Differential Diagnosis of Elbow Pain / 이화의대지

Elbow pain is a common symptom encountered in clinical practice. Pathology can arise from any component of the joint, including the bone, tendons, ligament, bursa, or nerves. This paper discusses how elbow pain can be differentiated according to its anatomic location and presents the corresponding causes, diagnosis, and treatment options.

Does Demineralized Bone Matrix Enhance Tendon-to-Bone Healing after Rotator Cuff Repair in a Rabbit Model?

Background@#The purpose of this study was to compare the histologic outcomes of rotator cuff (RC) repair with demineralized bone matrix (DBM) augmentation and those without DBM augmentation and to evaluate the role of DBM for tendon-to-bone (TB) healing in a rabbit model. @*Methods@#Twenty-six adult male New Zealand white rabbits were randomly allocated to the control group (n = 13) or the DBM group (n = 13). Repair was performed 8 weeks after complete transection of the right supraspinatus tendon of all rabbits. In the control group, RC repair was achieved by a standard transosseous technique. In the DBM group, RC repair was achieved using the same technique, and DBM was interposed between the cuff and bone. After 8 weeks, the RC tendon entheses from all rabbits were processed for gross and histologic examination. @*Results@#On gross TB healing, 2 of 11 specimens in the control group were unhealed and no specimen was grossly unhealed in the DBM group (p = 0.421). In the control group, the tendon midsubstance was disorganized with randomly and loosely arranged collagen fibers and rounded fibroblastic nuclei. The TB interface was predominantly fibrous with small regions of fibrocartilage, especially mineralized fibrocartilage. In the DBM group, the tendon midsubstance appeared normal and comprised densely arranged collagen fibers, with orientated crimped collagen fibers running in the longitudinal direction of the tendon. These fibers were interspersed with elongated fibroblast nuclei. The TB interface consisted of organized collagen fibers with large quantities of fibrocartilage and mineralized fibrocartilage. @*Conclusions@#The use of DBM for TB interface healing in rabbit experiments showed good results in gross and histologic analysis. However, it is difficult to draw a solid conclusion because the sample size is small. Further evaluation in the in vivo setting is necessary to determine clinical recommendations.

Does Demineralized Bone Matrix Enhance Tendon-to-Bone Healing after Rotator Cuff Repair in a Rabbit Model?

Background@#The purpose of this study was to compare the histologic outcomes of rotator cuff (RC) repair with demineralized bone matrix (DBM) augmentation and those without DBM augmentation and to evaluate the role of DBM for tendon-to-bone (TB) healing in a rabbit model. @*Methods@#Twenty-six adult male New Zealand white rabbits were randomly allocated to the control group (n = 13) or the DBM group (n = 13). Repair was performed 8 weeks after complete transection of the right supraspinatus tendon of all rabbits. In the control group, RC repair was achieved by a standard transosseous technique. In the DBM group, RC repair was achieved using the same technique, and DBM was interposed between the cuff and bone. After 8 weeks, the RC tendon entheses from all rabbits were processed for gross and histologic examination. @*Results@#On gross TB healing, 2 of 11 specimens in the control group were unhealed and no specimen was grossly unhealed in the DBM group (p = 0.421). In the control group, the tendon midsubstance was disorganized with randomly and loosely arranged collagen fibers and rounded fibroblastic nuclei. The TB interface was predominantly fibrous with small regions of fibrocartilage, especially mineralized fibrocartilage. In the DBM group, the tendon midsubstance appeared normal and comprised densely arranged collagen fibers, with orientated crimped collagen fibers running in the longitudinal direction of the tendon. These fibers were interspersed with elongated fibroblast nuclei. The TB interface consisted of organized collagen fibers with large quantities of fibrocartilage and mineralized fibrocartilage. @*Conclusions@#The use of DBM for TB interface healing in rabbit experiments showed good results in gross and histologic analysis. However, it is difficult to draw a solid conclusion because the sample size is small. Further evaluation in the in vivo setting is necessary to determine clinical recommendations.

Treatment Methods for Functional Recovery after Total Knee Arthroplasty / 대한정형외과학회잡지

Total knee arthroplasty is performed widely in degenerative arthritis of the knee joint, and the frequency of use is increasing. Efforts should be made to achieve functional recovery, such as returning to daily life, and the recovery of strength and range of motion after surgery. The procedure should be approached from a range of perspectives, such as patient factors, surgical technique and rehabilitation. The patient’s age, degree of obesity, sex, and strength of the quadriceps muscle can affect the functional recovery after surgery. In addition, the patient’s mental state, such as expectation value and satisfaction, can also have an effect. For functional recovery, patient education, pain control, and strengthening of the quadriceps muscle can be performed prior to surgery. Postoperative physiotherapy, such as icing and compression, transcutaneous electrical nerve stimulation therapy, neuromuscular electrical stimulation therapy, low frequency low intensity magnetic field therapy, strengthening of quadriceps muscle, and range of motion exercise can also be applied. In recent years, hydrotherapy, which restores the strength and balance of the leg, is being performed increasingly. These treatments are not only performed shortly after surgery, but are also performed continuously. In addition, the surgeon should apply it appropriately considering the patient’s condition, compliance, and social and psychological conditions.

Arthroscopic Treatment of Infrapatellar Fat Pad Impingement between the Patella and Femoral Trochlea: Comparison of the Clinical Outcomes of Partial and Subtotal Resection

PURPOSE: To compare the clinical outcomes of arthroscopic partial and subtotal resection of the impinged infrapatellar fat pad (IFP). MATERIALS AND METHODS: This study enrolled 55 patients with IFP impingement who underwent partial resection (n=29, P group) or subtotal resection (n=26, S group). Clinical outcomes at least 2 years postoperatively were evaluated using a visual analog scale (VAS) for pain, the International Knee Documentation Committee (IKDC) 2000 subjective knee score, and the Lysholm score. RESULTS: In the P group, the preoperative mean VAS, IKDC 2000, and Lysholm scores were 5.6±0.61, 47.5±7.41, and 42.5±7.17, respectively, which improved significantly to 1.4±0.63, 70.9±6.15, and 82.2±7.61, respectively (all, p≤0.001). In the S group, the preoperative mean VAS, IKDC 2000, and Lysholm scores were 5.7±0.43, 47.7±9.09, and 45.2±4.18, respectively, which improved significantly to 1.8±0.77, 71.9±9.33, and 82.3±6.01, respectively (all, p≤0.001). There were no significant differences in any outcome measure between the groups at the final follow-up. CONCLUSIONS: Arthroscopic resection of the impinged IFP between the patella and femoral trochlea resulted in favorable clinical outcomes regardless of whether the resection was partial or subtotal. Thus, partial resection can be an appropriate treatment option, considering partial resection was as effective as subtotal resection and retained more of the IFP.

Femoral Footprint for Anatomical Single-Bundle Anterior Cruciate Ligament Reconstruction: A Cadaveric Study

PURPOSE: To identify the femoral footprint of the anterior cruciate ligament (ACL) in Koreans. MATERIALS AND METHODS: Eighteen embalmed cadaveric knees (mean age, 70 years) were examined. First, the shape of the ACL was determined macroscopically. After the ACL femoral footprint was defined, the ACL was cut from the femur and a Kirschner wire was inserted into the center of the ACL, and the position was verified with a C-arm. The position was quantified on the C-arm field using the quadrant method. The length and width of the ACL were measured. RESULTS: Macroscopically, the ACL is a flat single bundle with an average length of 34 mm and an average width of 9 mm. On average, the center of the ACL insertion site measured with the quadrant method was positioned at 29.5%±2.8% in an anterior direction (from posterior), and at 38.5%±3.2% in a distal direction (from Blumensaat's line). The anterior and posterior margins of the ACL femoral footprint were the resident's ridge and the cartilage margin of the lateral femoral condyle, respectively. CONCLUSIONS: The center of the ACL femoral footprint is positioned more anteriorly and distally than the positions identified in previous studies.

Delayed Sciatic Nerve Palsy due to Hematoma Related with Anticoagulants Prophylaxis in the Femur Intramedullary Nailing: A Case Report

Femur intramedullary nailing can be one of the most predictable procedures in orthopedic traumatology. The advantage of this method is that the fracture site does not have to be widely exposed for reduction, which can minimize soft tissue damage. For this reason, the incidence of complications related to hematoma has been rare. We experienced only one case of sciatic nerve palsy due to hematoma after intramedullary nailing; the patient was receiving an anticoagulant therapy. Therefore, we report this case with literature review.

Anterolateral Meniscofemoral Ligament of the Lateral Meniscus

Anatomical variations of the meniscus are a common anomaly that knee surgeons frequently encounter. However, anomalies of the anterior horn of the lateral meniscus (AHLM) are extremely rare. In this report, we present a newly discovered anomaly of the AHML: an anterolateral meniscofemoral ligament is described with clinical features and radiographic and arthroscopic findings.

The Optimal Suture Site for the Repair of Posterior Horn Root Tears: Biomechanical Evaluation of Pullout Strength in Porcine Menisci

PURPOSE: There are few studies on biomechanical evaluation of suture points in repair of root tears. The purpose of this study was to determine the point of greatest pullout strength for root tear repair. MATERIALS AND METHODS: A total of 120 fresh porcine medial menisci were obtained. The red-red and red-white zones of the meniscus were divided by two lines designated as lines A and B (groups A and B). Groups A and B were further divided into three groups each by dividing lines A and B into three points: 3, 5, and 7 mm from the meniscal ligament root insertion. Vertical meniscal repair was performed on each point. The pullout failure strength was tested using a biaxial servohydraulic testing machine. RESULTS: The average maximal load at failure was significantly greater in group A than group B (87.65 vs. 62.93; p<0.001) The average length at maximal load failure was greater in group A than group B (4.35 vs. 3.2; p<0.001). Among the subgroups of 3, 5, and 7 mm in both groups A and B, 7 mm showed the greatest maximal load (p<0.001). CONCLUSIONS: The pullout strength was statistically significantly greater in group A than group B and in the 7 mm subgroup than the 3 and 5 mm subgroups. Thus, the 7 mm subgroup in group A showed the greatest pullout strength.

Septic Knee Arthritis Caused by Staphylococcus lugdunensis After Intraarticular Injection Therapy

Staphylococcus lugdunensis is a coagulase-negative staphylococcus. However, it causes various clinically important human infections and behaves similar to Staphylococcus aureus. S. lugdunensis reportedly causes infective endocarditis, skin and soft tissue infection, bone and joint infection, septicemia, endarteritis, urinary tract infection, ocular infection, and peritonitis. There are no reports of septic arthritis by this organism in Korea. We presented a case of septic arthritis due to S. lugdunensis in an elderly patient with diabetes mellitus after an intra-articular injection.

Usefulness of Ultrasound-Guided Lower Extremity Nerve Blockade in Surgery for Patellar Fracture

PURPOSE: To evaluate the usefulness of ultrasound-guided nerve blockade in patellar fracture surgery. MATERIALS AND METHODS: Twenty-three patients who underwent metal fixation under ultrasound-guided lower extremity blockade after diagnosis of patellar fracture from July 2011 to June 2012 were enrolled in this study. Under ultrasound guidance, femoral nerve, lateral femoral cutaneous nerve, obturator nerve, and sciatic nerve blockades were performed. For evaluation of anesthesia, interference with overall surgery, such as intraoperative knee pain and tourniquet pain, was checked. Individual anesthetic complications, satisfaction with nerve blocks, and choice of future anesthesia method were investigated. RESULTS: Nineteen patients underwent surgery without any pain and 4 patients with mild pain. Satisfaction was excellent in 17 patients, good in 5, and unsatisfactory in 1. No complications such as infection or nerve injury occurred. In terms of selection of future anesthesia, 22 patients chose a nerve blockade of the lower extremity under ultrasound guidance, and one chose general anesthesia. CONCLUSIONS: Overall, ultrasound-guided nerve block of the lower extremity for patellar fracture surgery showed satisfactory results. Therefore, it could be a useful method to prevent complications associated with general or spinal anesthesia.

Localized Nodular Tenosynovitis Originated near the Medial Plicae

The authors report a case of localized nodular tenosynovitis originating from the medial plicae of the knee that was grossly observable, palpable, and symptomatic. A 41-year-old male visited our hospital with a complaint of knee pain that began 4 years ago. He complained of intermittent catching and a mass that appeared in the medial side of the knee 18 months ago. On magnetic resonance imaging, the mass was found on the plicae area of the medial side of the knee, and thus excisional biopsy was performed under arthroscopy. Histological study showed characteristics of localized nodular tenosynovitis originating from the synovium of the knee. At the 1-year postoperative outpatient follow-up, no symptoms or signs of recurrence were found. Since the authors experienced excellent postoperative results of arthroscopically assisted resection of a grossly observable and palpable localized nodular tenosynovitis originating from the synovium of the knee plicae, we report the case with a review of the literature.

Correlation of Adjacent Segmental Disease with Tilt Angles of the Upper and Lower Instrumented Vertebra in the Degenerative Lumbar Scoliosis

STUDY DESIGN: Retrospective study. OBJECTIVES: To evaluate the correlation of adjacent segmental disease with tilt angles of the upper and lower instrumented vertebra after instrumented posterolateral fusion for degenerative lumbar scoliosis. SUMMARY OF LITERATURE REVIEW: There has been no study of radiologic measurement and decision of fusion level using the angle of pedicle screws inserted for treatment of degenerative lumbar scoliosis. MATERIALS AND METHODS: From 2004 to 2008, 74 patients that underwent decompression and posterolateral fusion for degenerative lumbar scoliosis were included in this study. In all cases, instrumentation and posterolateral fusion were both performed. The sex ratio was 31:43, the mean age was 68.7 years and the mean follow up duration was 37.4 months. The angle between each upper end plate of the upper vertebral body and lower end plate of the lower vertebral body of the fusion, and the line parallel to the axis of the sagittal line of vertebrae was each defined as UIV-a and LIV-b. The correlation of development of adjacent segment disease and UIV-a, and LIV-b angle was investigated. RESULTS: Sum of the absolute value of UIV-a and LIV-b had a statistically significant positive correlation with that of adjacent segment disease. Also, UIV-a alone, had a statistically positive correlation with the development of proximal adjacent segment disease. CONCLUSIONS: Since it is proven that adjacent segment disease has positive correlation with the sum of the absolute value of UIV-a and LIV-b, the extent of fusion should be adjusted to make the line parallel to the line perpendicular to the sagittal surface.

Prognostic Factors of Arthroscopic Adhesiolysis for Arthrofibrosis of the Knee

PURPOSE: To assess the results of arthroscopic adhesiolysis for arthrofibrosis of the knee and to investigate possible prognostic factors. MATERIALS AND METHODS: Among the patients who developed arthrofibrosis after knee joint surgery, 68 patients who underwent arthroscopic adhesiolysis and were available for at least one-year follow-up were evaluated with regard to the Lysholm knee score, International Knee Documentation Committee (IKDC) subjective knee score, patient satisfaction, and range of motion (ROM) of the knee. The influence of possible prognostic factors including the cause of arthrofibrosis, duration of disease, and age of the patient on the postoperative ROM was analyzed. RESULTS: Sixty-one patients (89.7%) obtained an average increase of 48.6degrees in ROM; however, the remaining seven patients (10.3%) did not show any increase at the final follow-up. The Lysholm knee score and IKDC subjective knee score increased significantly at the final follow-up. Patient satisfaction was high or very high in 89.7% of the patients at the final follow-up. There was no association between the cause of arthrofibrosis and the increase in postoperative ROM. The duration of disease was significantly related to the postoperative recovery of ROM. Age had no significant influence on the postoperative recovery of ROM. CONCLUSIONS: We believe that arthroscopic adhesiolysis is effective for the treatment of intraarticular arthrofibrosis. In particular, the duration of the disease had significant influence on the postoperative outcome.

The Relationship between the Pedicle Screw Loosening and Bone Mineral Density after Transpedicular Spinal Instrumentation / 대한골다공증학회지

OBJECTIVES: We have analyzed relationship between pedicle screw loosening and bone mineral densitiy (BMD) after spinal arthrodesis with pedicle screw. MATERIALS AND METHODS: We have chosen 31 cases that had screw loosening radiologically on the follow up X-ray among the patients who underwent spinal arthrodesis with pedicle screws, and compared Saville's index that was measured by lateral view of preoperative X-ray with Dual energy X-ray absortiometry (DEXA) score.

Patellofemoral Osteoarthritis

Patellofemoral arthritis is a fairly common disease, and it has been gaining interest with increasing number of studies due to its diverse treatment methods. Patellofemoral arthritis has a broad range of management options according to the characteristics of individual diseases. Identifying whether patellofemoral arthritis is the primary cause of knee pain and is compartment arthritis is necessary for establishing an adequate treatment method. Through investigation of the literature, the issues of recent knowledge of femoropatella arthritis and the diagnosis and treatment of which were studied.

Clinical Presentation of Staphylococcus epidermidis Septic Arthritis Following Anterior Cruciate Ligament Reconstruction

PURPOSE: This study evaluated the clinical presentations of Staphylococcus epidermidis (S. epidermidis) septic arthritis after arthroscopic anterior cruciate ligament reconstruction (ACLR). MATERIALS AND METHODS: Between September 2006 and February 2008, S. epidermidis septic arthritis developed in six patients following arthroscopic ACLR. We reviewed the medical records retrospectively and interviewed the patients. RESULTS: The average interval between ACLR and symptom onset was 4.7 days (range, 2 to 8 days). Local warmth, swelling limited knee motion and general malaise were observed in varying degrees in all the patients. The fever was generally slight with an intermittent spiking pattern. Postoperative erythrocyte sedimentation rate and C-reactive protein were elevated. After the development of infection, the joint was aspirated in all cases. The white blood cell count was at least 22,400, with the presence of 80 to 90% of polymorphonuclear cells. All the patients had a few Gram-positive cocci and positive cultures for S. epidermidis. CONCLUSIONS: The symptoms, signs and laboratory findings of S. epidermidis septic arthritis following ACLR are nonspecific with various clinical presentations. So the diagnosis is often delayed. Positive gram staining can be used to confirm septic arthritis. Careful observation for septic arthritis is advised in case of presence of any abnormality after ACLR.

Symptomatic Posterior Cruciate Ganglion Cyst Causing Impingement between Posterior Root of the Medial Meniscus and Anterior to the Posterior Cruciate Ligament

There are several reports of symptomatic ganglion cysts near the posterior cruciate ligament (PCL), but no reports of a symptomatic ganglion originating from the anterior aspect of the PCL in the deep recess between the posterior root of the medial meniscus and the PCL, bulging into the posteromedial joint space. In this report, we present the clinical features of a patient with a symptomatic ganglion cyst treated successfully by arthroscopic excision.

The Differentiation of Phase of Spinal Cord Injury Based on the Changes in Gene Expression

STUDY DESIGN: An experimental study. OBJECTIVES: To define the phases of chronic spinal cord injury by researching the changes in gene expression. SUMMARY OF LITERATURE REVIEW: The exact time of conversion from acute stage to chronic stage in spinal cord injury is unknown. MATERIALS AND METHODS: We used 18 month-old Beagle dogs as study subjects. Under spinal cord monitoring, we underwent laminectomy on thoracic vertebra 10 and 11, and induced cord injury by a weight-drop injury method. Dogs in each group with spinal cord injury and group without spinal cord injury on POD 1, 7, 30, and 90. The motor functions were evaluated using the Tarlov scale. Tissues were prepared from 0.5cm up and down from the 10th thoracic level. Additional cephalic and caudal lesions from the injured site were prepared. We have checked the differentially expressed gene(DEG). RESULTS: The mean Tarlov value was 0.67 which indicated a significant cord injury. 4 DEG (GP3, 9, 25, 34) were detected among 40 primers after screening, the detection percentage of which was 10. In the tissues of study subjects with spinal injury, DEG was found at the injury site and cephalic lesion. DEG expressed GP3, GP9 and GP34 started expression on day 30, and GP25 was expressed on day 90. CONCLUSIONS: According to the changes in gene expression, the day 30 would be considered as the date of conversion from acute to chronic phase of cord injury. Inhibiting secondary inflammatory change and apoptosis following spinal cord injury until this period would maximize the effect of chronic phase therapy such as cell-transplantation.

Epidemiology of the Spinal Cord and Cauda Equina Injury in Korea: Multicenter Study

STUDY DESIGN: Multi-center study, questionnaire survey. OBJECTIVES: To offer a database of spinal cord injury (SCI) by reviewing statistics and literatures of other countries, investigating the overall mechanism, injury patterns and treatment of SCI. SUMMARY OF LITERATURE REVIEW: There are no preexisting domestic studies (collectively conducted by multi-centers) of the prevalence and treatment of SCI. MATERIALS AND METHODS: From September 2006 to August 2009, 47 cases of SCI in 6 universities were investigated retrospectively. 17 questionnaire contents including the courses of injury-to-treatment were studied with data gathered from surveys. RESULTS: The average age of patients was 48.4-years-old, male to female ratio was 33 to 14. The cases of falling from a height were 22 cases (47%), lumbar area 19 cases (40%), and unstable bursting fracture 24 cases (51%) the most. Complete and incomplete paralyses were 19 cases (40%) and 28 cases (60%), respectively. High dose steroids were injected in 16 cases (NASCIS II) and 9 cases (NASCIS III). 14 cases presented complications and operations were performed 46 cases (98%). 12 cases (26%) arrived at the hospital within 4 hours of injury, 11 cases (23%) in 8 hours. On the way to the hospital, proper emergency treatment was performed in 25 cases (53%), and 30 cases (64%) had a clear understanding of SCI after the final diagnosis. CONCLUSIONS: This is the first study that offers a comprehensive database of spinal cord injury (SCI), by investigating the overall mechanism, injury patterns, and treatment of SCI; this study is expected to be used in the future as an important reference material for spinal cord injury statistics and a standard for care.