Gu-Hee Jung

A 9-month-old phosphaturic mesenchymal tumor mimicking the intractable rickets.

Phosphaturic mesenchymal tumor is an extremely rare disease and is frequently associated with oncogenic osteomalacia showing paraneoplastic syndrome, which is characterized by phosphaturia, hypophosphatemia, normocalcemia, and decreased levels of 1,25-dihydroxyvitamin D3 associated with a tumor. A 2-year-old boy, who had a soft tissue tumor on his right thigh and previously diagnosed as myositis ossificans at 9-months-old, was presented with rachitic rosary and mildly enlarged tumor. Biochemical investigations showed hypophosphatemia, hyperphosphaturia, and an increased alkaline phosphatase level of 440 U/l (25-100 U/l), suggesting rickets, which was resistant to vitamin D dietary supplementation. We were certain of intractable rickets because of oncogenic hypophosphatemia and thus decided to excise the soft tissue mass. We observed laboratory improvement of rickets after 2 weeks. On the basis of surgical and histopathological examinations, the tumor was finally diagnosed as the phosphaturic mesenchymal tumor.

The Interrater and Intrarater Agreement of a Modified Neer Classification System and Associated Treatment Choice for Lateral Clavicle Fractures

Background: As there is substantial variation in the classification and diagnosis of lateral clavicle fractures, proper management can be challenging. Although the Neer classification system modified by Craig has been widely used, no study has assessed its validity through inter- and intrarater agreement. Purpose: To determine the inter- and intrarater agreement of the modified Neer classification system and associated treatment choice for lateral clavicle fractures and to assess whether 3-dimensional computed tomography (3D CT) improves the level of agreement. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Nine experienced shoulder specialists and 9 orthopaedic fellows evaluated 52 patients with lateral clavicle fractures, completing fracture typing according to the modified Neer classification system and selecting a treatment choice for each case. Web-based assessment was performed using plain radiographs only, followed by the addition of 3D CT images 2 weeks later. This procedure was repeated 4 weeks later. Fleiss κ values were calculated to estimate the inter- and intrarater agreement. Results: Based on plain radiographs only, the inter- and intrarater agreement of the modified Neer classification system was regarded as fair (κ = 0.344) and moderate (κ = 0.496), respectively; the inter- and intrarater agreement of treatment choice was both regarded as moderate (κ = 0.465 and 0.555, respectively). Based on the plain radiographs and 3D CT images, the inter- and intrarater agreement of the classification system was regarded as fair (κ = 0.317) and moderate (κ = 0.508), respectively; the inter- and intrarater agreement of treatment choice was regarded as moderate (κ = 0.463) and substantial (κ = 0.623), respectively. There were no significant differences in the level of agreement between the plain radiographs only and plain radiographs plus 3D CT images for any κ values (all P > .05). Conclusion: The level of interrater agreement of the modified Neer classification system for lateral clavicle fractures was fair. Additional 3D CT did not improve the overall level of interrater or intrarater agreement of the modified Neer classification system or associated treatment choice. To eliminate a common source of disagreement among surgeons, a new classification system to focus on unclassifiable fracture types is needed.

Distractive bridge plating in metaphyseal comminuted fractures of the distal radius through a pronator sparing approach

For distal radial fractures with metaphyseal comminution and radial shortening, the key treatment goal, aside from anatomic reduction of the articular surface, is maintenance of radial length, in order to maintain the normal biomechanics of the wrist. Our distractive bridge plating technique, applied via a pronator sparing approach, was expected to be effective in maintaining the radial length of distal radial fractures with metaphyseal comminution treated with volar plating. However, there were some disadvantages to this approach, namely exposure of the surgeon to additional radiation as compared with conventional plating, satisfactory reduction except radial length by manual manipulation, and provisional fixation is a prerequisite to plating. Our technique has important benefits, in particular, the ability to preserve vascular supply and restore radial length.

COMPARISON OF RADIOLOGICAL AND CLINICAL OUTCOMES OF INTERNAL FIXATION USING TWO DIFFERENT VOLAR PLATES FOR DISTAL RADIUS FRACTURES

The purpose of this study was to compare the outcomes of volar plating using two different implants for distal radius fractures. Fifty-two patients with AO type C fractures were placed in either of two groups: the AO LDRS group (26 patients) or the Acu-Loc group (26 patients). Radiological parameters including radial length, radial inclination, volar tilt, and intra-articular step-off were significantly improved after surgery. The mean Mayo Wrist Performance Score was 84.6 in the AO LDRS group and 81.1 in the Acu-Loc group. The mean Subjective Wrist Value was 86.7% in the AO LDRS group and 86.3% in the Acu-Loc group. There were no significant differences between the two groups with respect to both radiological and clinical outcomes at the final follow-up evaluation. Volar fixed-angle plating for unstable distal radius fractures had satisfactory radiological and clinical outcomes. The difference of implant design did not influence overall final outcomes.

Successful Use of Fluoroscopic Inlet and Outlet Views to Verify Safe Screw Trajectories when Placing Percutaneous Iliosacral Screws

*Corresponding author: Gu-Hee Jung, Department of Orthopaedic Surgery, College of Medicine, Gyeongsang National University Changwon Hospital; Tel: +82-55214-3822; E-mail: jyujin2001@hotmail.com Abstract Purpose: The purpose of this study was to introduce practical landmarks for the successful use of the fluoroscopic inlet and outlet views to verify safe screw trajectories when placing percutaneous iliosacral (IS) screws. Materials and Methods: A total of 10 sacra (19 hemi-sacra) from cadavers without gross deformity or previous injury were included in this study. The upper boundaries and S1 were marked with 1 mm lead wire. The marked sacra were positioned on a radiolucent operative table similar to the operative supine position and projected into the pelvic inlet and outlet views and the true lateral view of the pelvis via an image intensifier. Using image editing software, fluoroscopic images were analyzed to identify the fluoroscopic landmarks and ideal entry points. Results: The posterior-superior corner of the lateral articular surface was constantly projected as a curve point in the pelvic inlet view, and the imaginary connecting line between two points did not violate the posterior walls of S1 in any of the sacra with a little space. Based on the curve points, screws had to be directed either straight or anteriorly (range: 18.3°-29.6°) on inlet view. On outlet view, the ideal screw trajectory was the imaginary oblique line from the height of the S1 foramen to the opposite upper corner of S1 (range: 15.5°-24.4°) and the sacral ala was not violated. Conclusion: For successful fluoroscopy, two simple landmarks could be utilized, the imaginary connecting line between the two curve points in the pelvic inlet view and the oblique screw trajectory toward the opposite corner of S1 in the pelvic outlet view, using the standard technique and irrespective of sacral dysplasia.