Iatrogenic Subtrochanteric Fractures Related to the Surgical Error: Two Cases Report

Iatrogenic fracture is not popular and might be recognized as a malpractice. Surgical error related to iatrogenic fracture which has occurred after an operation can be detected only by a surgeon. Stress riser fracture is another form of iatrogenic fracture also known as a Young's modulus fracture. As the majority of surgical related stress riser fractures can be preventive, the accurate prevalence is not known. The majority of fractures occurred in the weight bearing bones such as femur and tibia. The subtrochanter area is the most stress concentrated area in the human body, thus it is a common area for occurrence of stress riser iatrogenic fractures. We experienced 2 cases of stress riser iatrogenic fractures, which are related to technical errors, thus we report cases with literature review.

Failure of Long Spinal Construct and Pseudarthrosis in a Patient with Parkinson Disease for the Treatment of Degenerative Lumbar Spinal Disorder: Case Report

STUDY DESIGN: Case report. OBJECTIVES: We report a case of treated failure spinal construct and pseudarthrosis in a patient with Parkinson's disease. SUMMARY OF LITERATURE REVIEW: There have been no reports about revision surgery due to failure and pseuarthrosis of degenerative lumbar spine disease in patients with Parkinson's disease. MATERIALS AND METHODS: A 55-year-old female who had been diagnosed with Parkinson's disease 4 years ago presented with back pain and radiating pain on both legs. Radiographic assessment showed spinal stenosis from L2 to L5 combined with degenerative spondylolisthesis at L3-4. Posterior decompression, instrumentation, and posterolateral fusion were performed and her symptoms improved. RESULTS: Two years after the operation, she complained of severe back pain without injury. A simple X-ray showed the pull out of bilateral L5 screws, and revision surgery was performed. Three years after the revision, she underwent re-reoperation due to metal failure. The breakage of a unilateral pedicle screw at L5 was found, and her fusion level was extended to S1 with a posterior lumbar interbody fusion with cages and alar screws. Finally, she has not shown any further failure but, a sagittal imbalance and aggravation of pelvic incidence due to Parkinson's disease have been detected. CONCLUSIONS: Spine surgeons always should consider metal failure, pseudarthrosis, and aggravated spinal imbalance caused by natural history in patients with Parkinson's disease.

A Tenosynovial Giant Cell Tumor Arising from Posterior Cruciate Ligament of Knee Joint: A Case Report / 대한골관절종양학회지

Localized forms of giant cell tumor are known to arise commonly in the synovial membrane of the finger joints. Multinucleated giant cells are its characteristic pathology finding, giant cell tumor shows a low rate of recurrence after complete excision. When occurring at the knee joints, giant cell tumor manifests a wide form of symptoms, from no symptom at all, to intermittent locking. Complete excision is possible by arthroscopy, but if done incompletely, it is reported to recur in 45% of cases. We present here a case of giant cell tumor that has arisen from the anterior portion of the posterior cruciate ligament, excised by arthroscopy and followed by pathologic confirmation.

Results of Tension Band Wiring and Additional Circumferential Wiring in Treatment of Comminuted Patella Fracture

PURPOSE: The purpose of this study is to evaluate the results of tension band wiring and additional circumferential wiring in treatment of comminuted patella fractures. MATERIALS AND METHODS: A retrospective study of 67 patients with follow-up period longer than six months who underwent tension band wiring and additional circumferential wiring for comminuted patellar fracture from January 2004 to December 2012 was conducted. Analysis was based on radiological evaluation of bony union and articular surface displacement, and clinically by evaluating the postoperative function of the knee joint using the Levack scoring system. RESULTS: Only one case out of 67 (1.5%) showed nonunion without metal breakage while good bone union was achieved in all other cases. Excluding the nonunion case, range of motion was 90 degrees minimum, 135 maximum, 129 on average. Average displacement was less than 2 mm, and 64 out of 67 cases showed satisfactory outcome with excellent functional score according to the Levack scoring system. CONCLUSION: Tension band wiring and additional circumferential wiring technique for treatment of comminuted patella fractures can be considered as an effective treatment for achievement of good bone union and restoration of normal knee function.

Results of Asian Type Gamma 3 Nail in Treatment of Trochanteric Fractures

PURPOSE: This study was conducted in order to demonstrate the radiologic and clinical results of using the Asian type gamma 3 nail in treatment of trochanteric fractures. MATERIALS AND METHODS: Patients underwent operations with gamma 3 nails between August 2010 and August 2012. For the radiologic evaluation, we analyzed bone quality, fracture pattern, reduction quality, union period, and position of lag screw (tip-apex distance, Cleveland index). For the clinical evaluation, we analyzed mobility score of Palmer and Parker and Jensen's functional score. RESULTS: The mean union was taken at 17.4 weeks (14-25 weeks). Two cases (4.3%) underwent reoperation due to cutting out of the hip screws. The clinical outcomes of Parker and Palmer's average mobility score changed from 7.3 to 5.8 (79%), Jensen's functional score was 1.3 to 1.8 (72%). CONCLUSION: We achieved excellent clinical and radiological outcomes; therefore, Asian type gamma 3 nail is effective in treatment of trochanteric fractures of the femur in Korea.

Solitary Epidural Lipoma with Ipsilateral Facet Arthritis Causing Lumbar Radiculopathy

A 55-year-old obese man (body mass index, 31.6 kg/m2) presented radiating pain and motor weakness in the left leg. Magnetic resonance imaging showed an epidural mass posterior to the L5 vertebral body, which was isosignal to subcutaneous fat and it asymmetrically compressed the left side of the cauda equina and the exiting left L5 nerve root on the axial T1 weighted images. Severe arthritis of the left facet joint and edema of the bone marrow regarding the left pedicle were also found. As far as we know, there have been no reports concerning a solitary epidural lipoma combined with ipsilateral facet arthorsis causing lumbar radiculopathy. Solitary epidural lipoma with ipsilateral facet arthritis causing lumbar radiculopathy was removed after the failure of conservative treatment. After decompression, the neurologic deficit was relieved. At a 2 year follow-up, motor weakness had completely recovered and the patient was satisfied with the result. We recommend that a solitary epidural lipoma causing neurologic deficit should be excised at the time of diagnosis.

The Impact of Fentanyl Matrix on Pain and Function in Spinal Disorder-Related Chronic Pain: An Open Label Trial in Korea

STUDY DESIGN: This is a multicenter, open-label prospective, non interventional study. PURPOSE: We wanted to evaluate the impact of fentanyl matrix on the pain and function of patients with spinal disorder-related chronic, non-malignant pain. OVERVIEW OF LITERATURE: Patients with severe non-malignant chronic low back pain may require opioid analgesics for effective pain management. METHODS: A total of 1,576 patients with severe pain (numeric rating scale = 7) were evaluated for their pain intensity at the initial visit and at weeks 4 and 8 (Visits 1, 2, and 3, respectively). Disturbances in sleep, daily living and social activities, the Oswestry Disability Index (ODI), the researchers' and patients' global assessment and the patients' treatment preference were also assessed. RESULTS: The pain intensity score significantly decreased from 8.1 at Visit 1 to 5.4 and 4.4 at Visits 2 and 3, respectively. Sleep disturbance also significantly decreased and the extent of disturbance of daily and social activities was also significantly improved. The ODI significantly decreased from 61.9% to 45.8% and 38.2% at Visits 1, 2, and 3, respectively. Adverse events were reported by 197 (12.5%) patients and severe adverse events were reported by 12 (0.76%) patients. Overall, 76.3% of the patients and 78.4% of the investigators rated the test drug as effective. CONCLUSIONS: The fentanyl matrix is believed to be effective for the treatment of pain, sleep disturbance and the impact upon daily and social activities, yet physicians should pay attention to the risks of abuse and the adverse events.

Undetected Incomplete Stress Fracture in the Proximal Femur of a Patient with Paget's Disease: A Case Report

Paget disease is a well-documented skeletal disease and it has an increased rate of tissue breakdown due to the excessive turnover of osteoblasts and osteclasts. Stress fracture is one of the most common complications in the late phase of Paget disease, but the clinical presentation of incomplete pathologic fracture is rare and this is an important clue to plan the treatment. We experienced a case of Paget's disease in a 74 year old woman with a periprosthetic fracture from the undetected, imcomplete stress fracture in the proximal femur.

A Treatment Guideline for Neuropathic Pain

STUDY DESIGN: A review of literature including definition, diagnosis and treatment of neuropathic pain. OBJECTIVES: To review and discuss the treatment guideline for neuropathic pain. SUMMARY OF LITERATURE REVIEW: Neuropathic pains are characterized by partial or complete somatosensory change caused by various disorders affecting central and peripheral nervous system, and are especially problematic because of their severity, chronicity and resistance to simple analgesics. MATERIALS AND METHODS: Review of literature. RESULTS: Tricyclic antidepressants and the anticonvulsants gabapentin and pregablin were recommended as first-line treatments for neuropathic pain. Opioid analgesics and tramadol were recommended as second-line treatments that can be considered for first-line use in selected clinical circumstances. Other medications such as dual reuptake inhibitors of both serotonin and norepinephrine would be used in severe cases. More invasive interventions (e.g., spinal cord stimulation) may sometimes be helpful. CONCLUSIONS: Treatment must be individualized for each patient and aggressive, combinatory pharmacotherapy and multidisciplinary approach are recommended for the treatment of neuropathic pain.

Interposition Arthroplasty with Pectoralis Major Muscle Transfer for the Shoulder Arthropathy: 2 Cases Report

Interpostion arthroplasty with allograft has been known as a useful option for the shoulder arthropathy, but it has a limitation to immune response. We performed the pectoralis major muscle transfer for shoulder arthropathy. From January 2007 to December 2007, we performed the pectoralis major muscle transfer in 2 patients. They were 1 man and 1 woman, and the mean age of the patients was 70 years (range, 65 to 75). The average follow-up after surgery was 13 months (range, 12 to 14). We analyzed the clinical results by the American Shoulder and Elbow Surgeons (ASES) Score, and evaluated the pain by Visual Analogue Scale. The level of pain reduced from a preoperative average of 10 to a postoperative average of 1. The ASES scores increased from a preoperative mean of 9 to a postoperative mean of 58. These results indicated that interposition arthroplasty with the pectoralis major muscle transfer is a reliable treatment method for the shoulder arthropathy improving shoulder pain, and patient satisfaction.

Operative Treatment of Bilateral Tibial Tuberosity Fractures in Adolescent: A Case Report

Bilateral avulsion fractures of the tibial tubercles are extremely rare. There is no case report about this in Korean literature. We present simultaneous bilateral tibial tuberosity fractures in 14-year-old adolescent male fell on the ground during running. These fractures were managed by open reduction and screw fixation. We gained complete union and removed metal after 6 months. Functional results were excellent 6 month after surgical treatment.

Arthroscopic Treatment of Septic Arthritis of Acromioclavicular Joint

Septic arthritis requires an early diagnosis and proper treatment to prevent the destruction of articular cartilage and joint contracture. This paper presents a rare case of septic arthritis of the acromioclavicular joint that was treated with arthroscopic debridement and resection of the distal clavicle.

Bilateral Traumatic Anterior Dislocation of the Hip with an Unstable Lumbar Burst Fracture

Traumatic anterior dislocation of the hip is rare. Bilateral traumatic anterior dislocation is an even rarer injury; indeed, only 5 cases have been reported in the English literature. We describe a case of a bilateral traumatic anterior dislocation of the hip and a concomitant unstable lumbar burst fracture following a mechanism of injury distinctly different from other reports.

Surgical Treatment of Brucellar Spondylodiscitis with Epidural Abscess: A Case Report / 대한척추외과학회지

Brucellosis is a well known systemic, zoonotic disease that can affect many organs. We report a rare case of spondylodiscitis with an epidural abscess caused by brucellosis. The patient was treated surgically for severe pain and concomitant devastating neurological deficit. A diagnosis of spondylodiscitis or an epidural abscess due to brucellosis must be considered when acute back pain, radiating pain and febrile episodes occur, particularly in people in a high risk group.

F-18 FDG PET-positive Fibrous Dysplasia in a Patient with Intestinal Non-Hodgkin's Lymphoma / Journal of the Korean Cancer Association, 대한암학회지

Fibrous dysplasia (FD) is a common benign bone disorder of an unclear etiology. It is known that FD can appear without an increased FDG uptake on F-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT). However, there are also several reports that FD showed increased FDG uptake and this mimicked malignant bone involvement on FDG-PET. Herein we describe a case of biopsy-proven FDG-PET positive FD in a patient with intestinal non-Hodgkin's lymphoma (NHL). A 45-year-old woman was diagnosed with intestinal NHL, which was removed by right hemicolectomy. After the operation, the FDG-PET/CT scan showed hypermetabolic activity in the right transverse process of the T10 vertebra. The patient then received a total of 6 cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone) chemotherapy every 3 weeks. After completion of the planned chemotherapy, the 2nd FDG-PET/CT showed increased FDG uptake (SUVmax=6.0 g/mL) of the previous bone lesion. The MR images revealed a T1-hypointense lesion with sharp borders in the same region, and this showed homogenous contrast enhancement on the fat-suppressed T1-weighted images. After the radiologic studies were carefully reviewed, the bone lesion was assumed to be benign such as FD. We performed bone biopsy and the histological examination confirmed the diagnosis of FD. In conclusion, bone lesions with FDG uptake need to be carefully interpreted when evaluating patients with known malignancy.

The Results of Proximal Femoral Nail Antirotation: A Comparative Study with Proximal Femoral Nail

PURPOSE: This study was performed to compare the results between PFNA (Proximal Femoral Nail Antirotation) and PFN (Proximal Femoral Nail) in the treatment of peritrochanteric fracture. MATERIALS AND METHODS: The patient group with PFNA (n=24, group I) was taken from operations between February, 2007, and March, 2008, whereas the PFN patient group (n=24, group II) were taken from January, 2005, to January, 2007. Both groups were carefully compared with regard to operation time, estimated blood loss, amount of transfusion, ICU care, amount of drainage, average duration of admission, intra- and postoperative complications, radiologic union, Tip Apex Distance (TAD), the change of neck shaft angle, the sliding length of lag screw, Jensen's functional score, and Paker and Palmer's mobility score. RESULTS: The results of our study showed statistical (P0.05). CONCLUSION: PFNA appears to be more effective than PFN for the treatment of peritrochanteric fractures of the proximal femur.

A case of spinal myoclonus with radiculopathy following spine surgery: A case report / 대한마취과학회지

Despite adequate surgery, a number of patients have a return of back pain and radiculopathy of the legs following their operation. We present here a case of spinal myoclonus with radiculopathy after spine surgery. A 51 year old woman with bilateral radiculopathy and urinary incontinence was diagnosed with a cauda equina syndrome along with spinal stenosis. The patient underwent emergency operation for posterior decompression and internal fixation from the L2 to S1 levels. Immediately after surgery, the patient continued to experience intermittent myoclonic movement with severe shooting pain in her legs despite being given pharmacological treatments such as benzodiazepines, opioids, NSAIDs and gabapentin. The patient was found to have sudden, brief, bilateral involuntary muscle contraction on the lower extremities. The patient was referred to our pain clinic. She underwent a caudal block 2 times in 4 days. However, she reported only limited pain relief for 3 to 4 hours. She was then prescribed phenytoin 300 mg intravenously in a day; her myoclonic movement gradually subsided after 1 week of receiving phenytoin. Sixty days later, she was discharged without any long term sequelae.

Treatment for the Supracondylar Fractures of the Distal Humerus with Cannulated Screw

PURPOSE: To evaluate the results of the treatment of the supracondylar fractures of the humerus according to the fixation methods with cannulated screw. MATERIALS AND METHODS: Eight patients, aged 49 to 82 years (average, 65 years), were reviewed after a mean follow-up of 16 months (range, 12~24 months). According to AO classification all fractures were classified as type A2 (simple transverse supracondylar fracture). All patients underwent closed reduction. Percutaneous fixation with cannulated screws was performed in 8 patients. Three of 8 patients had associated medical problems and one patient had distal radius fracture. The functional results were assessed by the Mayo Elbow Performance Score. RESULTS: Mean operation time was 59 minutes (45~75) and all the patients with cannulated screw fixation had bony union and were able to early ROM exercise. Mean ranges of motion was 5~120 degrees with excellent functional results. Functional evaluation of elbow joint by Mayo method showed mean value of 88 (75~95). CONCLUSION: The cannulated screw fixation of supracondylar fracture of humerus, especially in the elderly aged group with medical disease had excellent functional results (rigid fixation & early ROM exercise) due to shortening of surgery time and anesthesic time, combined with decreased technical difficulties of the surgical procedure

Balloon Kyphoplasty using a Unilateral Approach for the Treatment of Osteoporotic Vertebral Compression Fractures / 대한정형외과학회잡지

PURPOSE: To evaluate the clinical results of a unilateral balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures (VCFs). MATERIALS AND METHODS: Twenty patients, 23 cases of osteoporotic VCFs who failed to respond to nonoperative treatments and who were confirmed by a consultant radiologist, were enrolled in this study. Times between injury and operation varied from 2 weeks to 2 months. All patients except two (18 female, 2 male patients), were female, and mean patient age was 71.7 (58-82) years. Follow-ups were conducted at least 12 months (12-27, mean 18.3). All patients underwent unilateral balloon kyphoplasty. Roentgenographic assessments were perform to evaluate fractured vertebra restoration and reduction loss. A ten-point visual analogue scale was used to measure pre- and postoperative pain severity. RESULTS: Preoperative anterior, middle and posterior heights of vertebra bodies were 57.8%, 66.1% and 85.3% of normal at presentation and these increased to 76.2%, 80.1%, 88.7% respectively at immediately after operation and at last follow-up, heights of each portion were 74.4%, 78.6%, 87.3%. Mean preoperative kyphotic angles of 17.6 degrees at presentation improved to 8.9 degrees at immediately after operations and to 9.1 degrees at last follow-ups. Loss of reduction was 1.8%, 1.5%, 1.4% and 0.2 degrees. Mean pain scores were 8.5 before surgery, 2.5 immediately after operations and 2.7 at last follow-ups. Statistical analysis showed a significant decrease in kyphotic angle (p=0.03) but VAS scores were no different (p=0.056). Anterior, middle and posterior body height was decreased with a statistical significance between two period (p<0.001). PMMA leakage occurred in 3 cases, but they did not cause neurologic deficits. CONSLUSION: Balloon kyphoplasty using a unilateral approach is a good treatment method for osteoporotic vertebral compression fractures and an alternative to the substitute bilateral approach.

Diagnosis of Herniated Tibialis Anterior Muscle by Dynamic Ultrasonography: A Case Report / 대한정형외과학회잡지

Muscle herniation is a relatively common disorder in the extremities, particularly in the lower extremity where the tibialis anteior muscle is the most commonly affected. Usually muscle herniation is asymptomatic or mild but a few patients complain of cramping or severe pain. We report a case of a bilateral hernia of the tibialis anterior muscle that was confirmed by dynamic ultrasonography.