Acute Compartment Syndrome of the Thigh Caused by the Pseudoaneurysm of the Femoral Artery: A Case Report / 대한정형외과학회잡지

A pseudoaneurysm occurs as a late complication of an arterial wall injury after a surgical procedure or injuries such as a fracture, stab injury and penetrating trauma. Acute compartment syndrome as an elevation of the pressure in a closed compartment results in vascular compromise and a dysfunction. However, its occurrence in the thigh is quite rare. We report a case of a patient treated with an excision of a pseusoaneurysm and an artificial vessel graft who had compartment syndrome of the thigh caused by a pseudoaneurysm of the femoral artery that had developed after a blunt injury.

Degenerative Change of Adjacent Segments according to the Fusion Method after L4-5 Segmental Fusion: Comparative Study of Posterolateral Fusion and Posterior Lumbar Interbody Fusion / 대한정형외과학회잡지

PURPOSE: We wanted to investigate the difference in the incidence of post-fusion adjacent segment degeneration between performing posterolateral fusion and posterior lumbar interbody fusion. MATERIALS AND METHODS: One hundred fifty seven patients who underwent L4-5 fusion using pedicle screws for degenerative lumbar disease and followed up more than three years were analyzed retrospectively. Eighty-six cases of posterolateral fusion (group I) and 71 cases of posterior lumbar interbody fusion (group II) were compared. Sampling bias was evaluated by comparing gender, age, the preoperative degeneration of adjacent segments, the sagittal angle of fusion segments on the last follow up and the follow-up period. The differences of adjacent segments degeneration and the revision rate between the two groups were investigated multilaterally. The actual risk factors for such degeneration were investigated by performing multiple logistic regression test, which contrasted the degeneration group with the non-degeneration group for all the above factors, including whether interbody fusion was done or not. RESULTS: Sampling bias was excluded except for the preoperative proximal adjacent segments degeneration (p=0.036). There was no statistical difference in the final proximal degeneration (31/86, 36% in group I, 26/71, 37% in group II, p=0.536) and revision (8/86, 9% in group I, 6/71, 8% in group II, p=0.536). There was no statistical difference in the final distal degeneration (9/86, 10% in group I, 8/71, 11% in group II, p=0.536) and revision (4/86, 5% in group I, 2/71, 3% in group II, p=0.435). When comparing those cases who developed degeneration on either side with the non-degeneration cases, the odds ratio of old age and an insufficient sagittal angle of the fusion segments reached statistical significance (p=0.024, 0.001). CONCLUSION: There were no differences in adjacent segments degeneration between the posterolateral fusion group and the posterior lumbar interbody fusion group. Rather than the operation methods, old age and insufficient sagittal angle of the fusion segments were the actual risk factors of such degeneration.

Pseudomeningocele After Spine Surgery: 3 cases of different symptoms / 대한척추외과학회지

Pseudomeningocele after spine surgery can cause various symptoms, but it can also be silent. We experienced 3 cases of pseudomeningocele with different symptoms and we analyzed the characteristics of each case. A small pseudomeningocele without connection to the subarachnoidal space can show no symptoms. A pseudomeningocele with a small dural tear and it's abutted on the duramater at a small portion can produce sciatica and limitations of straight leg raising due to adhesion of the cauda equina around the dural tear. In addition, a large pseudomeningocele with a big dural and lamina defect can produce back tenderness furthermore, a patient with such a lesion can have low back pain and leg pain that are aggravated by an increment of abdominal pressure or by impact to the body and even by walking. Pseudomeningocele should be suspected when symptoms recur after spine surgery and especially in the case of dural tear during an operation

Adjacent Segment failure after Lumbar Spine Fusion: Controlled Study for Risk Factors / 대한정형외과학회잡지

PURPOSE: To verify the risk factors associated with adjacent segment failure after lumbar spine fusion using pedicle screws. MATERIALS AND METHODS: The study group consisted of 35 patients who underwent lumbar spine fusion using pedicle screws and required revision surgery due to adjacent segment failure. These were compared with 73 control patients who were stratified according to the aspect of the surgical method and period. Gender, age, surgical procedures, the number of fusion segments, the fixation of the sacrum, initial instability and degeneration of the adjacent segments, lumbar lordosis, whole lumbar spondylosis, placement of most proximal screws, habitat, the demand of physical work, physical exercise, smoking, life style and BMI were reviewed retrospectively. RESULTS: Multivariate logistic regression showed that insufficient lumbar lordosis (odds ratio=3.041), instability of the distal adjacent segment (odds ratio=17.196), physically demanding jobs (odds ratio=2.462), delinquent exercise (odds ratio=2.534) and rural habitat (odds ratio=46.729) were associated with an increased incidence of adjacent segment failure. CONCLUSION: Insufficient lordosis, instability of the distal adjacent segment, physically demanding jobs, delinquent exercise and rural habitat were found to be risk factors. The postoperative life style has a large impact on adjacent segment failure. The extension of fusion to an unstable distal segment should be deliberated even though it is not attributable to the current symptoms. A reconstruction of the proper lordosis far outweights the other methodological factors.

Operative Treatment of Lumbosacral Spondylitis Through a Posterior-only Approach / 대한정형외과학회잡지

PURPOSE: To evaluate the efficacy of this operative method, which includes removal of infected materials, insertion of a bone graft and fixation with pedicle screws through a posterior-only approach in spondylitis with advanced bone destruction and radicular pain. MATERIALS AND METHODS: Ten patients with refractory single level spondylitis of the lumbosacral spine, who underwent the above operation and were followed-up for more than 2 years, were analyzed retrospectively. Six cases were tuberculous and 4 cases were pyogenic in etiology. Radiologically, bone union and restoration of sagittal alignment were assessed. Clinically, Visual Analog Scales (VAS) for back pain, leg pain and resolution of neurologic symptom were analyzed. RESULTS: Bone union was achieved in all cases. Sagittal angle was corrected significantly from -3.6+/-12.5 degrees to -11.4+/-9.3 degrees (p=0.007). However, loss of correction was noted from -16.2+/-10.2 degrees at immediate after surgery to -11.4+/-9.3 degrees at last follow-up (p=0.005). Back pain VAS was improved from 8.3+/-0.7 to 2.6+/-1.6 (p=0.005) and leg pain VAS was improved from 6.8+/-2.1 to 0.5+/-0.9 (p=0.005). There was strong positive correlation between age and final back pain (r=0.79, p=0.011) and leg pain VAS (r=0.75, p=0.020). There was no meaningful correlation between the sagittal angle and back pain (r=0.30, p=0.430) and leg pain VAS (r=0.41, p= 0.274). Implant related complications and deep wound infections did not occur. CONCLUSION: In single level spondylitis of the lumbosacral spine, a posterior-only surgical approach is a useful method in which debridement, bone graft placement and pedicle screw fixation can be performed. This procedure did not provide increased risk with respect to infection control, and it allowed correction of the sagittal angle. The younger the age of the patients, the better the back pain and leg pain VAS results.

Posterior Lumbar Interbody Fusion with Chip Bone and Pedicle Screw Fixation: Comparative Study between Local Chip Bone Graft and Autoiliac Chip Bone Graft / 대한정형외과학회잡지

PURPOSE: To evaluate the efficacy of posterior lumbar interbody fusion utilizing pedicle screw fixation and chip bone graft, and to compare the radiologic and clinical results in two group which use local chip bone and autoiliac chip bone respectively. MATERIALS AND METHODS: We analyzed 58 cases of single segment chip bone posterior lumbar interbody fusion which were followed up for more than 1 year. Group I was operated with local chip bone and group II with autoiliac chip bone. Radiologic union was assessed, based on Brantigan & Steffee method and functional outcome by Kirkaldy-Willis criteria. Student t-test and Fisher's exact test were used for statistical analysis. RESULTS: Clinical satisfaction of group I and II were 81.3% and 88.1% respectively (p>0.05). Though 12% of group II complained about pain on the donor site, no one among them were assessed as unsatisfactory. Radiological union was confirmed in 75% in group I and 90% in group II (p>0.05). Twenty five percent of group I and nineteen percent of group II showed collapsed union without significant differences. There were no significant differences between group I and II in loss of disc height, segmental lordosis, operation time and blood loss. CONCLUSION: Both local and autoiliac chip bone posterior lumbar interbody fusion are useful methods in the aspect of radiologic union and functional outcome and there are no significant differences between two groups. However, considerable collapsed unions were observed in both groups. It is necessary to investigate long term influence of collapsed union on the adjacent segment and functional outcome.

Epidural Tuberculoma which invades Cauda Equina of Lumbar Spine / 대한척추외과학회지

Epidural tuberculoma without bony involvement was first reported by Rao et al. in 1971; however, extraosseous spinal epidural tuberculoma and tuberculous infection of the cauda equina have never been reported. We experienced a case of epidural tuberculoma without bony involvement, which was diagnosed by decompression and biopsy, and treated with combined antituberculous chemotherapy. It resembled herniated nucleus pulposus at the L4-5 level, based on its clinical features, a physical examination, myelography and computed tomography. In the course of antituberculous medication, tuberculosis of the cauda equina occurred, which caused paraparesis. Herein, this case is reported in terms of its treatment and clinical course, with a review of the literature.

Altered Sagittal Rotation After Segmental Fusion in Degenerative Lumbar Disease: Comparative study by level, length of fused segments / 대한척추외과학회지

STUDY DESIGN: A stratified sampling and retrospective study. OBJECTIVES: To investigate the quantitative change in the sagittal rotation of the whole lumbar spine and adjacent segments after a lower lumbar segmental fusion in humans, according to the site, length, lordosis, age and gender. LITERATURE REVIEW SUMMARY: There have been many reports on experimental animal and human cadaveric studies. However, comparative studies on real patients are very rare. MATERIALS AND METHODS: One hundred cases of lumbar segmental fusion were selected by stratified sampling. These were divided into 5 groups: L34, L45, L5S1, L345 and L45S1, with each group containing 20 cases. Maximum flexion and extension decubitus films were checked preoperatively and 1 year postoperatively. The sagittal rotation of the whole lumbar spine and adjacent segments were compared. Statistical analyses were carried out with paired t, chi square test and ANOVA, according to the characteristics of variance. RESULTS: The sagittal rotation of the whole lumbar spine was reduced significantly, from 32.9+/-10.6 degrees to 24.6+/-10.7 degrees, postoperatively (p=0.000). The reduction in 2 segment fusion (10.1+/-11.3 degrees) was greater than for 1 segment fusion (8.4+/-11.6 degrees), but this was not statistically significant (p=0.462), there were no differences between the group (p=0.560). Sagittal rotation of the proximal adjacent segment was increased significantly, from 5.6+/-3.2 degree to 7.7+/-4.1 degrees, postoperatively (p=0.000). The increment for a 2 segment fusion (2.8+/-4.4 degrees) was greater than for a 1 segment fusion (1.7+/-4.2 degrees), but this was not significant (p=0.204), and there were no differences between the groups (p=0.350). The sagittal rotation of the distal adjacent segment showed only a trivial change from, 7.7+/-4.7 degrees to 7.0+/-5.2 degrees(p=0.314). CONCLUSIONS: After the fusion of one or two segments of the lumbar spine, the sagittal rotation of the whole lumbar spine decreased by about 25%, i.e. patients were considered to conform to a reduced number of motion segments, but the rotation of proximal adjacent segments increased by about 37%. However, the distal adjacent segment showed no changes, i.e. adjacent segment degeneration can develop at the proximal site more frequently. Differences according to the level, age, gender and lordotic angle were not significant.

Altered Sagittal Rotation After Segmental Fusion in Degenerative Lumbar Disease: Comparative study by level, length of fused segments / 대한척추외과학회지

STUDY DESIGN: A stratified sampling and retrospective study. OBJECTIVES: To investigate the quantitative change in the sagittal rotation of the whole lumbar spine and adjacent segments after a lower lumbar segmental fusion in humans, according to the site, length, lordosis, age and gender. LITERATURE REVIEW SUMMARY: There have been many reports on experimental animal and human cadaveric studies. However, comparative studies on real patients are very rare. MATERIALS AND METHODS: One hundred cases of lumbar segmental fusion were selected by stratified sampling. These were divided into 5 groups: L34, L45, L5S1, L345 and L45S1, with each group containing 20 cases. Maximum flexion and extension decubitus films were checked preoperatively and 1 year postoperatively. The sagittal rotation of the whole lumbar spine and adjacent segments were compared. Statistical analyses were carried out with paired t, chi square test and ANOVA, according to the characteristics of variance. RESULTS: The sagittal rotation of the whole lumbar spine was reduced significantly, from 32.9+/-10.6 degrees to 24.6+/-10.7 degrees, postoperatively (p=0.000). The reduction in 2 segment fusion (10.1+/-11.3 degrees) was greater than for 1 segment fusion (8.4+/-11.6 degrees), but this was not statistically significant (p=0.462), there were no differences between the group (p=0.560). Sagittal rotation of the proximal adjacent segment was increased significantly, from 5.6+/-3.2 degree to 7.7+/-4.1 degrees, postoperatively (p=0.000). The increment for a 2 segment fusion (2.8+/-4.4 degrees) was greater than for a 1 segment fusion (1.7+/-4.2 degrees), but this was not significant (p=0.204), and there were no differences between the groups (p=0.350). The sagittal rotation of the distal adjacent segment showed only a trivial change from, 7.7+/-4.7 degrees to 7.0+/-5.2 degrees(p=0.314). CONCLUSIONS: After the fusion of one or two segments of the lumbar spine, the sagittal rotation of the whole lumbar spine decreased by about 25%, i.e. patients were considered to conform to a reduced number of motion segments, but the rotation of proximal adjacent segments increased by about 37%. However, the distal adjacent segment showed no changes, i.e. adjacent segment degeneration can develop at the proximal site more frequently. Differences according to the level, age, gender and lordotic angle were not significant.

Posterior Instability in Shoulder / 대한정형외과학회잡지

Posterior instability of the shoulder is far less common than anterior or multidirectional instability. There is still controversy in the diagnosis and treatment of recurrent posterior instability, and many treatment protocols have been advocated. However the failure rate as high as 50% was reported. The purpose of this study is to introduce characteristic physical findings of posterior instability, to present our operative techniques, and to report the efficacy of a superior shift of the postero-inferior capsule in the treatment of recurrent posterior instability. From June 1995 to September 1996, five patients, six shoulders underwent postero-inferior capsular shift for posterior instahility and were evaluated at an average of 17 months(ranged from 9 to 26 months) after operation. The average age was 22.4 years. Preoperatively, mean scores of pain, stability and function according to American Shoulder and Elbow Society (ASES) scoring system were 21, 9, and 16 points respectively and mean overall ASES score was 46 points. After surgery, the average range of motion was 175 of forward elevation and 74 of external rotation and internai rotation in back was up to the sixth thoracic level. Postoperative mean scores of pain, stability and function were 29, 34 and 25 points respectively and mean overall ASES score was 88.5 points. No patient had a recurrence of posterior instability. All patients had satisfactory results with significant improvement in stability and function except one case who had multidirectional instability that mainly involved the posterior component

Treatment of Supracondylar Fractures Following Total Knee Arthroplasty

Supracondylar fractures of the femur following total knee arthroplasty are rare complication with reported rates ranging from 0.3% to 2.5%. Union of the fracture in proper alignment, without disruption of prosthetic component fixation and with maintenance of 90 of knee motion, is impotant in treatment of this type of fracture. Modalties of treatment are conservative or operative methods and operative treatment are open reduction 4 internal fixation, intramedullary nailing, revision arthroplasty using a prosthesis with a long stem and closed reduction and external fixation, but there are controversies in the method of treatment. Between Apr. 1989 and Jul. 1994, 10 patients were treated for supracondylar fracture of the ipsilaterai femur following total knee atthroplasty and 2 cases of them had arthrop]asty at other hospital. Average age of patients was 53 years (29-68 years), nine patients were women and one was man. The preoperative diagnosis was rheumatoid arthritis in four, degenerative osteoaithritis in three, posttraumatic osteoarthritis in one and tuberculosis sequelae of the knee in two. In nine cases mechanism of injury were slip down and in one was fall down. The interval hetween arthroplasty and fracture was an average of 22 months (9-79months). Two cases we.re treated with closed reduction and cast immobilization, one case was treated with open eduction and in1ernal fixation and seven patients of' ten cases were treated with closed intramedullay Ender nailing. The average foIlow-up period after fracture was 25 months (3 - 74months). We evaluated the results as the range of motion, bony union at simple radiograph and Knee Rating Score of Hospital for Special Surgery at last follow up. Eight cases of supracondylar fracture occuned among 350 patients, 514 cases of total knee arthroplasty which were operated at Kyung Hee Univcrsity Hospital between Apr. 1989 and Jul. 1994 and incidence was 1.6%. At the last follow up, all 10 cases achieved bony union and 7 cases using Ender naiIing achieved clinical bony union which enabled patients to do weight-bearing without pain at postoperative 6-8 weeks and radiological union was achieved at postoperative 12 weeks. Range of motion were average 105 degrees (80 J.20 degrees) hefore fracture and 86 degrees (6S 120 degrees) at the last follow up and HSS Knee rating score were average 80.3 points (59 94 points) before fracture and average 78.8 points (66-89 points) at the last follow up. At 7 cases using Ender nailing, range of motion were average 106 degrees (90 11S degrees) hefore fracture and 91 degrees (6S-105 degrees) at last follow up and HSS Knee rating score were average 80.6 points (59-94 points) before fracture and average 80.3 points (72-89 poiints) at the last follow up. Closed iintramedullary Ender nailing is a gecommendable operative method in the treatment of supracondylar fracture following total knee arthroplasty considering to good bony union, satisfactory functional result, easy operative technique and less postoperative complication.