Changhoon Jeong

Isolated fractures of the greater trochanter with occult intertrochanteric extension

IntroductionIsolated fractures of the greater trochanter (GT) are relatively rare. The diagnosis can be done on routine radiographs, but it is difficult to fully define the geographic extent of these injuries. This study examined the pattern and extent of an injury shown by magnetic resonance imaging (MRI) and radionuclide bone scan (RBS) in patients whose plain radiographs revealed fractures limited to the GT.Materials and methodsBetween July 2004 and October 2008, 25 patients who displayed an isolated GT fracture on plain radiograph examination were examined by both MRI and RBS due to a suspicion of an extension into the intertrochanteric (ITC) region. The patients were then divided into two groups. Group A patients had an isolated fracture of GT, and group B patients had an occult fracture of ITC.ResultsAll 25 cases were caused by a low-energy injury and plain radiographs showed non-displaced or minimally displaced isolated GT fractures. For 22 of the 25 patients, the result agreed with MRI and RBS. However, three patients had focal increased uptake at the GT region only according to RBS and an extension of signal intensity into the ITC region according to MRI. Group A and B comprised 5 and 20 patients, respectively. Of the group B patients, 8 had fractures with MRI evidence of complete extension across the ITC region and 12 had incomplete extension. Eleven of the 12 incomplete types showed an extension more than half way to the medial cortex. Fifteen group B patients underwent an internal fixation using a two-hole dynamic hip screw.ConclusionPatients with an isolated fracture of GT can have a broader fracture extending into the ITC region than that diagnosed by standard radiographs. We recommend that all patients presenting with an isolated GT fracture on the plain radiographs should undergo MRI examination.

Revisit of multiple epiphyseal dysplasia: ethnic difference in genotypes and comparison of radiographic features linked to the COMP and MATN3 genes.

Multiple epiphyseal dysplasia (MED) is a genetically heterogeneous group of diseases characterized by variable degrees of epiphyseal abnormality primarily involving the hip and knee joints. The purpose of this study was to investigate the frequency of mutations in individuals with a clinical and radiographic diagnosis of MED and to test the hypothesis that characteristic radiological findings may be helpful in predicting the gene responsible. The radiographs of 74 Korean patients were evaluated by a panel of skeletal dysplasia experts. Six genes known to be associated with MED (COMP, MATN3, COL9A1, COL9A2, COL9A3, and DTDST) were screened by sequencing. Mutations were found in 55 of the 63 patients (87%). MATN3 mutations were found in 30 patients (55%), followed by COMP mutations in 23 (41%), and COL9A2 and DTDST mutations in one patient (2%) each. Comparisons of radiographic findings in patients with COMP and MATN3 mutations showed that albeit marked abnormalities in hip and knee joints were observed in both groups, the degree of involvement and the morphology of dysplastic epiphyses differed markedly. The contour of the pelvic acetabulum, the presence of metaphyseal vertical striations, and/or the brachydactyly of the hand were also found to be highly correlated with the genotypes. The study confirms that MATN3 and COMP are the genes most frequently responsible for MED and that subtle radiographic signs may give precious indications on which gene(s) should be prioritized for mutational screening in a given individual.

Real-time sonoelastography in the diagnosis of rotator cuff tendinopathy

BACKGROUND Real-time sonoelastography can be used to assess tissue elasticity. The present study evaluated the relationship between tendon stiffness on sonoelastography and the magnetic resonance imaging (MRI) tendinosis grade in patients with rotator cuff tendinopathy. METHODS The study included 39 patients with chronic pain and no history of trauma or rotator cuff tear. The supraspinatus tendons were graded according to MRI findings (grade 0, normal; grade 1, mild tendinosis; grade 2, moderate tendinosis; grade 3, marked tendinosis), and the subcutaneous fat-to-tendon (Fat/T) and gel pad-to-tendon (Pad/T) strain ratios were assessed. We used the trend test to analyze the relationship of the MRI grade with the Fat/T strain ratio and the Pad/T strain ratio. RESULTS Of the 39 patients, 9 had grade 0, 17 had grade 1, 12 had grade 2, and 1 had grade 3 tendinosis. The mean real-time elastography Fat/T and Pad/T strain ratios were 2.92 ± 2.13 and 20.77 ± 21.78 in patients with grade 0 tendinosis, 4.08 ± 4.09 and 21.78 ± 17.16 in patients with grade 1 tendinosis, 13.48 ± 10.19 and 83.00 ± 48.26 in patients with grade 2 tendinosis, and 12.3 ± 0.00 and 16.58 ± 0.00 in patients with grade 3 tendinosis, respectively. The Fat/T and Pad/T strain ratios were positively associated with the MRI grade (P <.001). CONCLUSION The MRI tendinosis grade is associated with stiffness assessed using sonoelastography in patients with rotator cuff tendinopathy. Therefore, sonoelastography might be a useful diagnostic tool for supraspinatus tendinopathy. LEVEL OF EVIDENCE Level III; Diagnostic Study.

Spontaneous anterior interosseous nerve syndrome: clinical analysis of eleven surgical cases

Abstract The aetiology of anterior interosseous nerve (AIN) syndrome and an optimal treatment strategy remain controversial. Eleven patients with spontaneous AIN syndrome, who were treated by surgical exploration, were reviewed at a mean of 32.5 months after the operation. Eight men and three women were included in the study. None of the patients had a history of trauma and there was no evidence of a neuropathy other than AIN syndrome. Six patients showed complete paralysis of the flexor pollicis longus (FPL) and the flexor digitorum profundus of the index finger (FDS1). Five patients had incomplete paralysis, with isolated lesions of the FPL in two and the FDP1 in three. Surgery was performed 7.8 months after the onset of paralysis. The most common structure of nerve compression was a fibrous band of the flexor digitorum sublimis muscle. However, no definitive compression site or anatomic abnormality could be found in four patients. Ten of the 11 patients had recovered muscle strength above grade 4 within 12 months of the operation. Good results were obtained in 10 patients and fair in only one at final assessment. Four patients (one man and three women) raised cosmetic concerns due to excessive scar formation on the upper forearm. Surgical exploration is recommended only in cases where AIN syndrome is apparent, no other neuronal lesions are apparent, and where there was no recovery after 6 months of conservative treatment. Careful preoperative examination is essential to avoid misdiagnosis and inappropriate operation, particularly in cases of incomplete AIN syndrome.

Arthroscopic fixation of displaced greater tuberosity fracture of the proximal humerus

Single-row fixation with two inverted mattress stitches was used to treat displaced fracture of the greater tuberosity of the proximal humerus. The inverted mattress sutures were passed through the bone–tendon junction of the fragment by suture passer and crossed over the bone fragment, locking the suture ends into the lateral cortex. Level of evidence Therapeutic studies, Level V.

Bilateral Carpometacarpal Joint Dislocations of the Thumb

A traumatic carpometacarpal joint dislocation of the thumb accounts for less than 1% of all hand injuries. Optimal treatment strategies for this injury are still a subject of debate. In this article, we report a case of bilateral thumb carpometacarpal joint dislocations: a unique combination of injuries. We believe our case is the second report of bilateral carpometacarpal joint dislocation regarding the thumb in English literature. It was successfully treated with closed reduction and percutaneous K-wires fixation on one side, and an open reduction and reconstruction of the ligament on the other side.

Comprehensive genetic exploration of skeletal dysplasia using targeted exome sequencing

Purpose:The purpose of this study was to evaluate the clinical utility of targeted exome sequencing (TES) as a molecular diagnostic tool for patients with skeletal dysplasia.Methods:A total of 185 patients either diagnosed with or suspected to have skeletal dysplasia were recruited over a period of 3 years. TES was performed for 255 genes associated with the pathogenesis of skeletal dysplasia, and candidate variants were selected using a bioinformatics analysis. All candidate variants were confirmed by Sanger sequencing, correlation with the phenotype, and a cosegregation study in the family.Results:TES detected “confirmed” or “highly likely” pathogenic sequence variants in 74% (71 of 96) of cases in the assured clinical diagnosis category and 20.3% (13 of 64 cases) of cases in the uncertain clinical diagnosis category. TES successfully detected pathogenic variants in all 25 cases of previously known genotypes. The data also suggested a copy-number variation that led to a molecular diagnosis.Conclusion:This study demonstrates the feasibility of TES for the molecular diagnosis of skeletal dysplasia. However, further confirmation is needed for a final molecular diagnosis, including Sanger sequencing of candidate variants with suspected, poorly captured exons.Genet Med 18 6, 563–569.

Treatment of Popliteal Pterygium Using an Ilizarov External Fixator

Popliteal pterygium syndrome is a rare congenital disorder that consists of popliteal webs and craniofacial, genitourinary and extremity anomalies. Only moderate successful surgical excision of the fibrotic band within the popliteal web has been reported because the nerves and vessels in the affected site are short and displaced into the web and they are attached to adjacent tissues. We performed hamstring tenotomy on the ischial tuberosity, tenotomy of the flexor hallucis longus and Z-lengthening of the Achilles tendon on the ankle in our patient, and this was followed by gradual correction using an Ilizarov external fixator. Full extension of the knee joint was achieved at the ninth postoperative week. However, some recurrence of flexion contracture was noted at two years follow-up. Gradual soft tissue lengthening with an Ilizarov external fixator can be one of the optimal procedures when excision of a fibrous band and Z-plasty are not possible due to severe adhesion of the nerves and vessels into a fibrotic band. However, a cautious approach is recommended when considering the high risk of recurrence.

Transplantation of a Scaffold-Free Cartilage Tissue Analogue for the Treatment of Physeal Cartilage Injury of the Proximal Tibia in Rabbits

Purpose The purpose of this study was to investigate the effects of transplantation of an in vitro-generated, scaffold-free, tissue-engineered cartilage tissue analogue (CTA) using a suspension chondrocyte culture in a rabbit growth-arrest model. Materials and Methods We harvested cartilage cells from the articular cartilage of the joints of white rabbits and made a CTA using a suspension culture of 2×107 cells/mL. An animal growth plate defect model was made on the medial side of the proximal tibial growth plate of both tibias of 6-week-old New Zealand white rabbits (n=10). The allogenic CTA was then transplanted onto the right proximal tibial defect. As a control, no implantation was performed on the left-side defect. Plain radiographs and the medial proximal tibial angle were obtained at 1-week intervals for evaluation of bone bridge formation and the degree of angular deformity until postoperative week 6. We performed a histological evaluation using hematoxylin-eosin and Alcian blue staining at postoperative weeks 4 and 6. Results Radiologic study revealed a median medial proximal tibial angle of 59.0° in the control group and 80.0° in the CTA group at 6 weeks. In the control group, statistically significant angular deformities were seen 3 weeks after transplantation (p<0.05). On histological examination, the transplanted CTA was maintained in the CTA group at 4 and 6 weeks postoperative. Bone bridge formation was observed in the control group. Conclusion In this study, CTA transplantation minimized deformity in the rabbit growth plate injury model, probably via the attenuation of bone bridge formation.

Suprascapular neuropathy caused by heterotopic ossification after clavicle shaft fracture: a case report

Suprascapular neuropathy is a rare peripheral neuropathy that can be easily overlooked in the differential diagnosis of shoulder pain and dysfunction. The suprascapular nerve may be injured as a result of repetitive overuse, constriction due to anatomic variants, compression due to space occupying lesions, retraction due to a massive rotator cuff tear and iatrogenic or traumatic lesions. Trauma-related suprascapular neuropathies are often caused by glenohumeral joint dislocations, scapular fractures, proximal humeral fractures, penetrating injuries and displaced clavicle fractures. Although many causes of suprascapular neuropathy have been described, there have been few reports of suprascapular neuropathy caused by heterotophic ossification after trauma around shoulder. Heterotophic ossification is the formation of bone in non-skeletal tissue, usually between the muscle and joint capsule. It usually occurs following trauma, surgery, burns, fractures, dislocation or soft tissue trauma. The spectrum of heterotophic ossification ranges from incidental radiographic findings to severe functional limitations. The range of motion can be decreased, resulting in soft tissue contractures. It can also cause peripheral neuropathy by impinging adjacent nerves. Management of heterotopic ossification is aimed at limiting its progression and maximizing function of the affected joint. Nonsurgical treatment is appropriate for early heterotopic ossification; however, surgical excision should be considered in cases of joint ankylosis or significant complications. We report a very unusual case of suprascapular neuropathy that resulted from heterotophic ossification after clavicle shaft fracture. This case was treated by open excision of the heterotophic ossification and external neurolysis of the suprascapular nerve. Although the incidence is very low, the heterotophic ossification should be considered as a possible cause of suprascapular neuropathy.