPOSE: To present the results of mdivastus and paramedian approach for total knee replacement arthroplasty (TKA). MATERIALS AND METHODS: Thirty two patients having bilateral total knee replacement arthroplasty were randomized prospectively-one knee having a vastus muscle-splitting approach(MVS) and the other knee having a median parapatellar approach(MPP)- to compare the difference in lateral release, operation time, postoperative ROM and drain amount, HSS score, return to SLR and extension lag at 2 weeks in TKA. RESULTS: The MVS approach offered an early advantages compared with MPP approach, especially in terms of lateral release[22(68.7%)on MPP and 5 15.6%) on MVS (p=0.014)], ROM at postoperative 2 week (p=0.043) and early return to SLR (p=0.023). There were no significant differences in operation time, postoperative ROM and drain amount, HSS score and extension lag. CONCLUSION: The MVS approach has the potential to improves the rapid restoration of quadriceps mus-cle control and to lead to reduction in the need for lateral release in TKA.

The Effects of Transglutaminase on Perichondrocyte in Alginate Culture / 대한정형외과연구학회지

PURPOSE: To investigate the effects of transglutaminase in the environment of extracellular matrix on perichondrocyte in alginate culture. MATERIALS AND METHODS: Perichondrocyte cells were isolated from articular cartilage of New Zealand white rabbits by enzymatic digestion and maintained in monolayer culture. After 7 days, the cells were trypsinized and cultured in an alginate bead system. Four groups of the alginate beads were prepared as follow: containing 1 mg/ml of transglutaminase, 10 microgram/ml of fibronectin, mixture of 1mg/ml of TGase and 10 microgram/ml of fibronectin and only perichondrocytes as a control group. Cell proliferation was measure by [Methyl-3H] Thymidine uptake, and proteoglycan synthesis was measure by [35S] Sulfate uptake. The gene expression of integrin-alpha5, integrin-beta1 and type II collagen was analyzed by reverse transcription-polymerase chain reaction. Safranin-O staining was utilized for histological assessment of proteoglycan in extracellular matrix. One-way ANOVA was used to analyze the results statistically. RESULTS: Mixture of transglutaminase and fibronectin exhibited high synthesis rates of proteoglycan and active cell proliferation compared with other groups. The gene expression of type II collagen did not show significant difference between groups. The gene expression of integrin-alpha5 was down-regulated in all groups with time. The gene expression of integrin-beta1 was not down-regulated with time only in mixture of transglutaminase and fibronectin. Histological staining of the secretions by Safranin-O staining was in agreement with the data of proteoglycan synthesis, and Safranin-O staining showed that more cell-to-cell aggregates is developed in the mixture of transglutaminase and fibronectin. CONCLUSION: Mixture of transglutaminase and fibronectin can stimulate chondrocyte proliferation and proteoglycan synthesis, and integrin seems to modulate such interactions.

Treatment of Osteochondral Defects with Perichondrial Cells Embedded in Alginate Beads in Rabbit / 대한정형외과연구학회지

PURPOSE: The objective of this study was to investigate the use of cultured rib perichondrial cells embedded in alginate bead on healing in a rabbit osteochondral defect model. The degree of articular cartilage repair was evaluated histologically, histomorphometrically, and biochemical characteristics of the neocartilage. MATERIALS AND METHODS: A single defect, 3.5 mm wide by 3 mm deep, was created in the weight bearing area of the medial femoral chondyle in thirty New Zealand rabbits. The right defect filled with two alginate beads embedded with rabbit rib perichondrial cells, the left defect was empty as the control. The animals were killed at 1, 3, and 12 months, and the repair tissues were examined histologically, and histomorphometric differences were evaluated by an image analysis system. The defects also were examined biochemically for the glycosaminoglycan (GAG) and type II collagen to compare the results with normal articular cartilage. RESULTS: The attachment of repair tissue with the surrounding host tissue was incomplete, many specimens exhibited degenerative changes in adjacent tissue over a post transplant time period. Histomorphometric results showed that the repair groups (0.24+/-0.11 mm, -26.97 (25.62 mm) was decreased in surface roughness, and depression than controls (0.32+/-0.06 mm, -48.73 (32.59 mm) at 12 months. Repair area, repair area ratio, and repair thickness of the repair groups (6.89+/-2.1 mm2, 39.5+/-19.5%, 0.11 (0.01 mm) were increased than controls (2.65+/-2.35 mm2, 2.85+/-2%, 0.09+/-0.04 mm) at 12 months. After 12 months, the content of GAGs of neocartilage (36.45 microgram/mg) was similar to those of normal artilcular cartilage (36.74 microgram/mg), the percentage of type II collagen of the neocartilage increased up to 95%. CONCLUSION: Transplanted rib perichondrial cells were seen to proliferate to fill the osteochodral defect with neocartilage. Histomorphometric analysis should allow a more quantitative described the degree of articular cartilage repair.

Fixation Strength Analysis of Press-Fit Technique in Anterior Cruciate Ligament Reconstruction using Porcine Lower Limb / 대한정형외과연구학회지

PURPOSE: The objective of this study was to evaluate the initial fixation strength of press-fit technique compared with titanium and biodegradable interference screws in ACL reconstruction using bone-patellar tendon-bone grafts. MATERIALS AND METHODS: Fifty porcine lower limbs were used. The graft in the press-fit group was harvested with a hollow oscillating saw to obtain a consistent and complete circular shape and that in the interference screw group was obtained with a conventional oscillating saw. With preload of 20 N, the specimens underwent 250 loading cycles between 0-2 mm of displacement. Thereafter, the specimens were loaded to failure after restoration of the preload. RESULTS: During the cyclic loading, none of press-fit or interference screw fixations failed and there was no significant difference in maximum loads between the groups. In groups of press-fit fixation with diameter of bone plug being larger that that of the femoral tunnel by 1.4 mm, the ultimate failure load was comparable with that of the titanium or biodegradable interference screw groups. The complete circular shape and increased diameter of the bone plug seemed to contribute the strong initial fixation. CONCOUSION: Press-fit fixation technique provides a secure and consistent fixation strength comparable with the metal or biodegradable interference screws.

Operative Treatment in Acute Patellar Dislocation

PURPOSE: To analyze factors related with patellar dislocation and evaluate clinical results after early surgical treatment in acute patellar dislocation. MATERIALS AND METHODS: The study was done in 11 patients who underwent surgery due to acute patellar dislocation from February 1997 to January 2000. patients who had history of previous patella dislocation were excluded in this study. The average follow up period was 23 months. Radiographs were antero-posterior, lateral at 30 degree of flexion, and Merchant view. We looked for of patella alta, trochlear dysplasia, intraarticular loose body and measured sulcus angle, congruence angle, Q-angle. We checked the location of injured medial retinaculum and ostochondral lesions, and associated intraarticular lesions from MRI, arthrosopic and operative findings. We performed the 3 operative methods: Upon the completion of the arthroscopic evaluation, medial retinacular repair (5 cases), medial retinacular repair and lateral release(3 cases). augmented repair and plication of medial retinaculum ie, modified Madigan technique(3 cases). RESULTS: patella alta was present in 7 cases(63.6%), trochlear dysplasia(crossing sign) in 5 cases(45.5%), and increased sulcus angle in 5 cases(45.5%). one or more predisposing factors contribut-ing to patella dislocation were seen in 9 of 11 cases(81.8 %). Medial retinacular tear was present in the adductor tubercle in 5 cases and midportion(parapatellar tear) in 4 cases, and relaxed without tear in 2 cases. The clinical results showed that the average Kujala score was 91 points. The congruence angle became normal in 10 cases and patella subluxation was seen in 1 case postoperatively. CONCLUSIONS: Acute patellar dislocation was related in those cases with trochlear dysplasia and patella alta and increased sulcus angle . During the 23 months follow up preiods, Excellent clinical results were obtained with early surgical treatment.

Tibial Tunnel Changes after Arthroscopic ACL Reconstruction using Autogenous Bone-Patellar Tendon-Bone

PURPOSE: We analysed radiographic changes of bone tunnels after anterior cruciate ligament(ACL) reconstruction and evaluated the correlation between measurements and clinical variable. MATERIALS AND METHODS: Fifty patients were examined retrospectively. The interval between surgery and examination ranged from 12 to 48 months with a mean of 18 months. We measured the area and width of tibial tunnel from the radiographs of anteroposterior(AP) and lateral views of the knee after arthroscopic ACL reconstruction using computer program "Image-Pro ExpressRfi". The proximal, middle, distal one third of tibial tunnel area and maximum diameter of tibial tunnel were measured on AP and lateral radiographs. Each measurements were done on immediate postoperative, and postoperative 3, 6, 9, 12, 24, 36 months. RESULTS: The size of tibial tunnel was larger on lateral than AP radiograph. The proximal part was found to be the largest and the size decreased as it moved distally. The area of proximal one third was increased from postoperative 3 months and that of distal one third was decreased from postoperative 3 months. The shape of tibial tunnel area on the last follow-up was cylinder type in 33(66%) and 17(34%) on AP and lateral radiograph, mallet type 8(16%) and 4(8%), reverse bottle type 5(10%) and 11(22%), reverse triangle type 4(8%) and 18(36%) respectively. CONCLUSIONS: The tibial tunnel change was not correlated with clinical variable such as Lysholm score.

The Management of Bone Defects in Revision Total Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: Bone defects in revision TKA were classified according to AORI (Anderson Orthopedic Research Institute) system and results of the treatment are reported according to this classification. MATERIALS AND METHODS: The results of 24 revision TKAs operated from Mar. 1991 to Apr. 1999 were analysed. Fourteen knees had type 1 tibial defects, four knees had type 2 and six knees had type 3. On the femoral side, twelve knees had type 1, four knees had type 2 and seven knees had type 3 defects. Cement and chip bone grafts were mainly used to fill bone defects in type 1, wedges or blocks in type 2 and structural allograft combined with the other methods in type 3. Results were evaluated using the knee and functional scores of the American knee society. RESULTS: The analysis of the results according to the method of treatment- cement filling, chip bone graft, structural bone graft, wedge or blocks and custom made prosthesis- revealed improvements of knee scores in all groups except for custom made prosthesis. CONCLUSION: Satisfactory clinical results were obtained for the management of bone defects according to the AORI classification system in revision total knee arthroplasty.

Arthroscopic Treatment of Degenerative Arthritis of the Knee

PURPOSE: To evaluate the efficacy and the prognostic factors in arthroscopic treatment of degenerative arthritis of the knees MATERIALS AND METHODS: The results of 115 knees in 110 patients had been treated arthroscopically from Jan. 1990 to June 1999 were analysed. Mean age was 56 years old and mean follow-up period was 1 years 9 months(range: 1 year-7 year). Pain, Range of motion, Lysholm score, and changes of subjective symptoms were assessed for clinical evaluation, Preoperative and postoperative X-rays of the knees and arthroscopic findings were also reviewed and statistical analysis was performed. We tried to find out the clinical results and prognostic factars in arthroscopic treatment of the degenerative arthritis. RESULTS: The best clinical improvement was observed in postoperative 1-2 year period and the clinical improvement was continued by 3 years after surgery. Sixty two percents of patients had significant improvement of subjective symptoms for 1-2 year postoperatively, and 52% for at least 3 years after surgery. The patients of younger age, normal weight, normal alignment of lower leg(1 degrees - 7 degrees degree of tibio-femoral angle) and shorter duration of preoperative symptoms showed better clinical results. Eighty percents of improvement of subjective symptoms has been obseved in the group of patient who had the mechanical symptoms preoperatively. In the knee with mild cartilage degeneration(according to Jack-sons classification, stage I or II) and with torn meniscus showed better clinical improvement after surgery compared with those of severe cartilage degeneration or intact menisci. CONCLUSION: Arthroscopic treatment can be considered as a succesful treatment method for temperary relief of symptoms in the degenerative arthritis of knees. However, careful selection of patients looks mandatory for favorable results. The favorable prognostic factors in the study were younger age, no obesity, shorter duration of symptoms, nearly normal alignment of knees, less cartilage degeneration, mechanical symptoms, and torn meniscus.

Divergence of the Interference Screw and Clinical Outcome in Arthroscopic ACL Reconstruction

No Abstract Available.

The Relationship between Effective Muscle Index and Elbow Flexion Power after Steindler Flexorplasty / 대한정형외과학회잡지

PURPOSE: The most common cause of failure after Steindler flexorplasty has been known insufficient power of the transferred muscles. We develop "effective muscle index" which is calculated from the actual strength of each muscle to predict postoperative flexion power of the elbow for preventing the failure of the surgery. MATERIALS AND METHODS: We reviewed 10 patients who received Steindler flexorplasty from Aug. 1983 to Jan. 1997. We calculated "effective muscle index" with power of each transferred muscle, tension fraction2) by Brand, 1981, correction index of the magnitude of transferring muscle and correlated the "effective muscle index" with postoperative elbow flexion power. RESULTS: Excluding 4 out of total 10 patients who had grade 1 or 2 power of biceps and brachialis, "effective muscle index" has borderline significance with the postoperative flexion power of the elbow (p=0.123) . CONCLUSION: The authors concluded that the "effective muscle index" is maybe considered as a useful index for predicting the postoperative flexion power of the elbow after Steindler flexorplasty.