Effectiveness of Doppler Image of the Vertebral Artery as an Anatomical Landmark for Identification of Ultrasound-Guided Target Level in Cervical Spine

STUDY DESIGN: A prospective sonographic study. PURPOSE: To verify the effectiveness of simultaneous application of two landmarks, Doppler image of the vertebral artery and shape of the transverse tubercle of the seventh cervical (C7) vertebra. OVERVIEW OF LITERATURE: Counting upwards from the C7 vertebra which only has a posterior tubercle of the transverse process is a commonly used method for ultrasound-guided cervical nerve root block. However, each transverse process has a different shape. METHODS: Sonograms of 20 volunteers were examined. At first, we identified the C7 transverse process based on the presence of the vertebral artery without the anterior tubercle. The C5 and C6 transverse processes were identified based on the presence of anterior tubercle without the vertebral artery. Subsequently, we placed needles on the C5, C6, and C7 transverse processes and the location and direction of needles were confirmed by fluoroscopy. RESULTS: In the 120 segments, 93.3% of needles were placed correctly as desired; 97.5% of needles were placed on the 5C transverse process; 97.5% of needles were placed on the C6 transverse process; and 85.0% of needles were placed on the C7 transverse process, respectively. Both sides showed the same accuracy of 93.3%. CONCLUSIONS: Simultaneous application of Doppler image of the vertebral artery and shape of the C7 transverse tubercle showed 93.3% accuracy in identifying the target cervical level. Therefore, Doppler image of the vertebral artery can be considered to be a useful landmark for ultrasound-guided cervical nerve root block.

The Fate of Pronator Quadratus Muscle after Volar Locking Plating of Unstable Distal Radius Fractures

PURPOSE: The purpose of this study is to evaluate the pronator quadrates muscle in patients who underwent internal fixation with a volar locking plate for unstable distal radius fractures. MATERIALS AND METHODS: Forty patients who underwent internal fixation with a volar locking plate for unstable distal radius fracture were enrolled. We evaluated the clinical results according to the Mayo wrist score, the wrist range of motion, and the grip strength at the last follow-up. Using ultrasonography, muscle thickness of the pronator quadrates was compared between injured and uninjured arm. RESULTS: Bone union was achieved in all cases. The mean Mayo wrist score was 82.79 points. The grip strength of the injured arm was decreased to 89.1% of the uninjured side. The decrease of pronation range of the injured wrist motions was significant (82.3degrees, p=0.004). There was significant atrophy of the pronator quadrates muscle on the injured side (injured side: 3.19 mm, uninjured side: 4.72 mm, p=0.001); and the decrement of muscle thickness in pronator quadrates showed an association with the Mayo wrist score (r=-0.35, p=0.042). CONCLUSION: These results suggest that continuity of the muscle is maintained after use of the volar locking plating for unstable distal radius fractures with repair of pronator quadrates; however, there is atrophy of pronator quadrates muscle and limitation of pronation in the injured wrist.

Application of Vacuum-assisted Closure in Difficult Wounds / 대한정형외과학회잡지

PURPOSE: We analyzed the usefulness of vacuum-assisted closure (VAC) dressing to facilitate the healing of difficult wounds by comparing the results of conventional dressings. MATERIALS AND METHODS: We selected 20 cases for the experimental group (VAC group) and 20 cases for the control group (conventional dressing), and investigated the change in wound size, formation of granulation tissue, and duration of wound healing in the two groups. RESULTS: In the VAC group, the size of wound decreased from 60.2+/-59.1 cm2 to 29.7+/-18.8 cm2 (p=0.001). In the control group, it decreased from 60.3+/-83.3 cm2 to 34.4+/-47.6 cm2 (p=0.04). For formation of granulation, it increased from 1.2+/-0.4 to 2.7+/-0.6 (p=0.001) in the VAC group and from 1.2+/-0.4 to 2.4+/-0.5 in the control group. For the duration of healing, it took 17.5+/-8.3 days for the VAC group and 22.9+/-22.0 days in the control group (p=0.857). However there were no statistically significant differences in all the parameters between the 2 groups (p>0.05). CONCLUSION: The clinical application of VAC to difficult wound yield comparable results in terms of a decrease in wound size, formation of granulation, and the duration of healing. VAC dressing could be an alternative treatment option for a difficult wound considering the advantage of saving medical human resources.

Clinical Significance of the Rectus Abdominis Muscle Free Flap for Large Diabetic Ulcer and Necrosis of the Foot

The purpose of this study was to present the clinical significance of rectus abdominis free muscle flap for large sized diabetic ulcer and necrosis of the foot to salvage limb. From June 2000 to February 2006, eleven patients were included in our study. There were seven males and four females with a mean age of 58.3 years (48~65) at the surgery. All had a history of diabetics and subsequent huge soft tissue defect caused by necrotizing abscess formation around the foot and the ankle. After complete debridement of large sized, infected necrotic tissue, susceptible intravenous antibiotics and wound care were done. After control of infection, confirmed by clinical and laboratory findings, the rectus abdominis free muscle flap was applied to cover remained large soft tissue defect and to prevent the recurrence of infection. All flaps survived and it provided satisfactory coverage for the soft tissue defect on the foot and the ankle area for a mean of 41.1 months (24~85) follow up period. All except of one patients did not have any recurrence of infection on the operation site and could salvage their limbs. The rectus abdominis free muscle flap could be recommended for large sized soft tissue defect after necrotizing abscess in diabetic foot to salvage major limb.

Reconstruction of the Pretibial Soft Tissue Lesion after Chronic Tibia Osteomyelitis using Anterolateral Thigh Perforator Flap

The purpose of this study was to present the clinical result of anterolateral thigh free flap for pretibial soft tissue lesion after chronic tibia osteomyelitis. From December 2006 to September 2008, Five patients were included in our study. 4 of 5 were superficial or localized types of chronic tibia osteomyelitis, based on the classification of Cierny and Mader. Average age at the surgery was 45 years, three were males and two were females. All had a history of chronic tibia osteomyelitis and subsequent pretbial soft tissue lesions coming from previous operations or pus drainage. Pretibial soft tissue defects included small ulcers, fibrotic, bruisable soft tissue and small bony exposures, but not large-sized bony exposures nor active pus discharge. After complete debridement of large sized pretibial soft tissue lesions and decortication of anterior tibial cortical dead bone, anterolateral thigh free flap was applied to cover remained large pretibial soft tissue defect and to prevent the recurrence of infection. All flaps survived and provided satisfactory coverage of soft tissue defect on pretibial region for 16 months' mean follow up period. No patients has had recurrence of osteomyelitis. Anterolateral thigh free flap could be recommend for large sized pretibial soft tissue defect of supreficial or localized types of chronic tibia osteomyelitis after through debridement.

The Effectiveness of Bone Mineral Density as Supplementary Tool for Evaluation of the Osteogenic Potential in Patients with Spinal Fusion

STUDY DESIGN: Retrospective study. PURPOSE: This study was designed to determine the effectiveness of bone mineral density measurement as a supplementary tool for evaluation of osteogenic potential in patients with spinal fusion. To this end, we correlated bone mineral density (BMD) with osteogenic potential from cultured mesenchymal stem cells (MSCs). OVERVIEW OF LITERATURE: Many studies have correlated osteogenic potential of in vitro cultured MSCs with aging or osteoporosis. METHODS: We studied twenty-five individuals with harvested bone marrow from the ilium during lumbar spinal surgery. The BMD of the femoral neck was measured using dual energy X-ray absorptiometry prior to bone marrow aspiration, and the osteoporotic group was classified as those with T-scores below-2.5. After MSCs were isolated from bone marrow, in vitro induction of osteogenesis was performed. We analyzed the patient's osteogenic potential from cultured MSCs such as mineral deposition stain, bone alkaline phosphatase (ALP) activity and osteoblast-specific gene expression in RT-PCR. RESULTS: On mineral staining, the osteoporotic group had a scanty matrix mineral deposition in contrast to the non-osteoporotic group. The expression of osteocalcin in the osteoporotic group was 1.5 to 3 times less than in the non-osteoporotic group. At the 3rd week after the induction of osteogenesis, the activity of ALP of cultured MSCs in the osteoporotic group was lower than in the control group (mean, 45+/-19 u/L, in osteoporotic group vs 136+/-7 u/L in non-osteoporotic), and there was a statistically significant and positive correlation between BMD & ALP (r=0.487, p=0.013). CONCLUSIONS: There is a positive correlation between BMD and osteogenic potential derived from MSCs. The measurement of BMD can provide supplementary data for evaluating osteogenic potential clinically.

Lateral Arm Free Flap for Small Sized Diabetic Foot Ulcer around Toes

The purpose of this study was to present the clinical analysis of the results of lateral arm free flap for small sized and infected diabetic foot ulcer around toes. From May 2006 to December 2007, Seven patients were included in our study. Average age was 52.8 years, six were males and one was female. All had infected diabetic foot ulcer and had exposures of bone or tendon structures. Ulcers were located around great toe in four patients, 4th toe in one and 5th toe in two. Three patients had osteomyelitis of metatarsal or phalanx. After appropriate control of infection by serial wound debridement and intravenous antibiotics, lateral arm flap was applied to cover remained soft tissue defects. Posterior radial collateral artery of lateral arm flap was reanastomosed to dorsalis pedis artery of recipient foot by end to side technique in all cases in order to preserve already compromised artery of diabetic foot. All flaps were designed over lateral epicondyle to get longer pedicle and averaged pedicle length was 8 cm. Two cases were used as a sensate flap to achieve protective sensation of foot. All flaps survived and provided satisfactory coverage of soft tissue defects on diabetc foot ulcers. All patients could achieve full weight-bearing ambulation. No patients has had recurrence of infection, ulceration and further toe amputations. There were three complications, a delayed wound healing of flap with surrounding tissue, a partial peripheral loss of flap and a numbness of forearm below donor site. All patients were satisfied with their clinical results, especially preserving their toes and could return to the previous activity levels. Lateral arm free flap could be recommend for infected diabetic foot ulcers around toes, to preserve toes, coverage of soft tissue defect and control of infection with low donor site morbidity.

The Results of Surgical Treatment for Nonunion of Phalanges in the Hand

PURPOSE: To evaluate the results of internal fixation and autogenous bone graft for the phalangeal nonunion in the hand. MATERIALS AND METHODS: From Feb. 2000 until May 2006, thirteen cases that had been treated for non-union of phalanges in the hand were investigated retrospectively. Seven cases were treated with mini-plate fixation and autogenous cancellous graft and six cases with Kirschner wire fixation and autogenous cancellous graft. We analyzed bony union period radiographically and clinical results according to Belsky's score. RESULTS: Thirteen cases obtained bony union. Seven cases of mini-plate fixation and bone graft, and six cases of K-wire fixation and bone graft achieved the bony union postoperatively on average 7.9 weeks and 6.3 weeks, respectively. Clinical results were "good" in four cases and "poor" in nine cases according to the Belsky's score. Only one of ten cases with associated injuries, such as tendon, nerve, arterial injuries and other finger fractures in the injured hand, had the good clinical result, but all three cases without associated injuries had the good one. CONCLUSION: Internal fixation and autogenous bone graft can be a successful treatment of phalangeal nonunion. However, more careful choice of surgical treatment methods and preoperative explanation of poor post-operative results or complications should be made for phalangeal nonunion with associated injuries in the finger because of poor outcome in those cases.

Treatment of the Femoral Shaft Nonunion Occurredafter Intramedullary Nailing / 대한정형외과학회잡지

PURPOSE: To evaluate of efficacy of the treatment options for a femoral shaft nonunion occurring after intramedullary nailing. MATERIAL AND METHODS: Thirty-one patients with nonunion of a femoral shaft fracture, who had been treated with interlocking intramedullary nailing from January 1996 to December 2000, were examined. Twenty-six had oligotrophic nonunion and five were hypervascular. Forty-five procedures were performed for 31 nonunions; bone grafting for 14, exchange nailing for 13, plate augmentation and bone grafting for 14 and dynamization for 4 cases. RESULTS: The success rate after a single procedure was only 58%. The four dynamization cases failed to unite. Seven of the 13 (54%) nonunion cases treated with nail exchange healed satisfactorily. All cases treated with plate augmentation and bone grafting achieved successful union. The mean period from fracture to union was 20 months. CONCLUSION: Exchange nailing is not always a reliable procedure for treating nonunion of a femoral shaft fracture. Plate augmentation and bone grafting were found to be a successful mode of therapy for the femoral shaft nonunion without complications.

Vibrio vulnificus Infection Presenting as Septic Arthritis of the Knee: A Case Report / 대한정형외과학회잡지

Vibrio vulnificus is a fatal marine Gram-negative bacillus that might cause septicemia, necrotizing cellulites in patients with underlying liver disease or an immunocompromised health status, and is associated with high mortality. It is usually attributed to the ingestion of raw shellfish or traumatic exposure to the marine environment. The clinical manifestation includes fever, chill, hypotension, and skin lesions such as erythematous patch, vesicle, bullae that develop into necrosis and wound infections. We report a case of Vibrio vulnificus septicemia and necrotizing fascitis in a patient who presented with septic arthritis of the knee as the first clinical manifestation.

Early Radiographic Loosening Findings of the Hydrocyapatite-coated Acetabular Cup

Purpose: The purpose of our study is to examine early radiographic findings and clinical signs of failure of the microstructure surface HA-coated acetabular cup. Material and methods: This study included 41 revisions of 204 THA with hydroxyapatite-coated acetabular cup from April 1992 to November 1996. Radiolucent line around cups, change in the cup angle and osteolysis were evaluated in serial radiographs. Acetabular cup was defined as loosening if any movement occurred at the bone and socket interface by manual rotation and extension force intraoperatively or migration of more than 2 mm and change of the cup angle by more than 5 degrees in radiographs. Results: The radiolucent line was observed in 12 of the 41 hips at an average of 55.4 months postoperatively and was most commonly located in zone III. All of the 12 hips showing radiolucent lines were classified as loosening by radiographically in 8 cases and intraoperatively in 4 cases. Radiographic loosening occurred at an average of 28.8 months after the appearance of a radiolucent line. Inguinal pain was noted in 18 of the 19 cases revised for acetabular cup loosening. Conclusion: The most important radiographic finding for the early diagnosis of loosening was progressive radiolucent lines, which occurred most frequently in zone 3.

Radiologic Reduction Loss after Surgical Treatment of Distal Radius Fracture

PURPOSE: To compare and analyse radiologic reduction loss between fixation with K-wire only group and fixation with K-wire and external fixator group for surgical treatment of distal radial fracture. MATERIALS AND METHOD: We analysed 60 patients who received the operative treatment with K-wire fixation only or K-wire and external fixator and also were in regular follow up at least one year. We compared radiologic reduction loss of radial length, radial inclination and volar tilt between immediate post-operative radiograph and latest follow up radiograph according to operative methods, fracture patterns and age groups. RESULTS: Reduction loss of volar tilt was greater in fixation with K-wire only group than fixation with K-wire and external fixator group (p<0.05). Reduction losses of radial length and radial inclination were more in intra-articular subgroup than extra-articular subgroup in fixation with K-wire only group (p<0.05). No significant difference of reduction loss was noted between intra-articular and extra-articular subgroups in fixation with K-wire and external fixator group. CONCLUSION: More radiologic reduction loss can be expected in fixation with K-wire only group for intra-articular distal radius fracture compared with extra-articular distal radius fracture. Additional external fixation should be added in intra-articular distal radius fracture to reduce radiologic reduction loss.

Pelvic Bone Stress Fracture after Lumbar Spinal Fusion: Two Cases Report / 대한정형외과학회잡지

Fractures of the pelvic ring after long fusions to the lumbosacral spine is a heretofore rarely reported complication. Stress fractures of the pelvic ring are a potential source of late pain after fusions of the lumbosacral spine. We report two cases of stress fracture of the pelvic bone after lumbar spinal fusion.

Management of Ipsilateral Femoral Fracture After Hip Arthroplasty / 대한정형외과학회잡지

Periprosthetic fractures after total hip arthroplasty or hemiarthroplasty are an uncommon complication. These fractures have problems of fixation of fracture and stability of the femoral component. Ipsilateral femoral fractures after hip arthroplasty occurred in 14 cases (11 patients) out of 510 hip arthroplasties performed between January 1985 and May 1996. These fractures occurred at an average of 3 years and 6 months after primary hip arthroplasty. These fractures were classified by Johansson classification. Nine fractures were treated with plate and cerclage wires. Four fractures were treated with skeletal traction. Bone graft was applied to the fracture site in 9 fractures which were treated by open reduction and internal fixation with plate and cerclage wires. Average follow up period was 21 months. The results were as follows. 1. All but three of the fractures had been developed by low energy trauma. Seven patients had osteolytic lesion around femoral component. Of the seven patients who had osteolytic lesions, six patients had periprosthetic fractures which connected with osteolytic lesions. We think that osteolysis is one of the important factors of the periprosthetic fractures after hip arthroplasty. 2. Four cases were treated by skeletal traction. One case had malunion. Progressive subsidence of femoral component was noted after union of fracture in 3 cases. Therefore these periprosthetic fractures which had an osteolysis and subsidence preoperatively should be managed with operative methods. 3. Nine fractures which had treated with plates and autogenous bone graft showed good hip joint function with stable femoral component. We think that stabilization of periprosthetic fractures with plates and cerclage seemed to be a good method for femoral fractures after hip arthroplasty.