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Purpose: We introduce the novel treatment technique, scalene injection, and study its clinical efficacy for diagnosis, treatment, and pain control for patients with thoracic outlet syndrome.Methods: Between November 2001 and October 2018, 266 patients were studied retrospectively. To evaluate the efficacy and sustainability, we checked the numerical rating scale (NRS) for pain relief and neck disability index (NDI) for functional improvements, prior to and 1, 12 weeks after the injection. The safety was evaluated by examining side effects for at least 24 hours from the point of injection.Results: NRS was improved from 7.12 to 3.11 at 1 week, and to 3.05 at 12 weeks (p

Background/Aims: The present study aimed to investigate whether tocotrienol regulates interleukin 17 (IL-17)-induced osteoclastogenesis in rheumatoid arthri tis (RA). Methods: We evaluated the effect of tocotrienol on IL-17-induced receptor activa tor of nuclear factor kappa B ligand (RANKL) production using RA fibroblast-like synoviocyte (FLS), together with real-time polymerase chain reaction and en zyme-linked immunosorbent assay. Osteoclast differentiation was confirmed after culturing IL-17-treated RA FLS and Th17 cells with tocotrienol and monocytes. We analyzed the suppressive effect of tocotrienol on Th17 cells percentage or Th17-cy tokine levels among peripheral blood mononuclear cells using flow cytometry. Results: We found that IL-17 stimulated FLS to produce RANKL and tocotrie nol decreased this IL-17-induced RANKL production. Tocotrienol decreased the IL-17-induced activation of mammalian target of rapamycin, extracellular signal-regulated kinase, and inhibitor of kappa B-alpha. When monocytes were incubated with IL-17, RANKL, IL-17-treated FLS or Th17 cells, osteoclasts were differentiated and tocotrienol decreased this osteoclast differentiation. Tocotrie nol reduced Th17 cell differentiation and the production of IL-17 and sRANKL; however, tocotrienol did not affect Treg cell differentiation. Conclusions: Tocotrienol inhibited IL-17- activated RANKL production in RA FLS and IL-17-activated osteoclast formation. In addition, tocotrienol reduced Th17 differentiation. Therefore, tocotrienol could be a new therapeutic choice to treat bone destructive processes in RA.

Background: Previous research investigating rotator cuff (RC) tendinopathy has usually focused on pathoanatomy. The pathologic response to anticipatory postural adjustments (APAs) has not yet been investigated. Purpose/Hypothesis: To explore changes in APAs as detected by pre-emptive activation of shoulder muscles during ball catching. It was hypothesized that anticipatory muscle activation (AMA) would be present in the unaffected shoulder but delayed or absent in the affected shoulder in patients with RC tendinopathy. Study Design: Controlled laboratory study. Methods: This study included 21 RC tendinopathy patients with a mean age of 49.5 years. Patients were required to grab a ball embedded with an electromyography sensor when it dropped on their hand, and surface electromyography signals were recorded from the infraspinatus, upper trapezius, anterior deltoid, and biceps. The trials utilized 2 balls, weighing 200 g and 500 g. Each ball was used in 2 trials, 1 involving a number count preceding the ball drop (predictable) and the other involving a sudden drop (unpredictable). The onsets of AMA between the affected and unaffected limbs were compared. Results: Regardless of the experimental condition, significantly delayed AMA onsets were identified in all investigated muscles of the affected side compared with those of the unaffected side, except for the biceps muscle in the 500-g predictable trial. For the infraspinatus, the mean onset time in the 200-g predictable trial was –141.0 ± 60.2 ms on the affected side and –211.9 ± 67.1 ms on the unaffected side ( P < .001); in the 200-g unpredictable trial this value was –139.5 ± 54.9 ms on the affected side and –199.5 ± 56.2 ms on the unaffected side ( P < .001). Conclusion: Delayed AMA was observed in the affected shoulder compared with the unaffected shoulder in patients with RC tendinopathy, not only in the RC muscle but also in the periscapular and upper arm muscles. This may indicate that central hypoexcitability is partly responsible. Clinical Relevance: The basis for RC tendinopathy treatment should not be limited to the tendon pathoanatomy. Delayed AMA around the shoulder joint could provide insight into potential mechanisms related to the central nervous system.

Background Triangular fibrocartilage complex (TFCC) injury is common in distal radius fractures. The purpose of this study was to compare the conservative and surgical treatments of TFCC injury of the wrist associated with distal radius fractures. Methods A retrospective study was conducted on 39 patients who received treatment for TFCC injury with distal radius fractures. All patients were treated using a volar locking plate for distal radius fractures. Twenty-six patients who received conservative treatment for TFCC through long arm splinting were classified into group 1, and 13 patients who received surgical treatment for TFCC were classified into group 2. The splint was maintained for 6 weeks in both groups. For clinical evaluation, the range of motion (ROM) of the wrist joint, patient-rated wrist evaluation (PRWE) score, Disabilities of the Arm, Shoulder and Hand (DASH) score, and grip strength were measured. Distal radioulnar joint (DRUJ) stability was evaluated through a stress load test and graded between grade 0 and 3 intraoperatively after fixation and at the final follow-up. Results In group 1, the average DASH score was 11.1 ± 4.4, the average PRWE score was 10.2 ± 4.6, the grip strength was 89.4% relative to the unaffected side, the average ROM of the wrist joint was 65° ± 7.0° for extension, 51.5° ± 8.1° for flexion, 86° ± 5.1° for supination, and 85° ± 5.2° for pronation, and DRUJ stability at the final follow-up was grade 0 in 58.62%, grade 1 in 31.03%, grade 2 in 10.34%, and grade 3 in 0%. In group 2, the average DASH score was 13 ± 5.0, the average PRWE score was 12.4 ± 3.7, the grip strength was 87.3% relative to the unaffected side, and the average ROM of the wrist joint was 60° ± 9.8° for extension, 53.1° ± 7.0° for flexion, 85° ± 5.3° for supination, and 86.8° ± 4.5° for pronation. At the final follow-up, DRUJ stability was grade 0 in 66.67%, grade 1 in 25%, grade 2 in 8.3%, and grade 3 in 0%. The 2 groups showed no statistically significant differences in DASH score, PREW score, grip strength, ROM, and final follow-up DRUJ stability. Conclusions There were no statistically significant differences in the clinical outcomes between the surgical and conservative treatment groups. Therefore, when normal radiological indices are achieved after treatment of distal radius fractures, DRUJ stability can be obtained by conservative treatment.

Additional file 1: Supplementary Table 1. Characteristics of rheumatoid, osteoarthritis patients, and healthy control.

PURPOSE To evaluate the effectiveness and safety of transcatheter arterial embolization to relieve pain associated with shoulder and elbow tendinopathy refractory to conservative treatment. MATERIALS AND METHODS This study included 13 patients (15 cases) who underwent embolization between November 2015 and December 2016 to treat chronic shoulder pain (6 with rotator-cuff tendinopathy, 2 with calcific tendinitis) or elbow pain (7 with lateral epicondylitis) refractory to conservative treatment. Microspheres were used in the first 4 cases, and imipenem/cilastatin sodium was used in the remaining 11. Visual analog scale (VAS) score changes were recorded. Decrease in VAS score and degree of enhancement on digital subtraction angiography were compared. RESULTS The technical and clinical success rates were 100% (15/15) and 73% (11/15), respectively. The mean VAS scores at baseline, 1 day, 1 week, 1 month, and 4 months after embolization were 6.1, 5.8, 5.1, 4.3, and 2.5, respectively (P < .05 after 1 wk). Pain improved in 9 of 10 cases (90%) with "evident" enhancement and 3 of 5 cases (60%) with no evident enhancement. The VAS scores in the evident enhancement group decreased more than those in patients with no evident enhancement (4.5 vs 1.8; P < .05). Forearm cutaneous erythema was noted in 1 patient treated with microspheres. CONCLUSIONS Transcatheter arterial embolization may be an option for relieving pain associated with chronic shoulder and elbow tendinopathy refractory to conservative treatment. The degree of angiographic enhancement might be a possible factor affecting the degree of pain relief after embolization.

Objectives: The purpose of this study was to compare the outcomes of non-operative treatment and operative repair of grade III injuries with complete rupture of the collateral ligament of the proximal interphalangeal (PIP) joint. Patients and methods: Seventeen patients with grade III injuries with at least 6 months of follow-up were included. Seven patients underwent non-operative treatment and 10 patients underwent operative treatment. We evaluated the following clinical outcomes after treatment: 1) range of motion of the PIP and distal interphalangeal (DIP) joints, 2) joint stability, 3) pain score, and 4) amount of fusiform deformity of the PIP joint. Results: There was no instability in the lateral stress test in either group. The ranges of motion of the PIP and DIP joints were not statistically different between the two groups at final follow-up. However, the ranges of motion recovered more quickly in the operative group than the non-operative group within the first 3 months after treatment. Patients in the operative group had less pain and better cosmetic appearance of the PIP joint. Conclusion: Our results suggest that operative repair of the PIP collateral ligament can provide good joint stability, rapid functional recovery, and minimize fusiform deformity of the PIP joint. Level of evidence: Level III, Therapeutic study. Keywords: Proximal interphalangeal joint, dislocation, PIP collateral ligament, Surgical repair, Suture anchor

Background: Isotonic exercise is commonly adopted for shoulder rehabilitation, but the efficacy of isokinetic exercise for rehabilitation has not been evaluated. Purpose: To evaluate the efficacy of isotonic and isokinetic external shoulder rotation exercises. Study Design: Controlled laboratory study. Methods: Using surface electromyography (EMG) and the Biodex system, we investigated the EMG amplitude of the infraspinatus (IS), total work (tWK), and EMG(IS)/tWK ratio and examined the relative IS and posterior deltoid (PD) contributions to all exercises. A total of 24 healthy participants without musculoskeletal injuries were included. Participants performed isotonic external shoulder rotation at 10%, 20%, 30%, 40%, and 50% of the maximum voluntary isometric contraction (MVIC) as well as isokinetic external shoulder rotation at angular velocities of 60, 120, 180, 240, and 300 deg/s. Levels of intensity were classified from 1 to 5: level 1 corresponded to 10% of the MVIC and a 300-deg/s angular velocity; level 2 corresponded to 20% MVIC and 240 deg/s; level 3 corresponded to 30% MVIC and 180 deg/s; level 4 corresponded to 40% MVIC and 120 deg/s; and level 5 corresponded to 50% MVIC and 60 deg/s. Normalized IS and tWK amplitudes were calculated for each exercise. Results: During isotonic exercise, the EMG(IS)/tWK ratio significantly decreased from level 5 to 3, 2, and 1; from level 4 to 2 and 1; and from level 3 to 1. During isokinetic exercise, the EMG(IS)/tWK ratio at level 3 was greater than that at all other levels except level 1. Statistical differences were found between isotonic and isokinetic modes at levels 1, 2, and 3. The IS/PD activation ratios were not significantly different between exercise modes at any level. Conclusion: Isokinetic resistance may provide more effective stimulation of the IS muscle compared with isotonic resistance. Clinical Relevance: Isokinetic exercise needs to be considered as a method of rehabilitation that effectively increases infraspinatus muscle activity.

Introduction Certain type of injury of the triangular fibrocartilage complex associated with distal radius fracture can result in distal radioulnar joint instability (DRUJ). Untreated DRUJ instability may lead to poor result in the treatment of acute distal radius fractures. The aim of this study was to evaluate DRUJ instability in distal radius fractures through dorsal stress radiography comparing the affected and unaffected wrists intraoperatively. Materials and methods 49 patients with a distal radius fracture who were operatively treated with a volar locking plate were included. Dorsal stress radiography was used to evaluate both affected and unaffected wrists peri-operatively to detect DRUJ instability. Under general anesthesia, a dorsal stress test was performed on the unaffected wrist. Additionally, after fixation of the affected wrist, a dorsal stress test was performed. The ulnar translation ratio (UTR) was measured through the dorsal stress radiograph. Arthroscopic examination was performed on all affected wrists according to Palmer's and Atzei classification. Results The UTR of the affected wrist and the TFCC injury Palmer-type IB tendency were positively correlated (odds ratio: 1.18, p-value: 0.002). Additionally, as the UTR difference between the affected and unaffected wrists enlarged, it revealed a significant DRUJ instability tendency due to Palmer-type IB TFCC injury (p-value: 0.000006, Wilcoxon rank-sum test). Conclusions Dorsal stress radiography is a reliable, simple procedure to evaluate DRUJ instability intraoperatively. UTR value from dorsal stress radiography could be useful for evaluating DRUJ instability associated with distal radius fracture.

Background:Previous studies on massive rotator cuff tears have not addressed the outcomes of tears extending to the subscapularis tendon.Hypothesis:The retear rate in patients with a massive posterosuperior rotator cuff tear combined with a subscapularis tear is higher than that in patients with a massive posterosuperior rotator cuff tear with an intact subscapularis tendon.Study Design:Cohort study; Level of evidence, 3.Methods:Data were collected and analyzed from 92 consecutive patients who underwent arthroscopic repair of a massive posterosuperior rotator cuff tear. Patients were divided into 3 groups according to the status of the subscapularis tendon: intact subscapularis tendon (I-massive tear; n = 42), tear involving half or less than half of the subscapularis tendon (S-massive tear; n = 22), and tear involving more than half of the subscapularis tendon (L-massive tear; n = 28). The integrity of the rotator cuff was determined by ultrasonography at 4.5 and 12 months or later after surgery. Clinical evaluations were performed using the visual analog scale (VAS) pain score, the American Shoulder and Elbow Surgeons (ASES) score, the Constant score, and active shoulder range of motion. Data were collected on the day before surgery and at final follow-up (at least 24 months postoperatively).Results:A total of 25 retears (27%) were identified based on an ultrasonographic evaluation. Although statistical significance was not found, there was a trend toward a higher retear rate in patients with an L-massive tear (43%) compared with those with an S-massive tear (18%; P = .050) or I-massive tear (21%; P = .059) at final follow-up. The subclassification of retears according to the involved tendons revealed that subsequent retears of the subscapularis tendon were noted only in patients with an L-massive tear. In patients with an L-massive tear, postoperative data comparison between patients with intact subscapularis tendons and those with failed subscapularis tendons revealed that a significant difference was noted in the VAS (1.1 vs 3.8, respectively) and ASES (90.6 vs 58.5, respectively) scores. The improvement in clinical scores after repair was statistically significant in all groups but not different between the groups.Conclusion:The arthroscopic repair of massive tears results in substantial improvements in shoulder function, regardless of the presence of combined subscapularis tears. However, this study showed a trend toward a high failure rate for the repair of massive posterosuperior rotator cuff tears extending over half of the subscapularis tendon. Therefore, other treatment options should also be considered for this type of rotator cuff tear.

The purpose of this study is to evaluate the radiographic and clinical outcomes of the Frag-Loc(®) compression screw with palmar plate fixation on distal radius fractures that include a displaced dorsoulnar fragment.This retrospective comparative study enrolled 48 patients who had an unstable distal radius fracture and a dorsoulnar fragment that was more than 2 mm displaced and that had involvement of more than one-quarter of the articular surface. Twenty-six of the 48 patients were treated with a palmar locking plate without a Frag-Loc(®) compression screw (group 1) and the other 22 patients were treated with palmar locking plate with a Frag-Loc(®) compression screw to fix the dorsoulnar fragment (group 2). First, we reviewed all pre-surgical computerized tomographic (CT) scans. Second, we used the gap distance between the dorsoulnar and palmar fragment as seen on post-surgical axial and sagittal CT scans to determine outcome. The gap distance was measured at the point of maximum distance perpendicular to the plane of the main fracture line. Clinical outcomes were evaluated based on the patient-rated wrist evaluation (PRWE) score; the disabilities of the arm, shoulder and hand score; wrist active range of motion; and grip strength.There were no statistically significant differences in clinical outcome between the two groups. However, there were statistically significant differences in post-surgical gap distance. The mean post-surgical gap distances for group 1 were 1.3 mm (range 0.2-3.8 mm) on axial CT scans and 1.4 mm (range 0.5-2.4 mm) on sagittal CT scans, while the mean post-surgical gap distances for group 2 were 0.7 mm (range 0.7-1.6 mm) and 0.7 mm (range 0.3-1.1 mm).This study shows that the Frag-Loc(®) compression screw can reduce the gap distance between the dorsoulnar fragment and the distal radius, according to evaluation of post-surgical axial and sagittal CT scans. This result suggests that the Frag-Loc(®) compression screw is an effective and simple treatment option to immobilize a dorsoulnar fragment associated with distal radius fracture.

Background Total oxygen consumption has been found to be reduced under deep neuromuscular blockade due to a lower rate of metabolism of skeletal muscles. However, the magnitude of this effect in individual muscles has not been investigated. Thus the aim of this study was to compare the oxygenation of paralyzed versus non-paralyzed forearm muscle under tourniquet-provoked ischemia. Methods After ethics approval and written informed consent, 30 patients scheduled for elective hand and wrist surgery were included. Ischemia was provoked by inflation of bilateral upper arm tourniquets and muscle relaxation was achieved via intravenous administration of rocuronium 0.9 mg/kg. Bilateral tourniquets were applied to both upper arms before induction of anesthesia and near infrared spectrometry (NIRS) electrodes applied on both forearms. Muscular ischemia in an isolated (= non-paralyzed, NP) as well as a paralyzed forearm (P) was created by sequential inflation of both tourniquets before and after intravenous administration of rocuronium. Muscle oxygen saturations (SmO2) of NIRS in both forearms and their changes were determined and compared. Results Data of 30 patients (15 male, 15 female; 41.8 ± 14.7 years) were analyzed. The speed of SmO2 decrease (50% decrease of SmO2 from baseline (median [percentiles]: NP 210 s [180/480s] vs. P 180 [180/300]) as well as the maximum decrease in SmO2 (minimum SmO2 in % (median [percentiles]: NP 20 [19/24] vs. P 21 [19/28]) were not significantly affected by neuromuscular paralysis. Conclusions No significant effect of muscle relaxation on NIRS-assessed muscle oxygenation under tourniquet-induced ischemia was found in human forearm muscles.

Background The aim of the present study was to identify the clinical and radiologic factors affecting functional outcomes in patients with a distal radius fractures (DRFs) treated by volar locking plate fixation. Patients and methods Prospective cohort of patients with dorsally angulated DRFs requiring the volar locking plate fixation were recruited during one year. We evaluated wrist motion, grip strength, and DASH score at 3, 6 and 12 months after surgery. The factors assessed for their influence on functional outcomes included clinical variables representing patients' characteristics (age, gender, whether the dominant hand was fractured, the fracture mechanism, fracture classification, complications after surgery, and diabetes mellitus) and radiologic variables representing amount of displacement and quality of reduction (volar tilt angle, radial height, radial inclination, and ulnar variance) at initial injury plain radiographs before manual reduction, and at the radiographs within 1 week of surgery. We conducted a simple and multiple linear regression analysis to identify the clinical and radiologic factors affecting functional outcomes. Results 89 patients were recruited at 1 year after surgery. In the multivariate linear regression analysis, the significant factor affecting DASH score was diabetes ( p = 0.025) and the ulnar variance after surgery ( p = 0.042) after adjusting for age. However, Age was the only statistically significant factor affected grip strength ( p = 0.024) and wrist motion ( p = 0.012). Conclusions Because the ulnar variance after surgery is the modifiable factor in contrast with other factors such as diabetes and age, surgeons should pay attention to restore ulnar variance to improve functional outcomes during volar locking plate fixation in patients with distal radius fractures.

Background The purpose of this study was to report the ultrasonographic findings and clinical features of schwannoma of the hand. Methods We enrolled 8 patients who were initially diagnosed with ganglion by ultrasonography but finally with schwannoma by a tissue biopsy. We retrospectively analyzed the ultrasonographic findings of eight patients including echogenicity, internal homogeneity, posterior enhancement, internal vascularity, and clinical manifestations such as the occurrence site, tenderness, Tinel's sign, and paresthesia before the surgery. Results The occurrence sites were as follows: two cases on the thenar area, one case on the second web space, three cases on the third web space, one case on the radiovolar aspect of the proximal phalanx of the index finger, and one case on the radiovolar aspect of the proximal phalanx of the middle finger. Four patients suffered from tenderness and pain on presentation, and all patients had pain around the mass before presentation. Tinel's sign was present without paresthesia in one case. Ultrasonography revealed cystic lesions showing clear margins in all cases, and two of them had acoustic enhancement without internal flow. Conclusions It may not be easy to diagnosis schwannoma of the hand with ultrasonography alone when the lesion is small because of the similarity to the ultrasonographic findings of ganglion. Therefore, it is necessary to consider the possibility of schwannoma if a mass near the digital nerve or cutaneous nerve branch is accompanied by dull pain and tenderness.

Most of the clinical studies on the results of MIPO (minimally invasive plate osteosynthesis) with the use of anatomically preshaped locking plates for the complex distal femoral fractures have shown favorable results. In the application of bridge plating, placement of lag screws to the butterfly fragments is usually not recommended because it may make the whole construct too stiff. Recently, problems of nonunion related to excessive stiffness after MIPO using a locked plate were reported but the only solution suggested was reoperation with a bone graft. We herein report a case of nonunion after MIPO of the distal femoral fracture where we applied a concept of "dynamization of the plate-bone construct" to make it less stiff and in turn to get fracture healing with bridging callus formation. A 58-year-old woman sustained a simple oblique fracture of the distal femur (AO-OTA 33A1). We performed MIPO procedure using a locking compression plate-distal femur. To get the alignment, we have placed a conventional screw across the fracture line through the dynamic compression unit (DCU) of the combination hole. Postoperative radiographs revealed 7-8 mm gap across the entire fracture surface which was not obvious on the intra-operative C-arm images. Radiographs taken 6 months after operation showed almost no callus formation with shuttle marginal resorption. We interpreted the situation that the construct was too stiff to allow motion across the fracture site due to the lag screw. We thought we have used it as a reduction screw but it acted as a lag screw, preventing motion at the fracture site. Given this analysis, we have only taken the lag screw out to make the construct less stable. It caused the situation of absolute stability with a significant gap to turn into the one of relative stability with acceptable gap. Fracture has solidly healed with bridging callus formation 6 months after lag screw removal under local anesthesia. We would like to call this strategy as "dynamization" of the locked plating.

Pigmented villonodular synovitis(PVNS) is a benign proliferative lesion, involving synovial tissue in joints, tendon sheaths, and bursae. Pigmented villonodular synovitis is a rare and usually monoarticular condition and primarily affects the knee joint and hand. Polyarticular PVNS appears in less than 1% of all case and its occurrence in the shoulder is rare(

서론견갑-상완관절은구형의상완골두와접시모양의견갑골관절와가만드는관절로서같은구-와관절인고관절에비해골성구속이작아서운동범위는큰반면에안정성은낮은관절이다. 따라서안정성의유지에관절낭과인대및회전근개와같은연부조직이큰역할을한다. 그와같은구조적인문제점에의하여외상성탈구가빈발하며급성탈구가재발성불안정성으로진행하는비율이사지의관절중에서가장높다. 견갑골의안정성을좌우하는요소는상완골두와관절와사이의요철과염전에의한조화, 관절와순, 관절낭-인대복합체, 제한된관절용적,관절간격에서의접착및응집기전, 관절내의음압등과같은정적요소와회전근개와상완이두근, 견갑골회전전근등과같은동적요소들로나눌수있다. 또한가장중요한동적요소인회전근개는종지부근처에서정적 안정요소인관절낭과인대들에섞임으로써동적인대의역할을한다.견갑-상완운동의중간범위에서관절와상완인대는이완된상태이며회전근개와상완이두근건의동적작용에의한요형압박이대부분의안정성을좌우한다. 반면에탈구가발생하는위치인운동범위의최종호부근에서는인대가팽팽하게되어상완골두의과도한전위를방지할뿐아니라, 관절와상완인대와상완이두근장두건의부착점을제공함으로써관절의안정성에중요한역할을담당한다. 외상성견관절전방탈구의필수병변으로알려져있던 Bankart 병변은전하방관절하순의파열로서이는관절와상완관절의외전-외회전상태에서관절안정성에가장중요한역할을하는하관절와상완인대의기능상실을의미한다. 그러나 전형적인Bankart 병변뿐아니라관절낭의파열, 소성변형또는비정상적이완에의하여도견관절의탈구또는아탈구가발생할수있다. 상완골두급성전방탈구의후유증으로발생하는이상성전방불안정증은견관절의불안정증중에서가장많은유형으로서 2,30대의젊은연령

The purpose of this study was to evaluate the effect of oral prostaglandin E1( PGE1) on the patency of the microvascular anastomosis of the carotid artery in rat. A total of 48 rats were used, and divided into three groups. The first group (A) was used as a control with no medical agent being used after anastomosis, the second group (B) was medicated with aspirin, and the third group (C) was medicated with oral PGE1. In each group, four rats were sacrificed serially on every post-operative 3, 5, 10 and 15 days after arterial anastomosis. Patency and histologic evaluations at the anastomotic site were observed. The results revealed that the PGE1therapied group showed highest patency rate (100%), lesser formation of mural thrombosis, and also minimal changes in the intimal hyperplasia and medial fibrosis. From these findings, we could conclude that PGE1has superior effect on maintaining the patency after microvascular surgery.

Congenital pseudarthrosis of the ulna is very rare. We have experienced a case of pseudarthrosis of ulna to be treated with the vascularized fibular graft in a seven-years-and-three-month-old boy.

Purpose: The purpose of this study is to report the clinical results of excision of the hamate hook in baseball players with hamate hook nonunion. Materials and Methods: This study included 10 baseball players treated with excision of the hamate hook. Among 10 players, there were 3 professional players and 7 amateur players. The clinical outcomes were evaluated using the visual analog scale (VAS) pain score, exercise performance score, and grip power. We also checked complications and time to return to the game. Results: At final follow-up, the average VAS score was 0.4 points and the average performance score was 9.0 points. The grip power was recovered to 96.7% of the opposite hand at final follow-up. Significant improvement in pain and grip power was observed after surgery. The average time to return to the game was 11.8 weeks. There was one case of postoperative ulnar nerve neuropathy, which was completely resolved within 12 weeks after surgery. Conclusion: We think that excision of the hamate hook is an effective treatment to enable early return to the game without loss of grip strength in the baseball player with nonunion of the hamate hook.

Persistent ulnar-sided wrist pain after treatment of triquetral dorsal chip fracture even after union is a matter of concern. There could be various reasons for this persistent pain like arthritis, instability, fractures and non-union. We correlate our findings of physical examination and wrist arthroscopy as triangular fibrocartilage complex injury to be one of the causes of this persistent pain. Six subjects who had persistent ulnocarpal joint pain and tenderness after triquetral dorsal chip fracture, despite 2 months of conservative treatment, were subjected to physical tests. If the physical examination yields positive results, then magnetic resonance imaging followed by arthroscopic treatment was performed. The six patients were then evaluated using the visual analogue scale, the Mayo modified wrist score, and the grip strength test. Triangular fibrocartilage complex (TFCC) injury was observed in all six cases and partial TFCC resection and synovectomy were performed. Analysis of the visual analogue scale, Mayo modified wrist score, and grip strength test data revealed statistically significant improvements (P

골 형성 단백(bone morphogenetic protein, BMP)은 1965년에 Urist에 의해 처음으로 보고되었으며, Bostrom 등은 BMP-2, BMP-4가 내연골성 및 막성 골절 치유에 관여한다는 것을 밝혔 다. 이후에 BMP-2를 이용한 골 재형성 실험 연구들이 보고되었 으며 현재 BMP-2는 골 결손이 있는 부위에 골 이식 대체물 로 상품화되어 임상적으로 이용되고 있다. BMP-2는 골 유도 작 용 이외에도 관절 연골의 당단백 합성을 자극하여 관절 연골의 복원을 유도하는 작용이 있으며, 이러한 BMP-2의 특성을 이용 하여 관절 연골의 복원을 시도하는 실험 연구 결과들이 보고되 고 있으나 염증성 관절의 관절 연골에서는 BMP-2 단독으로 관 절 연골의 복원을 유도하지 못하는 것으로 알려져 있다. 본 연구 는 BMP-2의 특성을 이용하여 관절 연골의 전층 결손 부위에 미 세골절(microfracture)을 한 후 BMP-2를 충전하여 BMP-2가 관절 pISSN : 1226-2102, eISSN : 2005-8918 241

29 Copyright c 2014 The Korean Fracture Society. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Received February 20, 2013 Revised July 6, 2013 Accepted October 12, 2013 Address reprint requests to: Seoung Joon Lee, M.D., Ph.D. Department of Orthopedic Surgery, Konkuk University Medical Center, 120-1 Neungdong-ro, Gwangjin-gu, Seoul 143-729, Korea Tel: 82-2-2030-7360ᆞFax: 82-2-2030-7369 E-mail: lsjmd@naver.com 전방 부정유합된 원위 요골에서 개방성 쐐기형 절골술의 임상 결과 이승준 ⋅최진호

Carpal tunnel syndrome is the most common peripheral nerve entrapment syndrome. The elevated pressure in the carpal tunnel causes compression of median nerve. Although the diagnostic criteria for carpal tunnel syndrome are not clear, the diagnosis is based on the patient history and physical examination and may be confirmed by electrodiagnosis with nerve conduction test or ultrasonography. Nonsurgical treatments are generally recommended for early carpal tunnel syndrome and surgical treatments are preferred for failed nonsurgical treatment, however there is controversy regarding the optimal time when the surgery should be performed. Results of surgical treatment are usually satisfactory, however there are also complications after surgical treatment. In order to achieve good results without complications, normal anatomy around the median nerve and its anatomical variations should be thoroughly understood before the operation and careful surgical technique is absolutely required.

삼각섬유연골 복합체는 관절 원판, 원위 요척골 관절의 전 방 및 후방 인대, 척측 측부인대, 척수근 신건의 건막, 척수근 인대로 구성되는 해부학적 복합체로, 원위 요척골 관절 및 완 관절의 척측 부위의 안정성에 중요한 역할을 하며, 이 구조물 의 손상은 원위 요척 관절의 불안정, 완관절의 통증 등을 유발 할 수 있다. 특히 삼각섬유연골 복합체가 변연부에서 파열될 경우에는 원위 요척골 관절의 불안정성 및 지속되는 완관절 통증을 유발할 수 있으며 파열 부위에 대하여 봉합술을 시행 하는 것이 좋다고 알려져 있다. 삼각섬유연골 복합체의 중 심 부위 손상은 부분 절제술로 치료를 많이 하고 있으나 부분 절제술의 치료 결과를 보고하는 문헌은 많지 않다. 이에 저자 들은 삼각 섬유 연골 복합체의 급성 손상을 진단받고 완관절 관절경을 시행한 환자 중 삼각 섬유 연골 복합체의 중앙 부위 에서 파열이 있는 Palmer 1A형의 치료 결과를 보고하고자 한다. Treatment of Palmer Class 1A Triangular Fibrocartilage Complex Injuries with Arthroscopic Partial Resection

The Streptococcus milleri group, which also includes S. anginosus, S. intermedius and S. constellatus, is found in the oropharynx, upper respiratory tract, gastrointestinal tract, and urogenital tract mucosa. Bacteria in the Streptococcus milleri group are associated with bacteremia and abscess formation. Most of the reports of of Streptococcus milleri group (SMG) infection occur in patients with underlying medical conditions. Predisposing factors that have been associated with S. milleri group empyema include mucosal disturbances (sinusitis, periodontal disease, enteric disease), preceding to pneumonia, thoracic surgery, malignancy, neurological disease, alcohol abuse, and also diabetes mellitus. We report on a 42-year-old man with mental retardation. He who suffered from dyspnea and a fever that he had developed for over 14 days. S. constellatus and anaerobic bacterias (Prevotella buccae and Micromonas micros) were cultured. The patient was treated with the drainage of pleural effusion and clindamycin and levofloxacin.

249 통신저자:이 승 준 서울시 광진구 화양동 건국대학교 의학전문대학원 정형외과학교실 Tel:02-2030-7360ᆞFax:02-2030-7369 E-mail:lsjmd@kku.ac.kr 접수: 2010. 5. 19 심사(수정): 1차 2010. 6. 18, 2차 2010. 9. 18, 3차 2011. 3. 6 게재확정: 2011. 3. 14 Address reprint requests to:Seoung Joon Lee, M.D. Department of Orthopaedic Surgery, Konkuk University School of Medicine, Hwayang-dong, Gwangjin-gu, Seoul 143-701, Korea Tel:82-2-2030-7360ᆞFax:82-2-2030-7369 E-mail:lsjmd@kku.ac.kr 지연 진단된 유구-중수골 관절의 골절 및 탈구의 수술적 치료

179 통신저자:이 승 준 서울시 광진구 화양동 1번지 건국대학교 의학전문대학원 정형외과학교실 Tel:02-2030-7360ᆞFax:02-2030-7369 E-mail:lsjmd@kuh.ac.kr 접수: 2008. 11. 16 심사 (수정): 1차 2008. 12. 10, 2차 2009. 1. 9, 3차 2009. 2. 16, 4차 2009. 3. 20 게재확정: 2009. 5. 2 Address reprint requests to:Seoung-Joon Lee, M.D. Department of Orthopedic Surgery, Konkuk University School of Medicine, 1, Hwayang-dong, Gwangjin-gu, Seoul 143-701, Korea Tel:82-2-2030-7360ᆞFax:82-2-2030-7369 E-mail:lsjmd@kuh.ac.kr 삼각골 후방 피질 골절에 동반된 삼각섬유연골 복합체 손상

Carpal tunnel syndrome occurs infrequently in children. Genetic disorders and systemic disease of carpal tunnel syndrome may be the predisposing factors for carpal tunnel syndrome in children. Immunoglobulins (Ig) play a major role in adaptive immunity, and the loss of certain species of immunoglobulin is known to increase the risk of certain types of infection. Patients with hypogammaglobulinemia have an increased risk of cellulitis, arthritis and osteomyelitis. We describe the management of bilateral carpal tunnel syndrome in children with hypogammaglobulinemia.

Purpose : This study examined the displacement of the ulnar head with respect to the distal radius after distal radius malunion on the axial plane using computed tomography. Materials and Methods: Twenty-four patients with a residual dorsal tilt ＞10˚ or radial shortening ＞2 mm than the normal side, and no limitation in wrist rotation after radius union were enrolled in this study. The bilateral CT scans were obtained in 70˚ pronation, neutral, 70˚ supination. The radioulnar ratio was measured and the ratios of the abnormal side were compared with those of the opposite normal side. The results were statistically analyzed using a two-tailed paired t-test. Results : The ulnar head of the patients with a malunited radius had a tendency for anterior translation compared with the normal side. In patients with a dorsal tilt deformity, the anterior translation of the ulnar head with respect to the radius was significant, particularly in the supination and neutral position. However, no significant difference was found in patients with radial shortening in terms of the ulnar head translation between the normal and abnormal side. Conclusion : These results might explain the mechanism of distal radioulnar joint instability and low incidence of ulnocarpal impingement in patients with distal radius malunion.

목 적: 분만시 발생한 대퇴골 간부 골절의 발생 양상과 재형성 과정을 규명하고자 한다. 대상 및 방법: 3명, 4례의 대퇴골 간부 분만 골절을 대상으로, 산과적 과거력과 가족력을 조사하였고 평균 36.6개월 추시하여 방사선 사진에서 골절 부위에서 보이는 골절 각, 근위 골단판과 원위 골단판이 이루는 골단판 각을 측정하여 분석하였다. 결 과: 대퇴골 분만 골절의 발생률은 0.06%였으며, 2례에서는 골절 각과 골단판 각이 점차 감소하는 재형성을 보였고, 2례 중 1례는 골절 각 이 증가하다가 감소, 1례는 계속 증가하였으나 이 2례의 골단판 각은 골절 각의 증감과 관계없이 점차적으로 감소하여 정상적인 골단판의 재 정렬을 보였다. 산과적 과거력과 가족력상에서 한 명의 신생아는 정상으로 판단이 되었으며, 두 명의 신생아는 취약 골을 보이는 골형성 부전 증으로 판단이 되었다. 결 론: 대퇴골 분만 골절이 발생시 신생아의 동반 질환 여부의 확인이 필요하며, 골단판에서의 반응이 골절 각의 변화에 관계없이 지속적으 로 정상 관절면으로 배열하려는 골단판의 재정렬 과정이 발생하여 골절에 의한 각 변형의 재형성에 주도적 기전으로 여겨진다.

Purpose: To describe the clinical presentation and course of necrotizing fasciitis of low extremity and to analyze the factors affecting the clinical result of necrotizing fasciitis. Materials and Methods: The medical records and MRI of 26 patient who had suffered from necrotizing fasciitis were reviewed retrospectively. Results: There were 18 men and 8 women with a mean age of 43.8 years. Twenty two of 26 patients had a medical disease and the most common comorbidity was diabetes mellitus. Exquisite pain, erythema, warm skin were the most consistent clinica l feature at the time of admission. Only six patients had a diagnosis of necrotizing fasciitis initially. The interval between onset of symptom and operative treatment was average 5.4 days in 20 patients who didn’ have a diagnosis of necrotizing fasciitis initially, and among them, 2 patients died. There were limited range motion of knee joint in 3 cases, sacral osteomyelitis in 1 case, and sciatic nerve palsy in 1 case as a complication. Conclusion: We think that the diagnosis of necrotizing fasciitis should be considered with a high index of suspicion in patients who present with unexplained limb pain, and delay in operative treatment and wide involvement of the necrosis is associated with poor results of necrotizing fasciits.

Purpose: To investigate the relationship between the varus appearance and the axial alignment of the lower extremity. Materials and Methods: The axial alignments of the lower extremities of 46 normal male adults (volunteers) were measured from the radiographs and compared with the reports for Caucasians, and between the groups divided according to their subjective appearance. Results: The femorotibial mechanical angle was and the medial obliquity of the knee was , which were the varus compared with the reported reference points. In the group containing those with the subjective varus appearance of the lower extremities, the femorotibial mechanical angle and the medial obliquity of the knee and ankle joint were the varus, and the metaphyseal-diaphyseal angle was greater than in the group containing those with the subjective straight appearance of the lower extremity (p