Kwang Soon Song

Stress Fractures of the Ribs in Golfers

During a collaborative review at three institutions, we documented 19 cases of stress fractures of the ribs in golfers. There were 13 men and 6 women with an average age of 39 years (range, 29 to 51). The 4th to 6th ribs were the most commonly injured. All fractures occurred along the posterolateral aspect of the ribs, and nine patients had fractures in more than one rib. Sixteen golfers sustained injury on the leading arm side of the trunk. Eighteen golfers were beginners, and the one experienced golfer had dramatically increased his practice time on the driving range before injury. Plain radiographs were usually diagnostic. However, bone scintigraphy was necessary to reach a diagnosis in three cases. A delay in diagnosis of 6 to 8 months occurred in two cases that were originally misdiag nosed as back strains. Stress fractures of the ribs in golfers may be more common than previously realized and may be incorrectly diagnosed as recalcitrant back strains. Based on the findings of other studies, we think fatigue of the serratus anterior is the mechanism of injury. We recommend strengthening the serratus an terior as rehabilitation after this injury and in a general conditioning program for golfers.

Contiguous discitis and osteomyelitis in children.

Magnetic resonance imaging of 16 patients with contiguous discitis and osteomyelitis provided a specific diagnosis and defined the anatomic extent of vertebral and soft-tissue involvement. Altered signal changes were evident in the disc, adjacent vertebra in the end plate and metaphyseal equivalent regions, and the anterior prevertebral tissues. Significant posterior spread and disc herniation were not evident. Fourteen patients had lumbar involvement; two had cervical involvement. The patients were followed-up for an average of 4 years 5 months. Scoliosis has developed in one patient, and four continue to have a loss of lumbar lordosis. By comparing serial roentgenograms, the mean decrease of disc-space height after the acute episode was 43% (range, 51-61%). There was no restitution of normal disc-space height at the latest follow-up roentgenogram in any of the patients. A 14% (average) narrowing of the vertebral foramina was evident in seven cases. In one patient, a fusion progressively developed 7 years after the acute episode (before full skeletal maturity). However, several patients appear to be progressing toward fusion of adjacent vertebra. A study of histologic specimens elucidated vascular anatomy of the immature vertebra that further explain the disease characteristics.

Is shoulder pain for three months or longer correlated with depression, anxiety, and sleep disturbance?

BACKGROUND Recent studies have found a high prevalence of depression, anxiety, and sleep disturbance in patients with chronic musculoskeletal pain. We conducted a study to determine whether shoulder pain for 3 months or longer is correlated with depression, anxiety, and sleep disturbance. MATERIALS AND METHODS We prospectively evaluated 130 patients who had had shoulder pain for 3 months or longer (group I) and 60 healthy controls (group II). We obtained visual analog scale (VAS) pain score, and scores for the American Shoulder and Elbow Surgeons (ASES), Korean Shoulder Scale (KSS), Hospital Anxiety and Depression Scale (HADS), and Pittsburgh Sleep Quality Index (PSQI). RESULTS The mean VAS pain score, ASES score, and KSS score in group I were 6.2, 46.6, and 51.5, respectively. In that group, 22.3% had depression, 19.2% had anxiety, and 81.5% had sleep disturbance. The prevalences were higher in group I than in group II. There were no differences in depression, anxiety, or sleep disturbance by age, sex, type of disease, or duration of symptoms in group I. VAS pain scores positively correlated with PSQI scores (P = .01). ASES and KSS scores negatively correlated with HADS depression and anxiety subscale and PSQI scores (P < .001). Shoulder pain for 3 months or longer was the strongest predictor of sleep disturbance (P < .001). CONCLUSIONS Our study demonstrated high prevalence and close relationships of depression, anxiety, and sleep disturbance in patients with shoulder pain for 3 months or longer. These results may indicate importance of the psychologic approach as well as adequate pain control.

Arthrotomy and open reduction of the displaced fracture of the femoral neck in children.

The objective of the study was to examine the efficacy of limited arthrotomy coupled with open reduction and internal fixation to minimize potential complications of vascular disruption of the capital femoral physis and femoral epiphysis. It was a patient outcome study. Skeletally immature patients with femoral neck fractures were treated according to a protocol in which all patients underwent limited arthrotomy with decompression of the intercapsular hematoma, open reduction and internal fixation. Radiographic and magnetic resonance imaging studies were carried out on patients to assess whether avascular necrosis developed in the postoperative period. Patients were followed for a mean length of 2 years 8 months, with a range of 2 years to 5.5 years. Twelve patients had good results and one had fair results using Ratliff criteria. No patient developed avascular necrosis (ischemic necrosis), coxa vara, nonunion or premature epiphyseal closure. This study supports the hypothesis that limited decompression of the intracapsular hematoma in children with femoral neck fractures may be a factor in obviating the subsequent appearance of ischemic disruption of the epiphysis and physis.

Closed reduction and internal fixation of displaced unstable lateral condylar fractures of the humerus in children.

BACKGROUND Open reduction and internal fixation of a displaced unstable fracture of the lateral condyle of the humerus in a child usually produces a good result. Only a few reports have focused on closed reduction and internal fixation of these fractures. We prospectively studied closed reduction and internal fixation to determine its usefulness as the initial treatment for displaced unstable fractures of the lateral condyle of the humerus. METHODS We classified lateral condylar humeral fractures into five groups according to the degree of displacement and the fracture pattern as determined on four radiographic views and created an algorithm for the treatment of these fractures on the basis of this classification system. We prospectively treated sixty-three unstable fractures (in forty-two boys and twenty-one girls) and assessed the quality of closed reduction. RESULTS Thirteen of seventeen stage-3 fractures were reduced to < or =1 mm of residual displacement. Thirty of forty stage-4 fractures and three of six stage-5 fractures were reduced to < or =2 mm of displacement. In ten of forty stage-4 fractures and three of six stage-5 fractures, closed reduction to within 2 mm failed and open reduction and internal fixation was performed. There were no major complications such as osteonecrosis of the trochlea or capitellum, nonunion, malunion, or early physeal arrest. CONCLUSIONS Closed reduction and internal fixation is an effective treatment for unstable displaced lateral condylar fractures of the humerus in many children. If fracture displacement after closed reduction exceeds 2 mm, open reduction and internal fixation is recommended.

The Effect of Stem Alignment on Results of Total Hip Arthroplasty with a Cementless Tapered-Wedge Femoral Component

We evaluated the significance of the stem alignment in 98 consecutive primary total hip arthroplasties with a cementless CLS component (Zimmer, Winterthur, Switzerland) after a mean follow-up period of 7.7 years (range, 5-11 years) The patients were divided into 3 groups on the basis of stem alignment: neutral, 62 hips (63%); valgus, 20 hips (21%); and varus, 16 hips (16%). Clinical and radiographic results for the groups were compared. No significant clinical or radiographic differences were found between groups. There was no difference in the Harris hip scores and in the incidence of thigh pain between groups. For all hips, radiographs showed stable osseous fixation of the stem and the cup. A similar pattern of adaptive bone remodeling occurred in all 3 groups. Stem alignment of a tapered-wedge cementless femoral component does not compromise the clinical and radiographic results of total hip arthroplasty at a mean end point of 7.7 years.

Preoperative and postoperative evaluation of intra-articular fractures of the calcaneus based on computed tomography scanning

OBJECTIVE To define the relationship between postoperative congruency of the posterior facet of the subtalar joint based on computed tomography (CT) and clinical results. DESIGN Preoperative and postoperative CT scans were taken prospectively and analyzed. SETTING University medical center. PATIENTS Twenty-nine displaced fractures in twenty-five patients. INTERVENTION All patients were treated with open reduction and internal fixation without bone graft. MAIN OUTCOME MEASURES Postoperative CT findings were classified into three groups, according to the degree of displacement: anatomic, no displacement; nearly anatomic, displaced less than two millimeters; and approximate, displaced more than two millimeters. RESULTS The reduction state after operative treatment for the cases with more comminution showed worse results when analyzed in both preoperative and postoperative CT scans. Fifteen of seventeen fractures (88 percent) with anatomic reduction and seven of eight fractures (87 percent) with nearly anatomic reduction had excellent or good clinical results. In contrast, no fracture with an approximate reduction had an excellent result. CONCLUSION An excellent or good clinical result can be expected when the postoperative displacement of the posterior facet of the subtalar joint is less than two millimeters.

Internal Oblique Radiographs for Diagnosis of Nondisplaced or Minimally Displaced Lateral Condylar Fractures of the Humerus in Children

BACKGROUND Several radiographic criteria based on only standard anteroposterior and lateral radiographs have been suggested for predicting the stability of lateral condylar fractures of the humerus in children. Despite adherence to these guidelines, further displacement often occurs after the initial diagnosis and stability assessment. The purpose of this study was to define the usefulness of an internal oblique radiograph in the assessment of these fractures. METHODS We prospectively studied fifty-four lateral humeral condylar fractures in fifty-four children seen between March 2002 and December 2004 to determine the efficacy of internal oblique radiographs in gauging the amount of displacement and the fracture pattern. Plain anteroposterior, lateral, internal oblique, and external oblique radiographs were initially made for all fifty-four patients, and three-dimensional computed tomography scans were performed for seven patients. RESULTS A large percentage (70%) of the fractures were seen to have different amounts of displacement on the anteroposterior and internal oblique radiographs, and a large percentage (75%) were seen to have different fracture patterns, according to the criteria suggested by Finnbogason et al., on the two views. The internal oblique radiograph was more accurate for demonstrating the fracture gap (thirty cases were seen to have more displacement on that view) and for demonstrating the fracture pattern (twenty cases were seen to have more instability on the internal oblique view). We also confirmed the direction of the fracture line and the location of the fragment more accurately with three-dimensional computed tomography. CONCLUSIONS It is not optimal to evaluate the amount of displacement and the stability of a lateral condylar fracture of the humerus in children on the basis of just anteroposterior and lateral elbow radiographs. Classifications should be based on the greatest displacement seen on at least three radiographic views, especially the internal oblique view.

Focal fibrocartilaginous dysplasia of long bones: report of eight additional cases and literature review.

We report eight additional cases of focal fibrocartilaginous dysplasia (FFCD) in the proximal tibia (five), distal ulna (one), and distal femur (two). Spontaneous, complete resolution of the lesion was observed in two tibiae and one ulna. Three tibial lesions with genu varum deformity were managed with osteotomy. Two femoral FFCDs caused persistent or progressive deformity: one genu valgum with patellar dislocation, and one genu varum. These patients underwent concomitant deformity correction and lengthening by the Ilizarov method. The final results were satisfactory in all patients except one, who underwent valgus tibial osteotomy and developed mild postoperative genu valgum. The analysis of a total of 46 cases in the literature and our experience suggests that (a) FFCD has a wide histopathologic spectrum, ranging from purely dense, fibrous tendon-like tissue to benign fibrocartilaginous tissue; (b) at least 45% of tibial FFCD demonstrates progressive, spontaneous resolution; (c) in contrast, femoral and humeral FFCDs appear to have a slim possibility of spontaneous regression of the deformity; and (d) corrective osteotomy is indicated when the deformity is increasing or persistent, or when the existing deformity is severe enough to jeopardize adjacent joint mechanics and alignment.

Inflammatory cytokines are overexpressed in the subacromial bursa of frozen shoulder

BACKGROUND Frozen shoulder is a debilitating condition characterized by gradual loss of glenohumeral motion with chronic inflammation and capsular fibrosis. Yet its pathogenesis remains largely unknown. We hypothesized that the subacromial bursa may be responsible for the pathogenesis of frozen shoulder by producing inflammatory cytokines. MATERIALS AND METHODS We obtained joint capsules and subacromial bursae from 14 patients with idiopathic frozen shoulder and from 7 control subjects to determine the expression levels of interleukin (IL) 1α, IL-1β, IL-6, tumor necrosis factor α (TNF-α), cyclooxygenase (COX) 1, and COX-2 by real-time reverse transcriptase-polymerase chain reaction, immunohistochemistry, and enzyme-linked immunosorbent assay. RESULTS IL-1α, IL-1β, TNF-α, COX-1, and COX-2 were expressed at significantly high levels in the joint capsules of the frozen shoulder group compared with those of the control group. Intriguingly, IL-1α, TNF-α, and COX-2 were also expressed at significantly high levels in the subacromial bursae of the frozen shoulder group compared with those of the control group. Immunohistochemical analysis showed increased expression of COX-2 in both the joint capsules and subacromial bursae of the frozen shoulder group. CONCLUSIONS These findings imply that elevated levels of inflammatory cytokines in the subacromial bursa may be associated with the pathogenesis of inflammation evolving into fibrosis.