Background: Subchondral fatigue fracture of the femoral head (SFFFH) is a rare disease, and its disease entity is established in recent decades. Although there are a few studies on SFFFH, most of them are case series involving around 10 cases, and the clinical course of SFFFH is still not well known. This study analyzed the factors affecting the clinical course of SFFFH. Methods: Patients who visited our institution from October 2000 to January 2019 were retrospectively evaluated. Of eligible cases, 89 hips (80 patients) were diagnosed with SFFFH and non-surgical treatment outcomes were analyzed. Radiographs and medical charts were reviewed for following factors: the degree of femoral head collapse, the interval between the onset of hip pain and the first hospital visit, hip dysplasia, osteoarthritic changes, sex, and age. Results: Hip pain decreased in 82 cases (92.1%) through non-surgical treatment, and 7 cases (7.9%) underwent surgery. Patients with good results of non-surgical treatment had improvement 2.9 months on average after the treatment. All cases without a collapsed femoral head (55 cases) had hip pain alleviation through non-surgical treatment. Cases with femoral head collapse of 4 mm or less and non-surgical treatment within 6 months from the onset of hip pain (22 cases) all had hip pain alleviation. Among 8 cases with femoral head collapse of 4 mm or less and non-surgical treatment after 6 months or more from the onset of hip pain, 3 underwent surgery and 1 had persistent hip pain. Those with femoral head collapse of over 4 mm (3 cases) all underwent surgery. The osteoarthritic changes, dysplastic hip, sex, and age were not statistically related to the success of non-surgical treatment. Conclusions The success of non-surgical treatment for SFFFH can be affected by the degree of femoral head collapse and the timing of non-surgical treatment.

Background: Most isolated greater trochanter (IGT) fractures are treated conservatively. However, some require surgical fixation although indications for surgery have not yet been established. Many surgeons perform surgical fixation when the intertrochanteric extension crosses the midline on magnetic resonance (MR) images. Nevertheless, for mechanical strength, cortical bone integrity is more important than that of intramedullary cancellous trabeculae. We retrospectively evaluated the clinical usefulness of multiplanar reformation computed tomography (MPR CT) in determining treatment strategies for IGT fractures. Methods: We evaluated 99 cases of suspected IGT fractures between October 2004 and December 2019. They were 66 women and 33 men with a mean age of 77 years. The mean follow-up period was 34 months. Most patients were evaluated with plain radiographs, followed by additional imaging study via MPR CT in 65 cases, magnetic resonance imaging (MRI) in 5 cases, and both in 17 cases. Typically, fractures were fixed surgically when a cortical breakage was detected in the intertrochanteric area on MPR CT, while fractures without evidence of cortical breakage on MPR CT were treated conservatively. Results: In 13 out of 82 cases evaluated by MPR CT, incomplete cortical breakage in the intertrochanteric area was detected, of which 10 were treated surgically. The remaining 3 cases were treated conservatively due to patient’s refusal, poor medical condition, and failure to detect breakage. Of 69 cases without cortical breakage, 61 cases were successfully treated conservatively.Among the 17 cases evaluated by both MPR CT and MRI, cortical breakage was detected in 3, of which the intertrochanteric extension crossed the midline on the MR image only in 1 case. Of the remaining 14 cases without breakage, the intertrochanteric extension crossed the midline in 5. Among these 5 cases, 3 were treated conservatively. Conclusions The results suggest that MPR CT is a useful imaging modality for further evaluation of IGT fractures. It was especially valuable in evaluating cortical bone integrity, which may be more critical for fracture stability.

Background: Incomplete fractures are assumed to occur in the intertrochanteric area as fractures at other sites, but reports of incomplete intertrochanteric fractures (IIFs) are rare. In 1999, Schultz et al. defined isolated greater trochanter fractures (GTFs) as IIFs when intertrochanteric extension is observed on magnetic resonance (MR) images. On multiplanar reformation computed tomography (MPR CT) images acquired for further study of apparently isolated GTFs, we noted incomplete cortical breakage in the intertrochanteric area. We then found that the fracture line was incomplete on plain radiographs in some intertrochanteric fractures. We evaluated IIFs and apparently isolated GTFs using MPR CT and analyzed the fracture patterns of IIFs that were confirmed using MPR CT. Methods: Between February 2006 and June 2019, 36 cases of IIF were detected using MPR CT in 36 patients. They were 17 women and 19 men with a mean age of 74.7 years (range, 26–94 years). Plain radiographs and MPR CT images were evaluated by two experienced orthopedic surgeons. In addition, MR imaging was performed in 5 cases. Results: Plain radiographs showed no evidence of fracture in 2 cases, isolated GTF in 7 cases, and IIF in 27 cases. In all cases, incomplete cortical breakage in the intertrochanteric area was confirmed on MPR CT images. Cortical breakage was located in the anterior portion of the intertrochanteric area, whereas the posterior portion remained intact in all cases. The detection rate of cortical breakage was higher on coronal or sagittal images than that on axial images. On MR images of 5 cases, intertrochanteric extensions were found in the medullary space. All extensions originated in the greater trochanter area and extended anteriorly in the axial plane and inferomedially in the coronal plane. On the T1-weighted mid-coronal image, the extension reached or passed the midline in 3 cases, and cortical breakage was detected in only 2 cases. Conclusions In all cases of IIF, cortical breakage was detected in the anterior portion of the proximal femur, leaving the posterior cortex intact. This finding is notably different from that of intertrochanteric extension (from posterior to anterior) detected on MR images of isolated GTFs.

Laparoscopic cholecystectomy has been widely performed as the gold standard for patients suffering with symptomatic gallstone disease. However, conversion to open cholecystectomy is a dilemma when the surgeon encounters a variant biliary anomaly. A gallbladder lying to the left of the round ligament represents a rare congenital anomaly, which is termed as a left-sided gallbladder. The true left-sided gallbladder, situated on the inferior aspect of the left lobe of the liver, is extremely rare and this represents a truly ectopic gallbladder that may developmentally arise as a second gallbladder from the left hepatic duct. This is accompanied by the disappearance of the normal gallbladder on the right side. We report here on 2 cases of left-sided gallbladder that were successfully treated with laparoscopic cholecystectomy at Hallym Medical Center. In both cases, the true left-sided gallbladders were identified intraoperatively. The round ligament was indeed located in its normal position, and the gallbladder was located to the left of the round ligament, which is a type of malposition known as sinistroposition. The operation was carried out in the usual manner with the trocars placed their usual location. Although operations can be carried out with using the standard port sites, a better arrangement for laparoscopic cholecystectomy consists of more medial positioning of the gallbladder-retracting port and placement of the right hand operating port to the left side of the round ligament.
Cholecystectomy ; Cholecystectomy, Laparoscopic ; Deception ; Gallbladder ; Gallbladder Diseases ; Gallstones ; Hand ; Hepatic Duct, Common ; Humans ; Liver ; Round Ligament of Uterus ; Round Ligaments ; Stress, Psychological ; Surgical Instruments

There are many causes of extrahepatic biliary obstruction. The most common causes are gallstones and malignant or benign strictures. Web of the common bile duct is a rare disease, and it may produce obstructive jaundice. On cholangiography, a common bile duct web typically appears as a shelf--like radiolucent ring. It is frequently associated with bile duct stone, and it is occasionally related to bile duct trauma or primary sclerosing cholangitis. We report here on a case of a web of the common bile duct without choledocholithiasis in a 27-year-old man. The patient was treated by Roux-en-Y choledochojejunostomy above the level of the web.
Adult ; Bile Ducts ; Cholangiography ; Cholangitis, Sclerosing ; Choledocholithiasis ; Choledochostomy ; Common Bile Duct ; Constriction, Pathologic ; Gallstones ; Humans ; Jaundice, Obstructive ; Rare Diseases

Mechanisms of ceramic liner fractures have not yet been fully elucidated. Impingement between a stem and ceramic liner is a proposed cause of ceramic liner fractures. We experienced a case of ceramic liner fracture caused by direct impingement between the stem shoulder and the ceramic liner. This type of impingement, unlike impingements with a stem neck, has not been previously reported. While we assume that certain characteristics of the stem contributed to the impingement, we report this case to note that caution may be needed when using certain stem designs.

Gastrointestinal stromal tumors (GISTs) are rare tumers of the alimentary tract, and these tumors arise from primitive mesenchymal cells. Duodenal GISTs comprise 4-5% of all GISTs. In this article, we report on a case of duodenal GIST in 35-year-old male who presented with a fistulo in ano and anal bleeding. Abdominal computed tomography and magnetic resonance imaging revealed a huge tumor, about 11x7 cm in size, of the duodenum. Duodenoscopy revealed a protruded mass with central deep ulceration on the third portion of the duodenum. Endoscopic biopsies showed subepithelial spindle cell proliferation of the tumor, and this was consistent with GIST. Pylorus-preserving pancreaticoduodenectomy was then performed. He subsequently underwent the sphincter-preserving modified loose Seton surgical technique. The patient did not have any problems postoperatively and he remained symptom-free at 6 months after surgery.
Adult ; Biopsy ; Cell Proliferation ; Duodenoscopy ; Duodenum ; Gastrointestinal Stromal Tumors ; Hemorrhage ; Humans ; Magnetic Resonance Imaging ; Male ; Pancreaticoduodenectomy ; Ulcer

Gallbladder agenesis is a rare congenital biliary anomaly that may be associated with other biliary and extrabiliary congenital anomalies. Awareness of this condition is important because many of these patients may have vague biliary symptoms that lead to unnecessary operations. We treated a 46-year-old woman who was diagnosed with gallbladder agenesis during performance of gynecologic laparoscopic surgery. The gallbladder was not visualized by the preoperative abdominal ultrasonography, the abdominal computed tomography and the MRCP. The hepatobiliary scan revealed non-visualization of the gallbladder. Based on these imaging studies, there was a high suspicion of a sclero-atrophic gallbladder or agenesis of the gallbladder. At surgery, we carefully examined the porta hepatis and found that the gallbladder was absent. The operation involved only examination with a laparoscope. The patient has remained well and asymptomatic. It is extremely difficult to diagnose gallbladder agenesis in clinical settings; the identification of gallbladder agenesis is often an incidental finding. For cases where the gallbladder is not visualized preoperatively, a diagnostic laparoscopy can be an alternative diagnostic tool prior to performing laparotomy.
Female ; Gallbladder ; Humans ; Incidental Findings ; Laparoscopes ; Laparoscopy ; Laparotomy ; Middle Aged

Carbamazepine-induced liver injury is less common, but the consequences of the side effects can be very serious leading to death or a need for liver transplantation. We report a case of a 60-year-old female transverse myelitis patient with fulminant hepatic failure and Stevens-Johnson syndrome induced by carbamazepine who successfully underwent deceased donor liver transplantation. The patient, a 60-year-old female, was admitted to our service due to acute liver insufficiency and a drowsy mental state attributable to carbamazepine. She had been treated with carbamazepine to control transverse myelitis. Fifty days after the use of carbamazepine, she developed jaundice, erythematous papules and bullae, and decreased consciousness. The diagnosis of Stevens-Johnson syndrome was considered. She underwent deceased donor liver transplantation. She was discharged with normal graft functions 5 months after transplantation. Thus, liver transplantation can be a feasible therapy for patients with carbamazepine-induced hepatic failure associated with Stevens-Johnson syndrome.
Blister ; Carbamazepine ; Consciousness ; Female ; Hepatic Insufficiency ; Humans ; Jaundice ; Liver ; Liver Failure ; Liver Failure, Acute ; Liver Transplantation ; Middle Aged ; Myelitis, Transverse ; Stevens-Johnson Syndrome ; Tissue Donors ; Transplants

This study aimed to analyze the epidemiologic characteristics of patients who underwent hip arthroplasty using the Korean nationwide database and investigate the recent trends in implant fixation methods and bearing surface selection. We aimed to compare clinical characteristics and differences with the results from the registry of other western countries. We analyzed the data collected by the Health Insurance Review and Assessment Service database of Korea from 2007 to 2011 and the Main Surgery Statistical Yearbook from 2014 to 2018, published by the National Health Insurance Service. The number and rate of patients who underwent hip joint arthroplasty per 10,000 persons have been steadily increasing since 2007. There was a big difference in mean age and preoperative diagnosis of patients between the bipolar hemiarthroplasty and total hip arthroplasty groups. Most patients underwent surgery using a cementless biological fixation method, and the cemented fixation method was selectively used for a small portion of old aged osteoporotic patients. In relation to the use of bearing surfaces, the registry data showed that ceramic-ceramic bearings were used at an overwhelmingly high rate (81%) in Korea compared to other countries. The reason was attributable to various factors, such as patient’s age or economic status, differences in the health insurance system between countries, and recently reported complications, such as ceramic fracture or noise.