June Hyuk Kim

Comparison of glenohumeral and subacromial steroid injection in primary frozen shoulder: a prospective, randomized short-term comparison study.

BACKGROUND Glenohumeral (GH) joint steroid injection is one of the most well-known treatments for frozen shoulder. However, the low accuracy of GH joint injections and the improvement of symptoms after subacromial (SA) steroid injections led us to design a study that compares the efficacy of a steroid injection for primary frozen shoulder according to the injection site. MATERIALS AND METHODS Patients with primary frozen shoulder were randomly divided into 2 groups according to the location of the injection: a GH group of 37 for the glenohumeral joint and an SA group of 34 for the subacromial space. Injections were completed using ultrasonographic guidance. Evaluations using a visual analog scale (VAS) for pain, the Constant score, and passive range of motion (ROM) were completed at 3, 6, and 12 weeks after the injection. RESULTS The GH group showed lower pain VAS at 3 weeks, but no statistical difference was found between the 2 groups at 6 and 12 weeks. Improvement in pain was evident at every follow-up visit compared with the preinjection evaluation. There was no significant difference between the 2 groups with respect to the Constant score or ROM at serial follow-up. CONCLUSIONS The GH steroid injection was not superior to a SA injection for patients with primary frozen shoulder even though injection at the GH joint led to earlier pain relief compared with the SA injection. SA steroid injection along with a GH injection is an alternative modality, and the treatment should be individualized and tailored appropriately.

MRI-guided Navigation Surgery with Temporary Implantable Bone Markers in Limb Salvage for Sarcoma

BackgroundTechnical errors during navigation-assisted bone tumor resection may occur by: (1) incorrect registration of images and corresponding anatomic points of bone sent to the navigation system; and (2) incorrect fusion of two or more images that have been transported to the navigation system.Questions/purposesWe investigated new methods of navigation surgery to minimize technical errors during the registration and image fusion processes and specifically asked whether a navigated cannula probe would reduce unnecessary soft tissue dissection, and allow percutaneous registration and implantation of a reference base tracker in the margin of bone to be resected.MethodsWe performed direct MRI-guided navigation surgery without image fusion on a patient with osteosarcoma using absorbable pins as temporary implanted bone markers that prevent artifacts on MR images.ResultsDirect MRI-guided navigation surgery was possible using bone markers. A navigated cannula probe allowed percutaneous registration and a navigated blade-shaped probe provided a real-time check on the narrow osteotomy gap. The surgical procedure was facilitated by implantation of a reference base tracker on the margin of bone to be resected.ConclusionsOur modified technique of MRI-guided navigation surgery for patients with a malignant bone tumor may reduce processing errors by increased accuracy and be helpful for joint preserving surgery.

Clinical features of partial anterior bursal-sided supraspinatus tendon (PABST) lesions

BACKGROUND We characterized partial anterior and bursal supraspinatus tendon (PABST) lesions and compared their clinical features, postoperative functional scores, and healing rate with full-thickness rotator cuff tears (FTRCTs) and small FTRCTs. MATERIALS AND METHODS There were 31 PABST lesions (6.2%), 392 FTRCTs, and 32 small FTRCTs among 495 shoulders with rotator cuff disorders. The mean patient age was 52.7 years in the PABST group, 60.1 years in the FTRCT group, and 56.9 years in the small FTRCT group. Functional and clinical variables were compared between the groups, and cuff healing was evaluated with computed tomography arthrography or ultrasonography. RESULTS The mean patient age was statistically lower, the mean symptom duration was shorter, and trauma was more frequent in the PABST group compared with the FTRCT and small FTRCT groups. Coronal acromial spurs were found more frequently in the PABST group than in the FTRCT group. In all groups, range of motion, visual analog scale for pain, and functional scores improved continuously throughout the follow-up. There were 2 unhealed cuffs (10.5%) in the PABST group, 72 (35.6%) in the FTRCT group (P = .146), and 5 (25%) in the small FTRCT group (P = .238). CONCLUSIONS We characterized PABST lesions that may be overlooked because of their peculiar location in the far anterolateral insertional section of the supraspinatus tendon at the bursal side. PABST lesions usually occur in younger patients, and trauma is frequently associated with acute symptom onset. Surgical treatment was effective for pain reduction and functional improvement.

Grafting Using Injectable Calcium Sulfate in Bone Tumor Surgery: Comparison with Demineralized Bone Matrix-based Grafting

Background Injectable calcium sulfate is a clinically proven osteoconductive biomaterial, and it is an injectable, resorbable and semi-structural bone graft material. The purpose of this study was to validate the clinical outcomes of injectable calcium sulfate (ICS) grafts as compared with those of a demineralized bone matrix (DBM)-based graft for filling in contained bony defects created by tumor surgery. Methods Fifty-six patients (41 males and 15 females) with various bone tumors and who were surgically treated between September 2003 and October 2007 were included for this study. The patients were randomly allocated into two groups, and either an ICS graft (28 patients) or a DBM-based graft (28 patients) was implanted into each contained defect that was developed by the surgery. The radiographic outcomes were compared between the two groups and various clinical factors were included for the statistical analysis. Results When one case with early postoperative pathologic fracture in the DBM group was excluded, the overall success rates of the ICS and DBM grafting were 85.7% (24/28) and 88.9% (24/27) (p > 0.05), respectively. The average time to complete healing was 17.3 weeks in the ICS group and 14.9 weeks in the DBM group (p > 0.05). Additionally, the ICS was completely resorbed within 3 months, except for one case. Conclusions Although the rate of resorption of ICS is a concern, the injectable calcium sulfate appears to be a comparable bone graft substitute for a DBM-based graft, with a lower cost, for the treatment of the bone defects created during surgery for various bone tumors.

Minimally invasive surgery of humeral metastasis using flexible nails and cement in high-risk patients with advanced cancer

This study was conducted to evaluate the preliminary outcome of palliative minimally invasive surgery for humeral metastasis in patients who have multiple advanced cancers with short life expectancy. Percutaneous Ender nailing and direct transcortical intramedullary cementing were performed on a total of 15 patients with metastatic disease of the humerus. The origins of the cancers were the lung (n=9), breast (n=3), colon (n=2) and liver (n=1). Each patient had multiple unresectable organic metastases and proved to be at high risk for anesthesia and bloody surgery. All procedures were performed under regional anesthesia and fluoroscopic guidance. The mean amount of intramedullary cement injection after Ender nailing was 13.4ml. The mean of the numeric rating scale (NRS) score for pain decreased from 9.6 points before surgery to 3.6 points after surgery (P<0.001). The mean of the Musculoskeletal Tumor Society (MSTS) functional score increased from 10.6 points before surgery to 19.9 points after surgery (P<0.001). Seven patients died within 7 months. There were no complications associated with cement leakage, fixation failure and surgical wound even in cases of early postoperative radiation or chemotherapy. Percutaneous flexible nailing along with intramedullary cementing could be a useful minimally invasive surgical method for the palliation of humeral metastasis in selective terminal cancer patients by providing immediate reliable fixation and effective pain relief.

Minimally invasive surgery for femoral neck fractures using bone cement infusible hollow-perforated screw in high-risk patients with advanced cancer

OBJECTIVE Pathologic or osteoporotic femoral neck fractures usually treated with joint replacement surgery rather than joint-preserving surgery because multiple screw fixation has a high risk for fixation failure and nonunion as well as the need for a postoperative protection period. However, joint-preserving surgery might be preferable in high-risk patients with short life expectancy due to advanced disease. Recently introduced hollow-perforated screws are devices for achieving percutaneous fixation by simultaneous injection to the weak bone area through its multiple side holes. We report our experience of surgical treatment of femoral neck fractures by controlled bone cement injection into the femoral head and neck through a modified hollow-perforated screw in patients with advanced cancer. METHODS We modified the hollow perforated screw with variable placing of screw-side holes as fracture patterns. Polymethylmethacrylate (PMMA) bone cement was injected through the screw holes to control its injection into the selective areas of the femoral head and neck while avoiding the fracture sites. One or two of these were fixed percutaneously in 12 patients who have Garden stage I or II femoral neck fractures in the advanced state of advanced cancer. Seven patients had pathologic fracture by metastatic cancer, but 5 had osteoporotic fractures. RESULTS Eleven patients died a mean of 4.1 months after surgery and 1 patient lived with ability to walk for 48 months. Sixteen modified hollow perforated-screws and 16 standard cannulated screws were used for fixation. The mean volume of cement injection was 13.8 ml. The complication developed in 4 patients: cement leakage to the hip joint in 2 patients, subtrochanteric fracture in 1 patient (5 months after surgery) and fixation failure in 1 patients (2 months after surgery). Nine patients could walk with or without a walking aid, and all others also could return to the prefracture-ambulation state with effective pain relief on the third postoperative day. CONCLUSION This current surgical method could be useful in patients with short life expectancy because of quick pain relief, early return to ambulation, simple operative procedures and short hospital stay. The modified hollow perforated screw which has a diversity of side hole locations for the regulation of bone cement injection into the planned area seems useful for selective femoral neck fractures.

Soft Tissue Reconstruction of the Foot Using the Distally Based Island Pedicle Flap after Resection of Malignant Melanoma

Background We report on our experience with using a distally based island flap for soft tissue reconstruction of the foot in limb salvage surgery for malignant melanoma patients. Methods A distally based sural flap was used for 10 cases for the hindfoot reconstruction, and a lateral supramalleolar flap was used for 3 cases for the lateral arch reconstruction of the mid- and forefoot after wide excision of malignant melanomas. Results The length of the flap varied from 7.5 cm to 12 cm (mean, 9.6 cm) and the width varied from 6.5 cm to 12 cm (mean, 8.8 cm). Superficial necrosis developed in four flaps, but this was successfully treated by debridement and suture or a skin graft. All thirteen flaps survived completely and they provided good contour, stable and durable coverage for normal weight bearing. Conclusions The distally based sural flap is considered to be useful for reconstructing the hindfoot, and the lateral supramalleolar flap is good for reconstructing the lateral archs of the mid- and forefoot after resection of malignant melanoma of the foot.

Distinct Clinical Characteristics of Unplanned Excision in Synovial Sarcoma

Background We aimed to describe the clinical characteristics and outcomes of unplanned excisions of synovial sarcomas. Methods In total, 90 patients with synovial sarcomas in the extremities were retrospectively reviewed. Patients were divided into unplanned excision (n = 38) and planned excision (n = 52) groups. The average follow-up period was 6 years. The clinicopathological characteristics and oncologic outcomes were compared. Results The unplanned excision group showed longer duration of symptoms before diagnosis (p = 0.023), smaller lesion dimensions (p = 0.001), superficial location (p = 0.049), and predilection in the upper extremities (p = 0.037). Synovial sarcomas were most commonly misdiagnosed as neurogenic tumors (56%) in the upper extremities or as cystic masses (47%) in the lower extremities. Oncological outcomes, including disease-specific survival, metastasis-free survival, or local recurrence were not significantly different between the 2 groups (p = 0.159, p = 0.444, and p = 0.335, respectively). Repeated unplanned excision (p = 0.012) and delayed re-excision (p = 0.038) were significant risk factors for local recurrence in the unplanned excision group. Conclusions Synovial sarcomas treated with unplanned excision had distinct characteristics. These findings are important for developing diagnostic and therapeutic strategies for synovial sarcoma.

Low‐heat treated autograft versus allograft for intercalary reconstruction of malignant bone tumors

Low‐heat treated autograft may have an advantage over allograft in that they provide a size‐matched and biologically compatible graft.

Deep learning approach for survival prediction for patients with synovial sarcoma

Synovial sarcoma is a rare disease with diverse progression characteristics. We developed a novel deep-learning-based prediction algorithm for survival rates of synovial sarcoma patients. The purpose of this study is to evaluate the performance of the proposed prediction model and demonstrate its clinical usage. The study involved 242 patients who were diagnosed with synovial sarcoma in three institutions between March 2001 and February 2013. The patients were randomly divided into a training set (80%) and a testing set (20%). Fivefold cross validation was performed utilizing the training set. The test set was retained for the final testing. A Cox proportional hazard model, simple neural network, and the proposed survival neural network were all trained utilizing the same training set, and fivefold cross validation was performed. The final testing was performed utilizing the isolated test data to determine the best prediction model. The multivariate Cox proportional hazard regression analysis revealed that size, initial metastasis, and margin were independent prognostic factors. In fivefold cross validation, the median value of the receiver-operating characteristic curve (area under the curve) was 0.87 in the survival neural network, which is significantly higher compared to the area under the curve of 0.792 for the simple neural network (p = 0.043). In the final test, survival neural network model showed the better performance (area under the curve: 0.814) compared to the Cox proportional hazard model (area under the curve: 0.629; p = 0.0001). The survival neural network model predicted survival of synovial sarcoma patients more accurately compared to Cox proportional hazard model.