Ultrasound-Guided Shoulder Injections / 대한정형외과학회잡지

The shoulder pain is one of the most common problems to orthopaedic surgeons in clinic. Among therapeutic modality used to manage this pain, joint and periarticular injection, as well as suprascapular nerve block, show good clinical outcome. Ultrasound guidance is a safe technique, increasing the safety and accuracy of the procedure and reducing complications. An accurate understanding of the surface anatomy is important in performing the ultrasound-guided shoulder injections. This article aims to describe the surface anatomy and sono anatomy of both the shoulder and the surrounding structures and also summarize different infiltration techniques and peripheral nerve blocks.

The Volume of Subscapularis Muscle Remains Unaffected by Supraspinatus Tendon Tears: Three-dimensionally Reconstructed Magnetic Resonance Imaging Analysis

BACKGROUND: This study aimed to compare the subscapularis muscle volume between the intact groups (group I) and supraspinatus tendon tear groups (group T) based on the sex and three different age groups. METHODS: Subjects with a group I and subjects with group T without any other lesions were retrospectively evaluated from among patients who received a magnetic resonance imaging (MRI) scan between January 2011 and December 2013. The MRI scans were studied by a consultant radiologist. The subscapularis muscle volume was compared according to the age and sex; the age groups were categorized as patients in their 40s, 50s, and 60s. The volume of subscapularis muscle was measured by three-dimensional reconstructed images acquired through the axial section of 1.5T MRI. RESULTS: No statistically significant differences were observed between subscapularis muscle volume of the group I and group T, except for male patients in their 50s (group I: 100,650 mm3 vs. group T: 106,488 mm3) and 60s (group I: 76,347 mm3 vs. group T: 99,549 mm3) (p<0.05). Males had a larger mean volume of subscapularis muscle than females, and the subscapularis muscle volume decreased in a linear manner with increasing age. CONCLUSIONS: Decrease in subscapularis muscle volume was observed with increasing age, and the impact of supraspinatus tear on subscapularis muscle volume is age and sex dependent.

Three-dimensional Capsular Volume Measurements in Multidirectional Shoulder Instability

BACKGROUND: In a previous study undertaken to quantify capsular volume in rotator cuff interval or axillary pouch, significant differences were found between controls and patients with instability. However, the results obtained were derived from two-dimensional cross sectional areas. In our study, we sought correlation between three-dimensional (3D) capsular volumes, as measured by magnetic resonance arthrography (MRA), and multidirectional instability (MDI) of the shoulder. METHODS: The MRAs of 21 patients with MDI of the shoulder and 16 control cases with no instability were retrospectively reviewed. Capsular areas determined by MRA were translated into 3D volumes using 3D software Mimics ver. 16 (Materilise, Leuven, Belgium), and glenoid surface area was measured in axial and coronal MRA views. Then, the ratio between capsular volume and glenoid surface area was calculated, and evaluated with control group. RESULTS: The ratio between 3D capsular volume and glenoid surface area was significantly increased in the MDI group (3.59 ± 0.83 cm³/cm²) compared to the control group (2.53 ± 0.62 cm³/cm²) (p < 0.01). CONCLUSIONS: From these results, we could support that capsular volume enlargement play an important role in MDI of the shoulder using volume measurement.

A 3-dimensional Printed Molding Technique for the Management of Humeral Head Osteomyelitis

There are many methods of making cement spacer in patients who require a two-staged operation for humeral head osteomyelitis. However, limitation of motion after the first surgery—due to inadequate size and insufficient intra-articular space for second surgery—remain to be an issue. To mitigate this issue, we made a cement spacer with the same size and shape of the patient humeral head. Four patients with humeral head osteomyelitis were enrolled in this study. To make the cement spacer, we used the Mimics program, and designed the molding box by a reverse engineering technique. We evaluated the range of motion and pain using a Constant score. The mean abduction was 50° (40°–60°), forward flexion was 50° (30°–70°), and average Constant score was 47.75 (44–52). Three-dimensional printed molding technique is one of the effective methods for humeral head osteomyelitis allowing for daily activities prior to the second surgery.

A 3-dimensional Printed Molding Technique for the Management of Humeral Head Osteomyelitis

There are many methods of making cement spacer in patients who require a two-staged operation for humeral head osteomyelitis. However, limitation of motion after the first surgery—due to inadequate size and insufficient intra-articular space for second surgery—remain to be an issue. To mitigate this issue, we made a cement spacer with the same size and shape of the patient humeral head. Four patients with humeral head osteomyelitis were enrolled in this study. To make the cement spacer, we used the Mimics program, and designed the molding box by a reverse engineering technique. We evaluated the range of motion and pain using a Constant score. The mean abduction was 50° (40°–60°), forward flexion was 50° (30°–70°), and average Constant score was 47.75 (44–52). Three-dimensional printed molding technique is one of the effective methods for humeral head osteomyelitis allowing for daily activities prior to the second surgery.

Evaluation of Focal Bone Mineral Density Using Three-dimensional Measurement of Hounsfield Units in the Proximal Humerus

BACKGROUND: Although there are several methods for evaluating bone quality, Hounsfield units (HU), a standardized computed tomography (CT) attenuation coefficient, provide a useful tool for estimating focal bone mineral density (BMD). The aim of this study is to investigate the HU for evaluating the degree of osteoporosis in greater tuberosity with regard to anchor positioning. METHODS: Forty patients diagnosed as normal on shoulder CT were included and categorized according to age and gender. Axially sectioned CT images were processed to 3-dimensional models containing information about bone quality using Mimics (14.11 platform v14.1.1.1 Materialise). Three-dimensional anchors were simulated and positioned according to 6 regions of interest (ROI) in the greater tuberosity classified using Tingart's system. Mean HU of intra-anchor volumes in the 6 regions was measured. RESULTS: A significant decrease in HU was observed with increasing age (p=0.0001) and menopause (p<0.001). A significant difference in HU was found between male and female groups with males showing the higher values (p=0.0001). HU of proximal areas of ROI was higher than those of distal areas (p<0.005). However, although mean HU of distal posterior ROI showed the lowest values, no statistically significant difference was found between anterior, middle, and posterior regions (p=0.087). CONCLUSION: Mean HU of ROIs provides a tool for preoperative assessment of focal BMD, which is a factor of suture anchor stability and can be used to aid decision-making regarding secure anchor positioning for rotator cuff repair. Our data support that the most secure point is the proximal regions of ROI.

Evaluation of Focal Bone Mineral Density Using Three-dimensional Measurement of Hounsfield Units in the Proximal Humerus

BACKGROUND: Although there are several methods for evaluating bone quality, Hounsfield units (HU), a standardized computed tomography (CT) attenuation coefficient, provide a useful tool for estimating focal bone mineral density (BMD). The aim of this study is to investigate the HU for evaluating the degree of osteoporosis in greater tuberosity with regard to anchor positioning. METHODS: Forty patients diagnosed as normal on shoulder CT were included and categorized according to age and gender. Axially sectioned CT images were processed to 3-dimensional models containing information about bone quality using Mimics (14.11 platform v14.1.1.1 Materialise). Three-dimensional anchors were simulated and positioned according to 6 regions of interest (ROI) in the greater tuberosity classified using Tingart's system. Mean HU of intra-anchor volumes in the 6 regions was measured. RESULTS: A significant decrease in HU was observed with increasing age (p=0.0001) and menopause (p<0.001). A significant difference in HU was found between male and female groups with males showing the higher values (p=0.0001). HU of proximal areas of ROI was higher than those of distal areas (p<0.005). However, although mean HU of distal posterior ROI showed the lowest values, no statistically significant difference was found between anterior, middle, and posterior regions (p=0.087). CONCLUSION: Mean HU of ROIs provides a tool for preoperative assessment of focal BMD, which is a factor of suture anchor stability and can be used to aid decision-making regarding secure anchor positioning for rotator cuff repair. Our data support that the most secure point is the proximal regions of ROI.

EndNote X7 for Medical Writing

No abstract available.

Portable Document Format File Showing the Surface Models of Cadaver Whole Body

In the Visible Korean project, 642 three-dimensional (3D) surface models have been built from the sectioned images of a male cadaver. It was recently discovered that popular PDF file enables users to approach the numerous surface models conveniently on Adobe Reader. Purpose of this study was to present a PDF file including systematized surface models of human body as the beneficial contents. To achieve the purpose, fitting software packages were employed in accordance with the procedures. Two-dimensional (2D) surface models including the original sectioned images were embedded into the 3D surface models. The surface models were categorized into systems and then groups. The adjusted surface models were inserted to a PDF file, where relevant multimedia data were added. The finalized PDF file containing comprehensive data of a whole body could be explored in varying manners. The PDF file, downloadable freely from the homepage (http://anatomy.co.kr), is expected to be used as a satisfactory self-learning tool of anatomy. Raw data of the surface models can be extracted from the PDF file and employed for various simulations for clinical practice. The technique to organize the surface models will be applied to manufacture of other PDF files containing various multimedia contents.

Evaluation of Shoulder Disorders by 2-F-18-fluoro-2-deoxy-D-glucose Positron Emission Tomography and Computed Tomography

BACKGROUND: Although flourine-18-flourodeoxyglucose (FDG) positron emission tomography (PET) has a limitation for localizing anatomical structures, combining it with computed tomography (CT) has made it more efficient for overcoming such limitations. This study aims to evaluate the efficacy of PET/CT for evaluating diseases of the shoulder. METHODS: Retrospective examination was performed on 25 patients who underwent FDG-PET/CT scanning. All the patients were over 60 years of age, and they were evaluated both clinically and radiologically for shoulder pain. The study period was from May, 2006 to May, 2008. One of the patients had metastatic lesion in a shoulder and this patient was excluded from the study, so the total number of subjects in the study was finally 24 patients. RESULTS: PET/CT showed 67% sensitivity, 73% specificity, a positive predictive value of 60%, a negative predictive value of 79%, 27% false positivity and 33% false negativity concerning shoulder pain. PET/CT showed negative finding in 4 cases that were successfully treated by operative treatment (rotator cuff tear [RCT], 3 cases; impingement syndrome, 1 case). Negative findings were also noted in 6 cases in which the pain subsided after conservative treatment (RCT, 1 case; suspected RCT, 2 cases; impingement syndrome, 3 cases). All the patients with osteoarthritis and rheumatoid arthritis had positive findings on PET/CT scanning. CONCLUSIONS: PET/CT is a useful adjunct to the existing imaging modalities to assess functional and pathophysiologic processes and at a very early stage, and so PET/CT can help physicians make better preoperative and postoperative decisions on treatment.

Arthroscopic Bankart Repair for Post-seizure Anterior Instabilities of Shoulder : 2 Cases Report

PURPOSE: These case reports have been prepared to highlight the uncommon occurrence of anterior shoulder dislocation after an epileptic seizure, the recognition of which is important as this type of injury is associated with bony lesions and a high incidence of recurrence. MATERIALS AND METHODS: We report two cases of recurrent anterior dislocation of the shoulder due to grand mal epilepsy. These cases were treated as usual anterior dislocations of the shoulder, and were regularly followed to detect any recurrence of shoulder instability. RESULTS: Outcome of the surgery in the two cases was different because of the differences in seizure control. In the patient in whom seizures were well-controlled, there was no recurrence of instability, while the patient with poorly controlled seizures developed a recurrence of the dislocation following shoulder repair. CONCLUSION: The authors emphasize the need to control seizures in order to prevent injury recurrence in this subset of patients.

Arthroscopic Treatment with Suture Anchor for the Isolated Subscapularis Tear

PURPOSE: We wanted to evaluate the results of arthroscopic management of an isolated rupture of the subscapularis tendon using suture anchors. MATERIALS AND METHODS: Twenty nine patients with unilateral ruptures of the subscapularis tendon and who underwent arthroscopic repair between February 2001 and October 2007 were reviewed prospectively. All the cases were isolated tears of the subscapularis without the involvement of any other rotator cuff tendon. In 19 patients the tear was localized to the superior one third, in 7 cases the tear was localized to the upper two thirds and the entire tendon was involved in 3 cases. The mean follow up period was 12.2 months (range: 6-26 months). The results of the treatment were assessed by evaluating the constant shoulder score and the pain score before surgery and after surgery. RESULTS: The constant shoulder score improved from 49.9+/-7.3 to 73.8+/-3.0 points compared to before surgery and the pain score improved from 4.3+/-3.2 to 11.2+/-3.0 points postoperatively. CONCLUSION: Arthroscopic repair of isolated ruptures of the subscapularis tendon using suture anchors is a good option for effectively managing these tears.

The Primary Reverse Total Shoulder Arthroplasty for Post-septic Destroyed Shoulder: A Case Report

PURPOSE: We report here on a solution for the case of a 71 year old lady with cartilage destruction in the left shoulder and the loss of the rotator cuff secondary to post-septic arthritic sequelae. MATERIALS AND METHODS: After thorough laboratory, clinical and radiological investigation of the patient to rule out any foci of active infection, we contemplated performing reverse total shoulder arthroplasty as a primary procedure. RESULTS: At 22 months follow up, the patient had an excellent result according to the UCLA and ASES scales. CONCLUSION: Reverse total shoulder arthroplasty seems to be an efficient procedure to improve pain and function in the post-septic shoulder accompanying severe rotator cuff injury.

Normal Glenoid Size of the Korean in 7th and 8th Decades

PURPOSE: We wanted to evaluate the normal glenoid size of Koreans in their 7th and 8th decades by conducting Computed tomographic (CT) studies. MATERIALS AND METHODS: The CT images were obtained from the normal scapulae of the patients (mean age: 68.8) who had humeral fracture. A display workstation version 2.0.73.315 was used to measure the scans to determine the maximal superoinferior (SI) and anteroposterior (AP) diameters of the glenoid vault. RESULTS: The average diameters of curvature of the glenoid were 31.2 mm (range: 27 to 34 mm) in the superior-inferior direction and 26.1mm (range: 22 to 31mm) in the anterior-posterior direction. CONCLUSION: This study showed the normal glenoid size of Koreans and it is different from the size that the international literature reported. It should be an important factor for the treatment of fracture or in designing arthroplasty implants.

Bursoscopic Finding in Primary Adhesive Capsulitis of the Shoulder

PURPOSE: To evaluate the bursoscopic findings of refractory primary adhesive capsulitis of the shoulder and to determine the clinical correlation. MATERIALS AND METHODS: Arthroscopic capsular release was performed in 21 refractory adhesive capsulitis patients who had not responded to conservative treatment. The VAS for pain, range of motion, UCLA score was checked before and after surgery, and at the last follow up. RESULTS: Bursitis, mild friction and impingement on coracoacromial ligament, as well as adhesion were observed. The function and pain improved earlier than after simple acromiohumeral joint capsular release. CONCLUSION: Subacromial bursoscopy helps rule out a hidden secondary frozen shoulder or secondary changes with primary adhesion. In addition, it has the advantage of being both a treatment and procedure for making a prognosis.

Autologous bone marrow plasma injection after arthroscopic debridement for elbow tendinosis

<p><b>INTRODUCTION</b>The treatment of tendinosis of elbow can be challenging, yet rewarding. Nevertheless, for the patients who failed conservative management and develop persistent recalcitrant symptoms, surgical intervention should be considered. The hypothesis of this study is iliac bone marrow plasma injection after arthroscopic debridement of degenerative tissue will bring along biological cure. Thus, it will not only reduce pain but also improve function in patients with resistant elbow tendonitis.</p><p><b>MATERIALS AND METHODS</b>Twenty-four patients (26 elbows) with significant persistent pain for a mean of 15 months, despite of standard rehabilitation protocol and a variety of other nonsurgical modalities were treated arthroscopically. We applied autologous iliac bone marrow plasma injection following arthroscopic debridement. This material is produced by centrifugation of iliac bone marrow blood at 1,800 rpm for 20 to 30 minutes. Patients were allowed full range of motion (ROM) exercise after 2 to 3 days. Cytokine analyses for this injective material were done. Outcome was rated by postoperative sonography, visual analog pain scores (VAS) and Mayo elbow performance scores (MEPS) at 8 weeks and 6 months follow-up. Informed consent had been obtained from the subjects, and the study protocol was approved by the ethics committee of Chosun University Hospital, Korea.</p><p><b>RESULTS</b>All patients in this study noted improvement both in their VAS and MEPS. No complication occurred in any patient. Evidence of tendon healing was observed in postoperative sonographic examination. Predominant cytokines of this study were interleukin-12 (IL-12), interferon-gamma-inducible protein-10 (IP-10) and RANTES.</p><p><b>CONCLUSION</b>Biologic treatments in orthopaedics are just beginning to evolve. In the present investigation, the injection of iliac bone marrow plasma after arthroscopic debridement in severe elbow tendinosis demonstrated early recovery of daily activities and clear improvement.</p>

Evaluation of Infrequent-Restriction-Site PCR for Epidemiological Typing of Candida tropicalis / 대한임상미생물학회지

BACKGROUND: We evaluated the usefulness of a newly developed molecular typing method of infrequent restriction site polymerase chain reaction (IRS-PCR) as an epidemiological DNA fingerprinting tool for Candida tropicalis. METHODS: Thirty-two strains of C. tropicalis comprising eight sporadic strains and 24 clonal strains belonging to six clones, of which clonal type were previously confirmed by pulsed-field gel electrophoresis (PFGE), were tested by IRS-PCR to evaluate the usefulness of this technique. Twenty strains of Candida species, including C. glabrata, C. krusei, C. albicans, and C. parapsilosis, were also tested to assess the ability of IRS-PCR to discriminate among species of Candida. RESULTS: Using the IRS-PCR assay, sporadic strains of C. tropicalis could not be differentiated from clonal strains. Most strains belonging to the same clones were classified as different IRS-PCR types or clusters, and some different sporadic strains were classified as the same IRS-PCR types. When pattern variation was examined for different strains of C. tropicalis using IRS-PCR, pairwise similarity measured by the Dice coefficient was 75.4~100%. In contrast, pairwise similarity among isolates of five different species of Candida was 25~69.2%. Therefore, five different species of Candida were easily differentiated. CONCLUSION: The IRS-PCR typing assay appears to be an inadequate tool for the epidemiological typing of C. tropicalis, because the typing result of IRSPCR is not comparable to that of PFGE. To our knowledge, this is the first evaluation study for IRSPCR as an epidemiological typing tool for C. tropicalis.

Treatment of Senile Osteoporotic Intertrochanteric Fracture using Proximal Femoral Nail

PURPOSE: Clinical and radiologic results of femur intertrochanteric fractures treated with ITST nail in elderly patients with osteoporosis were analysized to evaluate the efficacy and complication of ITST nailing. MATERIALS AND METHODS: 32 patients who were treated with ITST nail due to femur intertrochanteric fracture and were followed up for more than 1 year were analysed. According to Evans classification, 11 cases were stable fractures and 21 cases were unstable fractures. Clinically, ambulatory function was compared and radiologically, BMD of healthy leg was checked with analysis of postoperative bone union and complication. RESULTS: In ambulatory function comparison before and after the operation, there were 9 cases of good, 17 cases of moderate and 6 cases of poor. Considering social activity after the operation, 7 cases showed normal ambulation, 9 cases showed ambulatory with one cane, 5 cases showed two cane ambulation and 11 cases showed dependent ambulation. In radiologic evaluation, T-score of ward triangle in healthy femoral neck showed BMD of -3.12. In 20 cases, bone union was observed within 3 months. The patients with low BMD result had poor outcome. There were 2 cases of intraoperative proximal femur fracture, 3 cases of nonunion and 4 cases of death within 1 year. CONCLUSION: In elderly patients with intertrochanteric fracture, ITST nailing is relatively efficient treatment. However, in pateint with severe osteoporosis (T-score<-3.0) and unstable fracture pattern, arthroplasty should be considered due to relatively high complicaton rate.

Discriminate between Traumatic and Degenerative Rotator Cuff Lesion in Rotator Cuff Injury Patient

No abstract available.

Life-threatening Airway Edema after Arthroscopic Repair of Massive Rotator Cuff Tear: A Case Report

Shoulder arthroscopic surgeries are an accepted technique for many shoulder disease and have many advantages over open surgeries4,6). To date, shoulder arthroscopic surgery have been rare complications that compromise patient airway, caused by the leakage of irrigation fluid out of the shoulder joint space into the surrounding soft tissues and then the neck and the pharynx. This report presents a case of life-threatening airway obstruction due to extra-articular saline collection during arthroscopic rotator cuff repair. In concluding we should hourly check the patient's neck swelling undergoing shoulder arthroscopic surgery, because anesthetized patients cannot complain of the airway problem may progress until it becomes life-threatening.