Clinical and Radiologic Outcomes of Open Reduction and Internal Fixation without Capsular Incision for Inferior Glenoid Fossa Fractures

Background@#Scapular surgery is usually undertaken via the posterior approach described by Judet. This approach allows access to the entire posterior scapular body; however, it results in severe soft-tissue injury and requires an incision in the deltoid muscle.To date, no clinical study has been reported on open reduction and internal fixation without capsular incision for displaced inferior glenoid fractures (Ideberg type II). The purpose of this study was to introduce an easy and less invasive approach to the inferior glenoid fossa and evaluate its clinical outcomes. @*Methods@#Ten patients with displaced inferior glenoid fractures underwent open reduction and internal fixation without capsular incision between January 2017 and July 2018. Postoperative computed tomography was performed to evaluate the reduction state within a week of the surgery. Clinical and radiological data from 7 patients who were followed up for more than 2 years were analyzed. @*Results@#The mean age of the patients was 61.7 years (range, 35–87 years). The mean follow-up period was 28.6 months (range, 24–42 months). The mean preoperative fracture gap and step-off values were 12.3 ± 4.4 mm and 6.8 ± 4.0 mm, respectively. Surgical stabilization was conducted 6.4 days (range, 4–13 days) after trauma. Mean postoperative-preoperative fracture gap and stepoff values were 0.6 ± 0.6 mm and 0.6 ± 0.8 mm, respectively. At 24 months after surgery, the mean Constant score was 89.1 ± 10.6 points (range, 69–100) and the mean pain visual analog scale score was 1.4 ± 1.7 (range, 0–5). Bony union was observed in all patients. The mean time to bony union was 11 ± 1.7 weeks. The mean active range values for forward elevation, external rotation, and abduction were 162.9° ± 11.1° (range, 150°–180°), 55.7° ± 15.1° (range, 30°–70°), and 158.6° ± 10.7° (range, 150°–180°), respectively. @*Conclusions@#The presented posterior open reduction and internal fixation without capsular incision or extensive soft-tissue dissection may be an easy and less invasive surgical approach for inferior glenoid fossa fractures (Ideberg type II).

Treatment of Atypical Ulnar Fracture Associated with Bisphosphonate Therapy - A Case Report -

Bisphosphonates can cause atypical fractures when taken for a long time. Atypical fractures appear mainly as femoral subtrochanteric or shaft fractures. On the other hand, reports of atypical fractures in the proximal ulna are relatively rare, with a high proportion of nonunion cases. This paper reports a case of nonunion after fixation for atypical fractures of the proximal ulna.

Leak Sign on Dynamic-SusceptibilityContrast Magnetic Resonance Imaging in Acute Intracerebral Hemorrhage

Purpose@#A CT angiography spot sign (CTA-spot) is a significant predictor of the early expansion of an intracerebral hemorrhage (ICH-Ex). Dynamic-susceptibility-contrast magnetic resonance imaging (DSC-MRI) can track the real-time leaking of contrast agents. It may be able to indicate active bleeding, like a CTA-spot. @*Materials and Methods@#From September 2014 to February 2017, we did noncontrast CT, CTA, and DSC-MRI examinations of seven patients with acute ICH. We investigated the time from symptom onset to the first contrast-enhanced imaging.We evaluated the time course of the contrast leak within the ICH at the source image of the DSC-MRI and the volume change of ICH between non-contrast CT and DSCMRI. We compared the number of slices showing CTA-spots and DSC-MRI leaks. @*Results@#The CTA-spot and DSC-MRI leak-sign were present in four patients, and two patients among those showed ICH-Ex. The time from the symptom onset to CTA or DSC-MRI was shorter for those with a DSC-MRI leak or CTA-spot than for three patients without either (70-130 minutes vs. 135-270 minutes). The leak-sign began earlier, lasted longer, and spread to more slices in the patients with ICH-Ex than in those without ICH-Ex. The number of slices of the DSC-MRI leak and the number of the CTA-spot were well correlated. @*Conclusion@#DSC-MRI can demonstrate the leakage of GBCA within hyperacute ICH, showing the good contrast between hematoma and contrast. The DSC-MRI leakage sign could be related to the hematoma expansion in patients with ICH.

The Changes in Axial and Radial Diffusivity in a Patient with Clinically Mild Encephalitis/Encephalopathy with a Reversible Splenial Lesion

Multiple studies have established that mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) exhibits reversible diffusion restriction in the white matter, including the splenium. There have been a few previous reports of the change in fractional anisotropy (FA) of MERS cases. Herein, we report the longitudinal changes in axial and radial diffusivity (AD and RD), and FA in a 15-year-old boy patient with MERS. Our case demonstrated that a MERS lesion had a significant drop of AD in the early period and gradual recovery. On the contrary, RD did not show any significant change.

Evaluation of Inferior Capsular Laxity in Patients with Atraumatic Multidirectional Shoulder Instability with Magnetic Resonance Arthrography

OBJECTIVE: To compare inferior capsular redundancy by using magnetic resonance arthrography (MRA) images in patients with multidirectional instability (MDI) of the shoulder and control subjects without instability and thereby develop a screening method to identify the presence of shoulder MDI. MATERIALS AND METHODS: The MRA images of patients with MDI of the shoulder (n = 65, 57 men, 8 women; mean age, 24.5 years; age range, 18–42 years) treated over an eight-year period were retrospectively reviewed; a control group (n = 65, 57 men, 8 women; mean age, 27.4 years; age range, 18–45 years) without instability was also selected. The inferior capsular redundancy was measured using a new method we named the glenocapsular (GC) ratio method. MRA images of both groups were randomly mixed together, and two orthopedic surgeon reviewers measured the cross-sectional areas (CSAs) and sagittal capsule-head ratios on oblique sagittal images, as well as the axial capsule-head ratios on axial images and GC ratios on oblique coronal images. RESULTS: The CSAs and GC ratios were significantly higher in patients than in controls (both, p 1.42 was found to be most suggestive of MDI of the shoulder, owing to its high sensitivity (92.3%) and specificity (89.2%). CONCLUSION: GC ratio can be easily measured and used to accurately screen for MDI of the shoulder.

The Result of Percutaneous Screw Fixation without Bone Grafting for Scaphoid Waist Nonunion under Local Anesthesia

PURPOSE: The purpose of this study was to analyze the results of patients with scaphoid waist nonunion treated with percutaneous screw fixation without bone grafting under local anesthesia. METHODS: We enrolled scaphoid waist nonunion of 15 patients which had no deformity, displacement, evidence of avascular necrosis and bone cyst under 5 mm on its radiological study. All patients were male with an average age of 28.9±6.2 years (range, 17–38 years). The mean time to surgery from initial injury was 10.8±2.2 months (range, 6–14 months). All patients were treated with percutaneous screw fixation without bone grafting via volar approaching under local anesthesia and postoperative radiographs were reviewed and documented the flexion and extension arcs of the injured wrist and uninjured wrist, disability of the arm, shoulder and hand (DASH) score at final follow-up. RESULTS: All 15 patients showed radiological union at an average 5.5±1.0 months. At 12 months follow-up, the flexion and extension arcs of the injured wrist were 95% and 98.5% of the uninjured wrist. The average DASH score at final follow-up was 7±3.9 (range, 0–15). None of these patients showed any complications associated with surgery. CONCLUSION: Percutaneous screw fixation without bone grafting under local anesthesia was reliable primary treatment method for scaphoid waist non-union without displacement or deformation in the fracture site.

Hyperperfusion in DWI Abnormality in a Patient with Acute Symptomatic Hypoglycemic Encephalopathy

The perfusion change in acute symptomatic hypoglycemic encephalopathy (ASHE) is not well known. We present the perfusion-weighted imaging of a patient with ASHE. The area of diffusion-weighted imaging abnormalities and adjacent normal-appearing white matter showed increased cerebral blood volume and flow, and shortening of time-to-peak.

Hyperperfusion in DWI Abnormality in a Patient with Acute Symptomatic Hypoglycemic Encephalopathy

The perfusion change in acute symptomatic hypoglycemic encephalopathy (ASHE) is not well known. We present the perfusion-weighted imaging of a patient with ASHE. The area of diffusion-weighted imaging abnormalities and adjacent normal-appearing white matter showed increased cerebral blood volume and flow, and shortening of time-to-peak.

Multiple Brachymetacarpia Treated by Distraction Osteogenesis

The treatment of a brachymetacarpia using a distraction osteogenesis was mostly single, unilateral pattern. In case of multiple brachymetacarpia, single-stage lengthening or rapid distraction lengthening with a bone graft were usually used. Multiple brachymetacarpia treated by distraction osteogenesis is rarely reported. We report a case of a 15-year-old female presented with bilateral multiple brachymetacarpia treated by distraction osteogenesis simultaneously without complications. Also, we have evaluated the clinical results and factors which influence the clinical results.

Delayed Severe Hemobilia after Endoscopic Biliary Plastic Stent Insertion

Hemobilia is a rare gastrointestinal bleeding, usually caused by injury to the bile duct. Hemobilia after endoscopic retrograde cholangiopancreatography (ERCP) is generally self-limiting and patients will spontaneously recover, but some severe and fatal hemorrhages have been reported. ERCP-related bowel or bile duct perforation should be managed promptly, according to the type of injury and the status of the patient. We recently experienced a case of late-onset severe hemobilia in which the patient recovered after endoscopic biliary stent insertion. The problem was attributable to ERCP-related bile duct perforation during stone removal, approximately 5 weeks prior to the hemorrhagic episode. The removal of the stent was performed 10 days before the onset of hemobilia. The bleeding was successfully treated by two sessions of transarterial coil embolization.

Gas Gangrene Caused by Streptococcus anginosus / 대한내과학회지

Gas gangrene, a subset of necrotizing myositis, is a bacterial infection that produces gas in tissues in gangrene. It is usually caused by Clostridium species, most commonly Clostridium perfringens. Streptococcus anginosus is a rare cause of gas gangrene, with very few cases reported. We report a rare case of traumatic gas gangrene caused by S. anginosus in a 57-year-old female with diabetes after being stabbed with scissors.

A Delayed Fatal Septic Cerebral Infarction after Endoscopic Retrograde Cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP)-related complications should be promptly and properly managed in accordance with the type and severity of the complication and the comorbidity of the patient. Neurologic complications occur very rarely, but despite of the prompt management, the patient status can severely deteriorate and sometimes result in fatality. A female patient visited SAM Medical Center for abdominal pain and yellow skin. She has taken a current medication for essential hypertension since 10 years ago. Initial laboratory findings showed obstructive jaundice and abdominal computed tomography (CT) showed two common bile duct stones with moderate dilation of bile duct. Her vital sign with oxygen saturation was stable until the first attack of seizure 12 hours later after removal of stones through the ERCP. Emergent brain CT and magnetic resonance imaging revealed multiple cerebral infarctions of both hemispheres with right predominance of middle cerebral artery territory and no evidence of air emboli. She died four days later despite of intensive care including high oxygen therapy and intravenous broad spectrum antibiotics with antiplatelet drug. We report a rare, delayed occurrence of a fatal multiple cerebral infarctions 12 hours after ERCP.

Measurement of Muscle Strength of Ankle Joint Using Isokinetic Dynamometer in Normal Korean Adults / 대한족부족관절학회지

PURPOSE: Restoration of ankle stability through the strengthening exercise of peroneus muscles is considered an important factor for achievement of successful outcomes, in the rehabilitation program following ankle ligament injuries. However, there were few definitive data on normal muscle strength, including eversion power by peroneus muscles. This study was conducted to evaluate the muscle strength of ankle joint measured using an isokinetic dynamometer in normal Koreans. MATERIALS AND METHODS: Sixty adults (120 ankles) were recruited and divided into three groups (20 in their twenties, 20 in thirties, and 20 in forties). Each group consisted of 10 males and 10 females. The selection criteria were no history of ankle injury and no evidence of instability. The peak torque, total work, and deficit ratio were measured using the Biodex(TM) (Biodex Medical Systems). Differences in muscle strength by age, gender and dominant versus non-dominant side were analyzed. RESULTS: The peak torque of dorsiflexion was average 31.5 Nm at 30degrees/s of angular velocity and 18.8 Nm at 90degrees/s; average 69.3 Nm (30degrees/s) and 42.4 Nm (90degrees/s) on plantarflexion; average 19.6 Nm (30degrees/s) and 10.8 Nm (90degrees/s) on inversion; average 12.9 Nm (30degrees/s) and 8.0 Nm (90degrees/s) on eversion. The deficit ratio of strength in women was average 61.1% of men on dorsiflexion; average 66.2% on plantarflexion; average 48.5% on inversion; average 55.4% on eversion. The deficit ratio in non-dominant foot was average 88.6% of dominant foot on dorsiflexion; average 90.1% on plantarflexion; average 85.1% on inversion; average 85.6% on eversion. CONCLUSION: The muscle strength of the ankle joint showed a tendency to weaken with age. There were significant differences in muscle strength by gender and dominancy. Further studies for comparison of patients with ankle instability, a comparison between before and after surgery for instability, the correlation between clinical outcomes and the recovery in muscle strength will be needed.

A Case Of Huge Brunner's Gland Adenoma With Acute Bleeding Treated By Endoscopic Resection / 고신대학교의과대학학술지

Brunner's gland adenoma is a rare benign small bowel neoplasm and it represents 10% of small bowel benign tumor. Most of adenoma manifest as polypoidal, multiple and size does not exceed 1 cm and mostly asymptomatic, but the lesion larger than 1cm is solitary and can cause bleeding, obstruction, intussusception and there are some reports of showing malignant transformation. Until the present, there are two cases of over cm huge Brunner's gland adenoma in Korea and each of their chief complaint was abdominal discomfort and melena, but there is no case report of over 8cm Brunner's gland adenoma accompanied with acute bleeding as seen in this case. We diagnosed an 8cm sized, huge duodenal Brunner's gland adenoma which accompanied with acute bleeding and treated it by endoscopic resection using an IT-knife, successfully.

Severe Scrub Typhus Complicated by Myofascitis Due to the Taguchi Strain of Orientia tsutsugamushi / 대한내과학회지

Scrub typhus is an acute febrile illness with focal or general vasculitis that is caused by Orientia tsutsugamushi. The spectrum of clinical severity ranges from mild to severe with potentially fatal complications including acute renal failure, gastrointestinal bleeding, meningitis, myocarditis, and pneumonia. However, myofascitis with scrub typhus has not been reported to date. We report a case of pneumonia, meningitis, and myofascitis in a 56-year-old male patient with scrub typhus due to the Taguchi strain of O. tsutsugamushi.

A Case of Malignant Granular Cell Tumor in the Sigmoid Colon

Granular cell tumor (GCT) is an uncommon, usually benign neoplasm; however, a malignant potential has been described. Malignant GCT is an extremely rare neoplasm showing rapid growth and invasion into adjacent muscles, lymph nodes, or vessels, or even distant metastasis. We recently experienced a case of a histologically benign or atypical but clinically malignant GCT, with invasion of the lymph nodes and vessels in the sigmoid colon, diagnosed by segmental colon resection with lymph node dissection. We also performed a review of relevant medical literature.

Clinical Effect of Surgical Treatment within 12 Months for Ankylosed Elbow Associated with Heterotopic Ossification / 대한정형외과학회잡지

Five patients presented with a limited range of motion in their elbow associated with heterotopic ossification. All of these patients underwent surgery within one year. Removal of heterotopic ossification and a posterior capsular release was performed within ten months on average after the initial injury. Each patient postoperatively received prophylaxis consisting of a single-shot radiation of 700 cGY and administration of nonsteroidal anti-inflammatory drugs (NSAIDs) for four weeks on average. With a median follow up period of 21 months, five patients had no radiographic evidence of recurrence. The arc of flexion-extension increased from an average of 64 degrees preoperatively to 133 degrees at the latest follow up. A 12- to 18-month period is generally recommended as necessary for an operation on an ankylosed elbow associated with heterotopic ossification. However, the operative treatment, together with radiation therapy and NSAIDs administration, showed good results within 12 months.

Subsidence of Polyetheretherketone Cage after Anterior Cervical Fusion / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to evaluate the rate and direction of subsidence that occurred after anterior cervical discectomy and fusion using the polyetheretherketone (PEEK) cage and to analyze the risk factors of subsidence. MATERIALS AND METHODS: Thirty two patients (36 segments) who underwent anterior cervical discectomy and fusion using the PEEK cage and autologous cancellous iliac bone graft from July 2003 to November 2011 were enrolled in this study. anterior segmental height (ASH), posterior segmental height (PSH) and cage corner distance (CCD) were measured on plain radiographs. Subsidence was defined as > or =2 mm decrease in the average of ASH and PSH at the final follow up compared to that measured in the immediate postoperative period. A decrease of more than 3 mm was defined as severe subsidence for further statistical analysis. RESULTS: Subsidence of more than 2 mm was observed in 14 segments (38.9%) and severe subsidence (> or =3 mm) was observed in seven segments (19.4%). The direction of subsidence was examined by comparison of means of decreased ASH and PSH and anterior subsidence outweighed posterior subsidence (p<0.001). Examination of CCD showed that inferior subsidence was more frequent than superior subsidence (p<0.001, p=0.047). Among the suspicious risk factors for subsidence, intraoperative disc space distraction (anterior distraction: p=0.031, posterior distraction: p=0.007) and height of inserted cage (p=0.032) showed statistical significance. CONCLUSION: Considerable incidence of subsidence was observed after use of the cage. Using a cage of appropriate height and prevention of intraoperative over-distraction of disc space will be helpful to prevention of subsidence of the cage after anterior cervical discectomy and fusion using the PEEK cage.

Functional Evaluation after Modified Brostrom Procedure with Suture Bridge Technique for Chronic Ankle Instability in Athletes / 대한족부족관절학회지

PURPOSE: Ligament reattachment technique using a suture anchor appears to show satisfactory functional outcomes and mechanical stability compared with conventional bone tunnel technique. This study was prospectively conducted in order to evaluate functional outcomes of modified Brostrom procedures using the suture bridge technique for chronic ankle instability in athletes. MATERIALS AND METHODS: Twenty eight athletes under 30 years of age were followed for more than two years after undergoing the modified Brostrom procedure using the suture bridge technique. Functional evaluation consisted of the foot and ankle outcome score (FAOS), foot and ankle ability measure (FAAM) score. Range of motion and time to return to exercise were evaluated using a periodic questionnaire. Talar tilt angle and anterior talar translation were measured through stress radiographs for evaluation of mechanical stability. RESULTS: FAOS improved significantly from preoperative mean 59.4 points to 91.4 points (p<0.001). Daily living and sport activity scores of FAAM improved significantly from preoperative mean 50.5, 32.5 points to 94.8, 87.3 points, respectively (p<0.001). Talar tilt angle and anterior talar translation improved significantly from preoperative mean 16.8degrees, 13.5 mm to 4.2degrees, 4.1 mm at final follow-up (p<0.001). Times to return to exercise were as follows: mean 10.2 weeks in jogging, 15.4 weeks in spurt running, 13.1 weeks in jumping, 11.5 weeks in walking on uneven ground, 9.1 weeks in standing on one leg, 7.2 weeks in tip-toeing gait, 8.4 weeks in squatting, and 10.6 weeks in descending stairs. CONCLUSION: Modified Brostrom procedure using the suture bridge technique showed satisfactory functional outcomes for chronic ankle instability in athletes. Optimal indication and cost-effectiveness of the suture bridge technique will be studied in the future.

Variations in Entrance of Vertebral Artery in Korean Cervical Spine: MDCT-based Analysis

BACKGROUND: Knowledge of the anatomical variation of the vertebral artery has clinical importance not only for the performance of interventional or surgical procedures itself but also to ensure their safety. We conducted a study of the anatomical variation by reviewing multi-detector computed tomography (MDCT) images of the cervical spine from 460 Korean patients. METHODS: 16-row MDCT data from 460 patients were used in this study. We observed 920 vertebral arteries. Examination points included level of entrance of the artery into the transverse foramen of the cervical vertebra, origin site of the vertebral artery, course of a vertebral artery with aberrant entrance. RESULT: The vertebral artery in 2 (0.2%) cases in this study entered into the transverse foramen of the 7th cervical vertebra from the left. In 45 (4.9%) cases, the vertebral artery entered into the transverse foramen of the 5th cervical vertebra. Of these, the entrance was on the right in 15 (1.6%) and on the left in 30 (3.3%). We found 17 (1.8%) cases in which the artery entered into the transverse foramen of the 4th cervical vertebra, 10 (1.1%) on the right and 7 (0.7%) on the left side. As is commonly acknowledged, the 6th cervical vertebra was the most common site of entry; the vertebral artery entered the transverse foramen of the 6th cervical vertebra in the remaining 855 (93.0%) cases, on the right in 434 (47.2%) and on the left in 421 (45.8%). CONCLUSIONS: In conclusion, the possibility of an atypical course of the vertebral artery in segments V1 and V2 should be evaluated with magnetic resonance imaging (MRI) or CT images before carrying out procedures involving the anterior cervical vertebrae.