Predictive Variables for Sonographically Guided Corticosteroid Injection in Mild-to-Moderate Carpal Tunnel Syndrome

OBJECTIVE: To assess the predictive variables after sonographically guided corticosteroid injection in carpal tunnel syndrome. METHODS: A prospective, observational study was carried out on 25 wrists of 20 consecutive patients with carpal tunnel syndrome, confirmed by the American Association of Neuromuscular and Electrodiagnostic Medicine criteria, which includes clinical history, symptoms, and evidence of slowing of distal median nerve conduction. Visual analogue scale (VAS) and Boston Carpal Tunnel Questionnaire (BCTQ) were asked to the patients before and 4 weeks after the procedure. On a basis of VAS difference before and after the procedure, we divided the patients into two groups: more than 50% of VAS improving (good response group) and less than 50% of VAS improving (poor response group). Also, nerve conduction studies and ultrasound evaluations were performed prior to sonographically guided corticosteroid injection and at 4 weeks after the procedure. The cross-sectional area (CSA) of median nerve at maximal swelling point around wrist was measured by manual tracing using ultrasonography. With assessments mentioned above, we tried to assess predictive variables for prognosis after sonographically guided corticosteroid injection in carpal tunnel syndrome. RESULTS: The CSA of median nerve at wrist measured before the procedure was significantly larger in good response group than in poor response group. Furthermore, the CSA of median nerve at wrist, symptom severity scale of BCTQ, motor/sensory latency and sensory amplitude were correlated with VAS improving. CONCLUSION: The CSA of median nerve at wrist is the strongest predictive value for sonographically guided corticosteroid injection in mild-to-moderate carpal tunnel syndrome.

Conformity of Proximal Humerus Internal Locking Plate System (PHILOS) and Anatomic Features of Proximal Locking Screws: Cadaveric Study / 대한정형외과학회잡지

PURPOSE: The purpose of this cadaveric study was to evaluate the conformity of the anatomically preshaped proximal humerus internal locking plate system (PHILOS) to the humeri of the Korean and anatomical features of nine locking screws for the proximal humerus. MATERIALS AND METHODS: This study included 20 adult humeri (average length 30.2 mm) with no deformity or previous surgery. PHILOS was applied to the lateral surface of the proximal humerus according to the contour. Then, the distance from the outer surface of the plate to the greater tuberosity and bicipital groove was measured. After K-wires were passed through the proximal locking guide, the intra-osseous length of K-wire and the configuration of the K-wire exit were evaluated. RESULTS: The overall conformity of PHILOS was excellent at the lateral aspect of the proximal humerus. The tip of the plate had an average distance of 3.6 mm (range, 1.4-6.6 mm; standard deviation [SD], 1.27) from the greater tuberosity and 2.5 mm (range, 0.0-4.6 mm; SD, 1.24) at the bicipital groove and the average intra-osseous length of K-wire through the locking guide was 41.1 mm (range, 23.5-53.7 mm). K-wires were evenly penetrated through the humeral head. On H8 and H9, the bottom hole of PHILOS is closely located at the most inferior area of the humeral articular surface. The bicipital groove was pierced by K-wires of H5, which was the middle hole of PHILOS in four cases (20%). CONCLUSION: PHILOS had excellent conformity with the proximal humerus and K-wires through the locking guide were evenly penetrated through the humeral head. However, much care should be taken in piercing of the bicipital groove in H5.

Treatment Outcome of Langerhans Cell Histocytosis / 대한골관절종양학회지

PURPOSE: To analyze the clinical features and treatment outcome of Langerhans' cell histocytosis. MATERIALS AND METHODS: From August 1996 to June 2013, 28 patients who histologically proven with LCH were analyzed of medical records, radiography, pathologic character retrospectively. RESULTS: A total of 28 cases of LCH including 22 child has been reported. Onset age was 0.6 to 51 years old, occurred in the average age was 14.8 years. Follow-up period was 6 months to 134 months average was 44.6 months. The M:F ratio was 2.5:1. The initial symptoms was pain in 18 cases, 5 cases of pathologic fracture, 3 case of palpable mass, 1 case of discovered by accident in radiography, 1 case of torticollis. In radiological examination osteolysis was seen all cases, 7 cases showed a periosteal reaction, 1 case showed soft tissue extension. Clinical type of all cases were eosinophilic granuloma. 25 cases were classified as unifocal disease and 3 cases were multifocal single systemic diseases. In all cases, incisional biopsy was performed. After histologic confirmed, 14 cases was treated with curettage or surgical excision of the lesion and the other 14 cases were followed up without treatment. There is no death during follow up period. 11 cases has no radiological improvement after 3-6 months observation, intralesional steroid injection was performed. CONCLUSION: Patients with LCH who has rapid systemic onset is very rare, so if you meet the young children who suspected LCH, you shoulder avoid the examination which cause excessive radiation exposure to the young patient. In order to confirm the diagnosis of disease, biopsy is needed. Close observation after confirmed by histological method will bring the satisfactory results. But the patients who had pathologic fracture or wide bone destruction already may need curettage and bone grafting to lesion or internal fixation. The lesion which has no radiological improvement after 3-6 months observation or appear with pain interferes daily life may need local steroid injection as a good treatment.

Tumor Treated by Endoscopy

BACKGROUND: This study was conducted to examine the clinical usefulness and efficacy of endoscopic curettage on benign bone tumor. METHODS: Thirty-two patients (20 men and 12 women) with benign bone tumor were included in the study. The patients were aged between five and 76 years; the mean follow-up period was 27.05 months (range, 9.6 to 39.9 months). The primary sites include simple bone cyst (9 cases), fibrous dysplasia (6 cases), enchondroma (5 cases), non-ossifying fibroma (4 cases), bone infarct (3 cases), aneurysmal bone cyst (1 case), chondroblastoma (1 case), osteoblastoma (1 case), intraosseous lipoma (1 case), and Brodie abscess (1 case). A plain radiography was performed to assess the radiological recovery. Radiological outcomes, including local recurrence and bone union, were evaluated as excellent, good, poor, and recurred. RESULTS: In our series, there were 27 cases (84.4%) of good or better outcomes, six cases (18.8%) of complications (4 local recurrence, 1 wound infection, and 1 pathologic fracture). CONCLUSIONS: Our results showed that endoscopic curettage and bone graft had a lower rate of recurrence and a higher cure rate in cases of benign bone tumor. It can, therefore, be concluded that endoscopic curettage and bone graft might be good treatment modalities for benign bone tumors.

Surgical Fitness for Trochanteric Fracture in Elderly: Prospective Study

PURPOSE: The purpose of this study was to evaluate the risks of undergoing intramedullary nailing with minimum surgical optimization (fast-track) for geriatric trochanter fracture due to fall from a standing height. MATERIALS AND METHODS: From May 2006 to August 2013, 48 fractures were enrolled in fast-track, and were an average age of patients was 77.6 years (range, 62-97 years). They underwent primary testing for anesthesia, including basic body fluid test, arterial blood, electrocardiography, and chest radiographs. The time from visit to surgery was 28.9 hours (range, 1-96 hours). RESULTS: During hospitalization, there was one case of stress-induced cardiac arrest; however, other complications, infection, and 30-day mortality did not occur. According to preoperative classic test, the average albumin was 3.45 g/dl, blood sugar, 169 mg/dl, blood urea nitrogen, 20.5 mg/dl, Cr, 1.5 mg/dl, Na, 135.3 mEq/L, and K, 4.21 mEq/L. The average PaCO2 of arterial blood was 37.6 mmHg. CONCLUSION: We found that the fast-track for trochanteric fracture due to slip-down was relatively safe, and could be considered as a therapeutic approach.

The Analysis of Treatment of Aggressive Fibromatosis Using Oral Methotrexate Chemotherapy

BACKGROUND: Aggressive fibromatosis is a rare but invasive tumor infiltrating widely between fascia and muscle fibers. It has a high tendency to be locally recurrent despite complete resection. Effectiveness of adjuvant treatment for aggressive fibromatosis including radiotherapy, pharmacological agents, hormonal treatments, and chemotherapy have been previously reported. The purpose of this article was to collect and analyze all information regarding the effectiveness and side effects of oral methotrexate in aggressive fibromatosis. METHODS: From 2005 to 2011, eleven patients with aggressive fibromatosis treated with oral methotrexate at our institution were analyzed in this study. Oral methotrexate was administered once per week at 10 mg per week. Authors collected information about effectiveness concerning cases of local recurrence and metastasis. RESULTS: Eleven patients had remission, two patients had local recurrence. Fatal complications or toxicity were not observed. CONCLUSIONS: Oral methotrexate given at this dose and schedule was considered as a useful treatment in primary inoperable fibromatosis and recurrent fibromatosis.

Biologic Fixation through Bridge Plating for Comminuted Shaft Fracture of the Clavicle: Technical Aspects and Prospective Clinical Experience with a Minimum of 12-Month Follow-up

For comminuted shaft fracture of clavicle, the operative goal, aside from sound bone healing without complications of direct reduction, is maintenance of the original length in order to maintain the normal biomechanics of adjacent joint. Our bridge plating technique utilizing distraction through a lumbar spreader was expected to be effective for restoring clavicular length with soft tissue preservation. However, there are two disadvantages. First, there is more exposure to radiation compared to conventional plating; and second, it is difficult to control the rotational alignment. Despite these disadvantages, our technique has important benefits, in particular, the ability to preserve clavicular length without soft tissue injury around the fracture site.

The Efficacy of Percutaneous Long-Segmental Posterior Fixation of Unstable Thoracolumbar Fracture with Partial Neurologic Deficit

STUDY DESIGN: Retrospective analysis. PURPOSE: The aim of this study was to evaluate the clinical and radiological outcomes of patients with unstable thoracolumbar fracture (UTLF) who were treated by percutaneous long-segmental posterior fixation (PLSPF) by two vertebrae cranial to the fracture with two vertebrae caudal. OVERVIEW OF LITERATURE: To the best of our knowledge, PLSPF for stabilization of UTLF has not been reported. METHODS: The study involved retrospective analysis and investigation from the results of 27 patients who had undergone PLSPF for stabilization of a UTLF with partial neurologic deficit, over a follow-up period of two years. Kyphotic angle (KA), anterior vertebral height percentage (AVHP) and cross-sectional ratio of the displaced fragment within the spinal canal were evaluated with simple radiographs and axial computed tomography scans preoperatively and two years postoperatively. The clinical outcome for pain was assessed by a visual analogue scale (VAS) and Denis' scale, and the degree of neurologic deficit was measured by modified Frankel classification. RESULTS: Five patients had minor complications. The KA, AVHP, and cross-sectional ratio of the displaced fragment improved significantly after surgery (p<0.001, p<0.001, p<0.003, respectively). Neurologic recovery of one or more for the Frankel grade was seen in 19 patients with an average improvement of 1.7. The VAS and Denis' score improved significantly at a two year follow-up (p=0.02, p=0.012, respectively). CONCLUSIONS: The technique of PLSPF is useful for the treatment of UTLF with partial neurologic deficit, and produces decreased morbidity and fewer complications.

Anatomical Study of the Pronator Quadratus Muscle and Comparison to Fracture Sites of the Distal Radius / 대한정형외과학회잡지

PURPOSE: To collect data regarding the pronator-sparing approach using an anatomical study, which compared the fractures of the distal radius and pronator quadratus (PQ) muscle of an adult cadaveric radius. MATERIALS AND METHODS: Fourteen adult cadaver wrists that did not have previous fractures or previous surgery and computed tomography data 32 fractures of the distal radius, were obtained. The size of the distal fracture fragment was measured using the picture archiving and communication system. The distance between the distal margin of the PQ muscles and the articular margin was measured using a caliper. RESULTS: The PQ muscles had an average distance of 10.9 mm (range, 8-13 mm) from the radial styloid process and 10 mm (range, 8-12 mm) from the distal radioulnar joint (DRUJ). The fracture sites were located an average of 21.8 mm (range, 10-39 mm) from the radial styloid process and an average of 14.4 mm (range, 10-28 mm) from the DRUJ. Distal radial fractures overlapped an average of 11.8 mm from the radial styloid process and an average of 3.5 mm from the DRUJ. CONCLUSION: The pronator-sparing approach could be applied to a functionally reduced fracture because the non-overlapping area of the distal fracture fragment was > or =10 mm and it is possible to repair the anatomic plate without detaching the PQ muscle.

Radiation Exposure Over the Course of a Year from an Image Intensifier in the Orthopaedic Operating Room

PURPOSE: To measure the annual radiation exposure of staff in the orthopaedic surgical room. MATERIALS AND METHODS: From January 2010 to December 2010, we measured the radiation exposure of a tumor surgeon, spine surgeon, trauma surgeon, six residents, and six scrub nurses. Radiation was monitored with the use of thermoluminescent dosimeters placed on the chest under the lead apron. The annual dose of radiation exposure was compared to the maximum yearly permissible dose (20 mSv). During the study period, the trauma surgeon made a deliberate effort to minimize the radiation time and maintain a distance of 1 m from the image intensifier. RESULTS: The annual exposure levels were 0.04 mSv (radiation time, 34 min 50 s), 0.08 mSv (151 min 46 s), and 0.12 mSv (135 min 27 s) for the tumor surgeon, trauma surgeon, and spine surgeon, respectively. The mean exposure was 0.0146 mSv (range, 0.4~0.39 mSv) for the residents and 0.06 mSv (range, 0.04~0.13 mSv) for the scrub nurses. Overall, the annual radiation exposure was 0.2~1.95% of the maximal yearly permissible dose. Despite the longer period of radiation exposure, the trauma surgeon was exposed to a lower dose of radiation than the spine surgeon. CONCLUSION: The annual radiation exposure of a trauma surgeon can be reduced by a deliberate effort to decrease exposure time and maintain a distance of at least 1 m from the image intensifier.