2023 Korean Thyroid Association Management Guidelines for Patients with Thyroid Nodules

Thyroid nodules are a prevalent condition that can be detected through palpation or ultrasound. However, a small fraction of these nodules can be cancerous, and even benign nodules can cause symptoms if they grow and compress surrounding tissue. As such, it is important to monitor thyroid nodules and determine appropriate treatment options. In recent years, there has been a shift towards enhancing diagnostic accuracy and less aggressive treatment options. As a result, there is a growing need for the development of appropriate recommendations for their clinical application to ensure optimal patient outcomes. The present clinical practice guideline was developed by extracting the nodule section from the prior version of guidelines and updating it to fit the Korean circumstances. Task force members reviewed relevant studies selected after electronic database searching, and the recommendations are provided with a level of recommendation for each section. The revised guideline includes recommendations for thyroid cancer screening in high-risk groups, appropriate diagnostic methods for thyroid nodules, the role of pathological and molecular marker tests in diagnosis, long-term follow-up and treatment of benign thyroid nodules, and special considerations for pregnant women. The major changes in this revision are the definition of high-risk groups for thyroid cancer screening, the application of the revised Korean Thyroid Imaging Reporting and Data System (K-TIRADS), the addition of the role of core needle biopsy and molecular marker tests, the application of active surveillance in low-risk papillary thyroid microcarcinoma, and updated indications for non-surgical treatment of benign thyroid nodules. These evidence-based recommendations are expected to assist in clinical decision-making for thyroid nodule management, ensuring that patients receive the most appropriate and effective treatment options.

Cubital Tunnel Syndrome Caused by Anconeus Epitrochlearis Muscle

OBJECTIVE: We evaluated the clinical manifestation and surgical results following operative treatment of cubital tunnel syndrome (CuTS) caused by anconeus epitrochlearis (AE) muscle.METHODS: Among 142 patients who underwent surgery for CuTS from November 2007 to October 2015, 12 were assigned to the AE group based on discovery of AE muscle; 130 patients were assigned to the other group. We analyzed retrospectively; age, sex, dominant hand, symptom duration, and weakness in hand. Severity of the disease was evaluated using the Dellon classification and postoperative symptom were evaluated using disability of arm shoulder and hand (DASH) and visual analogue scale (VAS) scores. Surgery consisted of subfascial anterior transposition following excision of AE muscle.RESULTS: AE muscle was present in 8.5% of all patients, and was more common in patients who were younger and with involvement of their dominant hand; the duration of symptom was shorter in patients with AE muscle. All patients showed postoperative improvement in symptoms according to DASH and VAS scores.CONCLUSION: The possibility of CuTS caused by AE muscle should be considered when younger patients have rapidly aggravated and activity-related cubital tunnel symptoms with a palpable mass in the cubital tunnel area. Excision of AE muscle and anterior ulnar nerve transposition may be considered effective surgical treatment.

Cubital Tunnel Syndrome Caused by Anconeus Epitrochlearis Muscle

OBJECTIVE: We evaluated the clinical manifestation and surgical results following operative treatment of cubital tunnel syndrome (CuTS) caused by anconeus epitrochlearis (AE) muscle. METHODS: Among 142 patients who underwent surgery for CuTS from November 2007 to October 2015, 12 were assigned to the AE group based on discovery of AE muscle; 130 patients were assigned to the other group. We analyzed retrospectively; age, sex, dominant hand, symptom duration, and weakness in hand. Severity of the disease was evaluated using the Dellon classification and postoperative symptom were evaluated using disability of arm shoulder and hand (DASH) and visual analogue scale (VAS) scores. Surgery consisted of subfascial anterior transposition following excision of AE muscle. RESULTS: AE muscle was present in 8.5% of all patients, and was more common in patients who were younger and with involvement of their dominant hand; the duration of symptom was shorter in patients with AE muscle. All patients showed postoperative improvement in symptoms according to DASH and VAS scores. CONCLUSION: The possibility of CuTS caused by AE muscle should be considered when younger patients have rapidly aggravated and activity-related cubital tunnel symptoms with a palpable mass in the cubital tunnel area. Excision of AE muscle and anterior ulnar nerve transposition may be considered effective surgical treatment.

Surgical Treatment of Piriformis Syndrome

BACKGROUND: Piriformis syndrome (PS) is an uncommon disease characterized by symptoms resulting from compression/irritation of the sciatic nerve by the piriformis muscle. Uncertainty and controversy remain regarding the proper diagnosis and most effective form of treatment for PS. This study analyzes the diagnostic methods and efficacy of conservative and surgical treatments for PS. METHODS: From March 2006 to February 2013, we retrospectively reviewed 239 patients who were diagnosed with PS and screened them for eligibility according to our inclusion/exclusion criteria. All patients underwent various conservative treatments initially including activity modification, medications, physical therapy, local steroid injections into the piriformis muscle, and extracorporeal shock wave therapy for at least 3 months. We resected the piriformis muscle with/without neurolysis of the sciatic nerve in 12 patients who had intractable sciatica despite conservative treatment at least for 3 months. The average age of the patients (4 males and 8 females) was 61 years (range, 45 to 71 years). The average duration of symptoms before surgery was 22.1 months (range, 4 to 72 months), and the mean follow-up period was 22.7 months (range, 12 to 43 months). We evaluated the degree of pain and recorded the responses using a visual analog scale (VAS) preoperatively and 3 days and 12 months postoperatively. RESULTS: Buttock pain was more improved than sciatica with various conservative treatments. Compared with preoperatively, the VAS score was significantly decreased after the operation. Overall, satisfactory results were obtained in 10 patients (83%) after surgery. CONCLUSIONS: PS is thought to be an exclusively clinical diagnosis, and if the diagnosis is performed correctly, surgery can be a good treatment option in patients with refractory sciatica despite appropriate conservative treatments.

Pyogenic Arthritis of the Metacarpophalangeal Joint Treated with External Fixation in Adolescent

When hand injuries caused by human bite are overlooked and they can progress to pyogenic arthritis. Pyogenic arthritis is difficult to treat and can make severe sequelae in the joints. We report a case of pyogenic arthritis of the hand that occurred after human bite injury in adolescent treated with wide debridement and external fixator. Our literature searches revealed that the use of external fixator is good treatment option for the treatment of pyogenic arthritis of the hand.

Extensor Digiti Minimi Triggering Caused by an Anatomical Variation: A Case Report

Although flexor tendon triggering due to stenosing flexor tenosynovitis is common clinically, extensor triggering is quite rare. Known common causes are impingement between extensor tendon and extensor retinaculum, stenosis of the tendon sheath, and impingement between extensor tendon and osteophyte. We report rare case of triggering in the little finger caused by impingement between extensor digiti minimi and synovial septum.

A Comparative Study of CG CryoDerm and AlloDerm in Direct-to-Implant Immediate Breast Reconstruction

BACKGROUND: To date, various types of acellular dermal matrix (ADM) have been developed for clinical use. AlloDerm is the most familiar type of ADM to most surgeons in breast reconstruction. It is prepared by freeze-drying. CG CryoDerm is the first form of ADM that requires no drying process. Therefore, theoretically, it has a higher degree of preservation of the dermal structures than AlloDerm. We conducted this study to compare the clinical course and postoperative outcomes of patients who underwent direct-to-implant breast reconstructions using AlloDerm and those who did using CG CryoDerm. METHODS: We performed a retrospective analysis of the medical records in a consecutive series of 50 patients who underwent direct-to-implant breast reconstruction using AlloDerm (n=31) or CryoDerm (n=19). We then compared the clinical course and postoperative outcomes of the two groups based on the overall incidence of complications and the duration of drainage. RESULTS: The mean follow-up period was 16 months. There were no significant differences in the overall incidence of complications (seroma, infection, skin flap necrosis, capsular contracture, and implant loss) between the two groups. Nor was there any significant difference in the duration of drainage. CONCLUSIONS: CG CryoDerm has the merits of short preparation time and easy handling during surgery. Our results indicate that CG CryoDerm might be an alternative allograft material to AlloDerm in direct-to-implant breast reconstruction.

Treatment of Humeral Shaft Fracture with Retrograde Intramedullary Nail

PURPOSE: The purpose of this study was to report the outcome of treatment of humeral shaft fracture with retrograde intramedullary nail of advanced insertion opening. MATERIALS AND METHODS: From April 2005 and August 2012, 22 patients with a humeral shaft fracture were treated by a single surgeon using the technique of retrograde intramedullary nail at Department of Orthopedic Surgery, Yeouido St. Mary's Hospital (Seoul, Korea). To avoid causing fractures at the insertion site, the entry point was more distally located than conventionally, and was extended proximally to include the proximal marginal cortex of the olecranon fossa. The outcome was evaluated clinically and radiologically. RESULTS: The mean period of achievement of bony was 5.8 months (4-11 months). Additional fixations were needed in one patient with intraoperative lateral condylar fracture and 2 patients with postoperative nonunion. There were no limitations of movement or pain in the shoulder joint, and 8 cases had a 6.5degrees flexion contracture on average. CONCLUSION: This retrograde intramedullary fixation technique using a distal entry portal near the olecranon fossa is particularly useful in humeral shaft fractures without a neurovascular injury. The risk of an intraoperative fracture (supracondylar fracture or fracture around the entry portal) can be decreased using this treatment. We recommend this technique because of the safety and the satisfactory outcome.

The 4+5th Extensor Compartmental Artery- Pedicled Vascularized Bone Graft in Lichtman Stage III Kienbock's Disease

PURPOSE: The purpose of this study was to evaluate the clinical results of the 4+5th extensor compartmental artery pedicled vascularized bone graft in advanced Lichtman stage III Kienbock's disease. MATERIALS AND METHODS: Eight patients with advanced Lichtman stage III Kienbock's disease who underwent the 4+5th extensor compartmental artery pedicled vascularized bone graft and followed up more than 1 year were analyzed retrospectively. There were 3 men and 5 women. The mean age was 43.6 years old. Two patients were Lichtman stage IIIA and six patients were IIIB. The clinical outcomes were evaluated with radiocarpal joint pain, range of motion, grip strength, carpal-height ratio, radioscaphoid angle, return to daily living activity and/or work. The mean follow up period was 38.5 months (range from 12 to 86 months). RESULTS: On last follow up, the pain was disappeared in 6 patients, and mild occasional pain was remained in 2 patients. Mean radiocarpal joint flexion and extension were 55 degrees and 60 degrees, 87% and 88% of the normal side, respectively. The carpal-height ratio was maintained or improved in 6 patients and slightly decreased in 2 patients. Radioscaphoid angle were improved or maintained in 7 patients. Mean grip strength was 67 lb, 93% of the normal side. All 8 patients returned to daily living activities and/or their previous works. CONCLUSION: The 4+5th extensor compartmental artery pedicled vascularized bone graft prevented the progression of disease and provided clinical improvement even in advanced Lichtman stage III Kienbock's disease.

Clinical Durability and Deflation of Saline-Filled Breast Implant in Breast Reconstruction

PURPOSE: Despite wide clinical use of breast implants, there is continued concern about the lifespan of these devices. The causes of explantation were infection, deflation of implant and patient's want. The deflation of saline-filled breast implant was related to strength and durability of implant shell. The purpose of this study is to evaluate the clinical durability of saline-filled breast implant through the analysis of duration until deflation occurred, causes, incidence and influencing factors. METHODS: Retrospective analyses were conducted on clinical records for 19 cases of deflation of saline-filled breast implant from 201 cases of breast reconstruction with saline-filled implant between May 1995 and June 2011. The authors had been analyzed the causes of deflation, survival duration, symptom, sign, nipple excision, volume of implant, saline filling, method of reoperation, breast cancer stage and combined capsular contracture. RESULTS: The causes of deflation were attributed to the cases that cannot be evaluated the causes in 15 cases, fall down in 1 case, mammography in 2 cases, accidental needle injury in 1 case. Mean survival duration was 4 years and 5 months. The duration of survival was less than 1 year for 5 cases, 1 year to 10 years for 10 cases, more than 10 years for 4 cases. The volume between 201 and 250cc of deflated breast implant was rated as high by 14.0 percent. The deflation rate of underfilled implants was 11.4 percent, adequate filled implants was 9.3 percent. None of overfilled implant was deflated. The deflation of smooth surface implant was 5 of 152 cases. Textured implant was 14 of 49 cases. The capsular contracture of non-deflated breast implant was 28 of 182 cases and that of deflated breast implant was 6 of 19 cases. CONCLUSION: The patients who underwent saline-filled breast implant implantation should be informed that their implant could deflate. The analysis of clinical durability and causes of deflation in breast implant was important for the prediction and prevention of reopeation. The authors could suppose the causes of deflation of saline-filled breast implant through history, duration of survival, inspection of the shell of implant.

Adventitial Cyst of the Radial Artery in the Wrist: A Case Report

Simple ganglions are most common benign tumor of the hand and wrist. However, cystic adventitial disease is an uncommon vascular anomaly first described in 1947 in the external iliac artery. It usually involves the popliteal artery, although other arteries and veins may also be involved. Radial artery adventitial cysts are found directly within the adventitia, whereas the more common wrist ganglions may extrinsically compress or adhere to the artery walls. The diagnosis is rarely made before surgery because of their similar appearance and location. The authors report a rare case of a 46-year old woman with mucoid adventitial cyst of the radial artery in the wrist.

The Treatment for Kienbock's Disease using the Fourth Extensor Compartment Artery Vascularized Bone Graft: Preliminary Results

Lunate revascularization with the vascularized bone grafts is a current concept in the treatment of Kienbock disease. The aim of this study is to present our experience and preliminary results of the treatment using the fourth extensor compartment artery (4 ECA) vascularized bone graft for Kienbock disease. Between May 2009 and June 2010, five patients (3 men and 2 women) with Kienbock disease were treated with 4 ECA vascularized bone grafts. The mean age was 32.8 years and mean follow-up time was 13 months. The patients were composed of two patients in stage II and three patients in stage IIIa according to Lichtman's classification. Modified Mayo wrist score including pain, grip strength, range of motion and functional status and radiographic parameters such as carpal height ratio and radioscaphoid angle were evaluated at a final follow-up. Pain was markedly diminished and modified Mayo wrist score was 82 at last follow up period. There were no or little changes in carpal height ratio and radioscaphoid angle. All patients showed satisfactory bony union and no further lunate collapse on follow-up radiographs. The 4 ECA vascularized bone graft is a reliable alternative procedures among revascularization procedures for treatment of Kienbock's disease. It is less invasive and has low risk of kinking of pedicle compared to the 4+5 ECA vascularized bone graft. However, long term follow-up and MRI evaluation at follow up period should be needed for the future.

Ankle Deformity Secondary to Acquired Fibular Segmental Defect in Children

BACKGROUND: The authors report the long-term effect of acquired pseudoarthrosis of the fibula on ankle development in children during skeletal growth, and the results of a long-term follow-up of Langenskiold's supramalleolar synostosis to correct an ankle deformity induced by an acquired fibular segmental defect in children. METHODS: Since 1980, 19 children with acquired pseudoarthrosis of the fibula were treated and followed up for an average of 11 years. Pseudoarthrosis was the result of a fibulectomy for tumor surgery, osteomyelitis of the fibula and traumatic segmental loss of the fibula in 10, 6, and 3 cases, respectively. Initially, a Langenskiold's operation (in 4 cases) and fusion of the lateral malleolus to the distal tibial epiphysis (in 1 case) were performed, whereas only skeletal growth was monitored in the other 14 cases. After a mean follow-up of 11 years, the valgus deformity and external tibial torsion of the ankle joint associated with proximal migration of the lateral malleolus needed to be treated with a supramallolar osteotomy in 12 cases (63%). These ankle deformities were evaluated using the serial radiographs and limb length scintigraphs. RESULTS: In all cases, early closure of the lateral part of the distal tibial physis, upward migration of the lateral malleolus, unstable valgus deformity and external tibial torsion of the ankle joint developed during a mean follow-up of 11 years (range, 5 to 21 years). The mean valgus deformity and external tibial torsion of the ankle at the final follow-up were 15.2degrees (range, 5degrees to 35degrees) and 10degrees (range, 5degrees to 12degrees), respectively. In 12 cases (12/19, 63%), a supramalleolar corrective osteotomy was performed but three children had a recurrence requiring an additional supramalleolar corrective osteotomy 2-4 times. CONCLUSIONS: A valgus deformity and external tibial torsion are inevitable after acquired pseudoarthrosis of the fibula in children. Both Langenskiold supramalleolar synostosis to prevent these ankle deformities and supramalleolar corrective osteotomy to correct them in children are effective initially. However, both procedures cannot maintain the permanent ankle stability during skeletal maturity. Therefore any type of prophylactic surgery should be carried out before epiphyseal closure of the distal tibia occurs, but the possibility of a recurrence of the ankle deformities and the need for final corrective surgery after skeletal maturity should be considered.

Modified Volar Percutaneous Screw Fixation for the Scaphoid Fractures: Trans-trapezial Approach

PURPOSE: The purpose of this study is to evaluate the clinical results of modified volar percutaneous fixation, in which a screw is introduced through the trapezium (trans-trapezial approach) for the treatment of undisplaced scaphoid fractures and nonunions. MATERIALS AND METHODS: We performed modified volar percutaneous screw fixation in 15 patients between December 2008 and October 2009. There were ten men and five women. The mean age was 45 years (range, 20-59 years). Seven patients had a isolated scaphoid fracture, four had a concomitant distal radius fracture, two had multiple fractures besides scaphoid fracture, one had a trans-scaphoid perilunar fracture-dislocation and one had a cystic nonunion of the scaphoid. The mean follow-up time was 13 months. A standard Acutrak headless screw (Acumed(R)) was used in all cases. RESULTS: At the final follow-up, the average arc of wrist motion was 60degrees of flexion and 65degrees of extension. The average grip power of the affected hand reached 90% compared with the unaffected side. The clinical results assessed by the modified Mayo wrist score showed twelve excellent and three good results. Plain radiographs showed accurate central placement of the screw without degenerative change in the scaphotrapezial joint in all patients. The mean time to union was 7.8 weeks. CONCLUSION: We believe that the modified volar percutaneous screw fixation is reliable method. However, long term follow-up is required to determine whether this approach would increase the risk of scaphotrapezial joint osteoarthritis.

Medial Transposition of Radial Nerve in Distal Humerus Shaft Fracture: A Report of Six Cases

Sometimes serious tension occurs in the radial nerve when doing internal fixation for distal humerus shaft fracture or neurorrhaphy for radial nerve injury. Medial transposition of radial nerve on fracture site can avoid direct radial nerve injury by fracture fragment, radial nerve tension by plating for distal humerus shaft fracture, and also safe from neural tension during neurorrhaphy of damaged radial nerve. We reported here total 6 cases of backward transposition of radial nerve including 2 cases of radial nerve injury associated with humerus fracture and 4 cases of comminuted fracture of humerus shaft.

Treatment of Failed Intertrochanteric Fractures to Maintain the Reduction in Elderly Patients

PURPOSE: The aim of this study was to evaluate and report the new method with a cement augmented screw fixation again to treat the failed intertrochanteric fracture in elderly which were treated with ordinary compression hip screw initially. MATERIALS AND METHODS: From Mar. 1988 to May 2007, 10 patients (mean age 69 years) with the failed intertrochanteric fracture which were treated with initial hip screw, were treated with a cement augmented compression hip screw again. The mean follow-up after surgery was over 18 months. The cause of failure, the period upto the reoperation, the neck-shaft angle after the reoperation, the position of lag screw in the femoral head, and the degree of union at last follow-up were analyzed. The change in the functional hip capacity were evaluated by the classification of Clawson. RESULTS: Causes of failure were superior cutting-out in 6 cases, cortical anchorage failure in 3, and nonunion in one case. The period upto the reoperation was average 7.8 months. Valgus reduction of average 5.7degrees was achieved, and the positions of lag screw were postero-inferior in 6 cases, center in 3, infero-center in one case. We obtained complete union in 9 cases. The functional outcome showed moderate in 6 cases, good in 3 and poor degree in one case. CONCLUSION: Cement augmented compression hip screw treatment will possibly reduce cutting-out of screw and bring more stability in fixation for intertrochanteric fractures in old osteoporotic patients, as well, even in failed cases treated with initial compression hip screw, but proper selection of patients is important.

Operative Treatment of the Cubital Tunnel Syndrome: Comparison of Anterior Submuscular Transposition and Anterior Subfascial Transposition of the Ulnar Nerve

Surgical treatment of compressive ulnar neuropathy at the elbow has been performed with a wide variety of techniques. Among these techniques, anterior submuscular transposition of the ulnar nerve has been regarded as the method of choice by many authors. It has many advantages including a low recurrence rate, scar-free vascular bed, and protection from repeated trauma to the nerve. However, anterior submuscular transposition is technically demanding and requires more extensive soft tissue dissection. On the other hand, anterior subfascial transposition is less invasive, requires a relatively shorter operation time than the submuscular technique, and also can be done safely even in patiensts with elbow arthritis. We evaluated the clinical results of anterior submuscular transposition compared with anterior subfascial transposition. Fifteen patients underwent anterior submuscular transposition and ten patients underwent anterior subfascial transposition of the ulnar nerve. The mean follow-up time was 15 months (range 10 to 38 months) in the anterior submuscular transposition group and 7 months (range 6 to 15 months) in the anterior subfascial transposition group. According to the outcome status determination algorithm devised by Mowlavi, 3 patients (20%) showed total relief, 10 patiensts (66.7%) improvement and 2 patients (13.3%) no changes in the anterior submuscular transposition group. In the anterior subfascial transposition group, 2 patients (20%) showed total relief, 7 patients (70%) improvement and 1 patient (10%) displayed no changes. Statistically there was no significant difference of the clinical results between the two surgical techniques. Therefore we would suggest anterior subfascial transposition of the ulnar nerve as a preferred method for treatment of cubital tunnel syndrome.

Pathophysiology of Synovial Chondromatosis / 대한정형외과학회잡지

PURPOSE: To confirm the pathophysiology and proper treatment of synovial chondromatosis according to preoperative radiographs, intraoperative findings, and postoperative histology. MATERIALS AND METHODS: Twenty one patients with synovial chondromatosis who underwent the removal of loose bodies and synovectomy since 1995 were investigated. Patients were analyzed in terms of various radiologic and histologic findings of osteochondromas and synovium. RESULTS: The joints involved were the shoulder joint in 9, the knee in 7, the hip in 3, and the elbow in 2 patients. Removals of osteochondromas were performed in all patients, and four who had intrasynovial proliferating nodules were treated by partial synovectomy. Histologically, the synovia were hypertrophied, and osteochondromas classifiable as three distinct types: premature, maturing, and matured. Osteochondromas in the synovium were of the premature type. There were no recurrences at an average 39 months of follow-up. CONCLUSIONS: Based on a study of 21 cases of synovial chondromatosis, there appear to be three separate types of this disease: premature, maturing, and matured. Partial synovectomy may be necessary in premature and maturing types with intrasynovial proliferating nodules.

A Case of Ileal Duplication with Intestinal Hemorrhage

Duplications of the alimentary tract are uncommon congenital anomalies that usually present in childhood. They are cystic or tubular in shape, and composed of muscular walls with gastrointestinal mucosal lining. These lesions are almost invariably adjacent to the alimentary tract, most often found in the ileum, may communicate with the lumen, and may be multiple. We experienced an unusual case of a 18-month-old male patient who presented with intermittent blood-tinged stool as an initial manifestation of ileal duplication. The lesion was revealed by bleeding scan and Meckel's scan and was suspected to be a bleeding Meckel's diverticulum due to peptic ulceration of the ileum adjacent to the ectopic gastric mucosa. At laparotomy, a 3-cm-sized cystic mass communicating with the adjacent bowel lumen and multiple conglomerated lymph nodes were identified at the mesenteric side of the distal ileum. Resection of the lesion and adjacent ileum containing enlarged lymph nodes was done. In microscopic findings, the unilocular cystic structure lying in the mesenteric border showed an intestinal wall lined in part by gastric fundic mucosa with a small ulcer, especially at the blind end, and in part by small intestinal mucosa. Muscularis propria and serosa were also present.