Effectiveness after Designation of a Trauma Center: Experience with Operating a Trauma Team at a Private Hospital

PURPOSE@#The present study aimed to evaluate the influence of how the trauma care system applied on the management of trauma patient within the region.@*METHODS@#We divided the patients in a pre-trauma system group and a post-trauma system group according to the time when we began to apply the trauma care system in the Halla Hospital after designation of a trauma center. We compared annual general characteristics, injury severity score, the average numbers of the major trauma patients, clinical outcomes of the emergency department, and mortality rates between the two groups.@*RESULTS@#No significant differences were found in the annual patients' average age (54.1±20.0 vs. 52.8±18.2, p=0.201), transportation pathways (p=0.462), injury mechanism (p=0.486), injury severity score (22.93 vs. 23.96, p=0.877), emergency room (ER) stay in minutes (199.17 vs. 194.29, p=0.935), time to operation or procedure in minutes (154.07 vs. 142.1, p=0.767), time interval to intensive care unit (ICU) in minutes (219.54 vs. 237.13, p=0.662). The W score and Z score indicated better outcomes in post-trauma system group than in pre-trauma system group (W scores, 2.186 vs. 2.027; Z scores, 2.189 vs. 1.928). However, when analyzing survival rates for each department, in the neurosurgery department, in comparison with W score and Z score, both W score were positive and Z core was higher than +1.96. (pre-trauma group: 3.426, 2.335 vs. post-trauma group: 4.17, 1.967). In other than the neurosurgery department, W score was positive after selection, but Z score was less than +1.96, which is not a meaningful outcome of treatment (pre-trauma group: −0.358, −0.271 vs. post-trauma group: 1.071, 0.958).@*CONCLUSIONS@#There were significant increases in patient numbers and improvement in survival rate after the introduction of the trauma system. However, there were no remarkable change in ER stay, time to ICU admission, time interval to emergent procedure or operation, and survival rates except neurosurgery. To achieve meaningful survival rates and the result of the rise of the trauma index, we will need to secure sufficient manpower, including specialists in various surgical area as well as rapid establishment of the trauma center.

Bilateral Chylothorax Due to Blunt Spine Hyperextension Injury: A Case Report

Bilateral chylothorax due to blunt trauma is extremely rare. We report a 74-year-old patient that developed delayed bilateral chylothorax after falling off a ladder. The patient had a simple 12th rib fracture and T12 lamina fracture. All other findings seemed normal. He was sent home and on the 5th day visited our emergency center at Halla Hospital with symptoms of dyspnea and lower back pain. Computer tomography of his chest presented massive fluid collection in his right pleural cavity and moderate amounts in his left pleural cavity with 12th rib fracture and T11-12 intervertebral space widening with bilateral facet fractures. Chest tubes were placed bilaterally and chylothorax through both chest tubes was discovered. Conservative treatment for 2 weeks failed, and thus, thoracic duct ligation was done by video assisted thoracoscopic surgery. Thoracic duct embolization was not an option. Postoperatively, the patient is now doing well and happy with the results. Early surgical treatment must be considered in the old patient, whom large amounts of chylothorax are present.

Large Focal Extrapleural Hematoma of Chest Wall: A Case Report

Although hemothorax and pneumothorax are common complications seen in rib fractures, focal extrapleural hematoma is quite rare. We report a 63-year-old female patient that developed large focal extrapleural hematoma after falling off a second floor veranda. The patient had sustained 3, 4, 5th costal cartilage rib fractures and a sternum fracture. She had developed suspected empyema with loculations with small amount of hemothorax. She underwent a planned early decortication/adhesiolysis by video assisted thoracoscopic surgery at the 12th post-trauma day due to failed drainage. Unexpectedly, she had no adhesions or any significant retained hematoma mimicking a mass, but was found with the focal extrapleural chest wall hematoma. She was discharged on postoperative 46th day for other reasons and is doing fine today.

Rib Fixation for a Patient with Severely Displaced and Overlapped Costal Cartilage Fractures

Rib fixations for flail chest or displaced rib fractures are not a new technique. However, reports on rib fixations involving costal cartilage fractures are very few and surprisingly there are no reports of internal fixations involving only the costal cartilage in the English literature. The diagnosis is difficult and the necessity of the procedure may be quite controversial. Placing plates in screws into the costal cartilage alone may seem unstable and easily dislodged or stripped through the cartilage. We report a 31-year-old male scuba diver instructor who underwent rib fixations over his 7th and 8th costal cartilage ribs for severe pain. The procedure was done with conventional plates and screws. He had the plates and screws removed 2 months later due to lingering pain, but with them removed he is now quite happy with the results without pain. The procedure for fixation of painful overlapped costal cartilage is quite simple and can be done with the usual conventional methods, fixating plate and screws directly over the cartilage alone without fixation over the bony rib.

Esophageal Rupture Due to Diving in Shallow Waters

Delayed esophageal rupture due to blunt injury is not new. However, rupture due to suspected barotrauma is very rare. We describe a case of esophageal rupture in a male 24-year-old patient after diving in shallow waters. The patient was quadriplegic and could not experience the typical chest pain related to rupture and resulting mediastinitis. The rupture was discovered 4 days after emergency decompressive laminectomy and fusion for his cervical spine. The rupture was evidently caused by barotrauma and was discovered four days after admission. He underwent primary closure and pericardial flap as a life-saving procedure.

Endovascular Treatment for Chronic Total Occlusions of Peripheral Arteries

PURPOSE: The TransAtlantic Inter-Society Consensus offers the proper guidelines for the treatment of peripheral arterial disease (PAD). Many new devices and surgical techniques have been introduced to the medical field and these have been aggressively used to manage the patients with PAD. We performed this study to evaluate the current status of endovascular therapy based on the literature and we review the efficacy and safety of the new devices used in the field. METHODS: A search of the literature was performed in the PubMed and science websites. The keywords were "chronic total occlusions", "superficial femoral artery revascularization", "peripheral arterial disease" and "endovascular therapy". RESULTS: The variation of the results was large according to the studies. The rough technical success rate was 80~90% and the 1 year clinical success rate, the primary patency rate and the limb salvage rate for chronic total occlusions were approximately 50~70%, 50% and 80~90%. The efficacy and safety of the new devices used in the field were acceptable. CONCLUSION: Further refinement of the guidewires and sheaths and the development of adjunctive devices have allowed traversal of even the long lesions and this has increased the technical success. Although surgery remains the principal treatment for patients with lower limb ischemia, surgeons must now assess the benefits and risks associated with various treatment options, including endovascular therapy.

Treatment of Thoraco-Lumbar Bursting Fractures According to Load-Sharing Classification

PURPOSE: To determine optimal levels of posterior fixation in thoraco-lumbar bursting fractures according to the Load-sharing classification. MATERIALS AND METHODS: From Aug. 1999 to Aug. 2003, 50 patients who had been operated with the posterior fixation in one-body thoraco-lumbar bursting fracture were selected. They were divided into two groups, group I, 6 points and below in the Load-sharing score and group II, 7 points and above. And also, each groups subdivided into two subgroups, A (short segment fixation including below and above one body) and B (long segment fixation including below and upper two body). So patients subdivided into I-A, I-B, II-A, II-B. Change of the corrected kyphotic angle was measured and compared with each subgroups. RESULTS: The loss of the corrected kyphotic angle was measured average 1.7degrees in group I and 4.1degrees in group II, and there was significant difference between two groups (p>0.05). The loss of the corrected kyphotic angle in the subgroups was average 1.8degrees in I-A, 1.6degrees in I-B, 3.5degrees in II-A and 4.9degrees in II-B. And there was significant difference statistically in I-A and II-A (p>0.05). CONCLUSION: In the thoraco-lumbar bursting fracture with 6 points and below of the Load-sharing score, the fixation of the short segment is a useful method. But in the fracture with 7 points and above, the fixation of the short segment is not enough, and these findings be required the further evaluation for some cause of the loss of corrected angle and treatment modalities including the fixation of the long segment.

Safe Approaching Angle and Distance in Percutaneous Endoscopic Discectomy / 대한척추외과학회지

STUDY DESIGN: A retrograde study, using Computerized Tomography (CT), to evaluate a safer approaching angle and distance for a percutaneous endoscopic discectomy. OBJECTIVES: To measure the safest approaching angle and distance in a percutaneous endoscopic discectomy at each vertebra level in Koreans. LITERATURE REVIEW SUMMARY: Some authors have shown an approaching angle of between 25 to 30 degrees, but reports on Koreans patients are very rare. MATERIALS AND METHODS: 200 cases of abdomino-pelvic CT were investigated. The minimal angle of safe approach was composed of two lines, one horizontal line passing through the mid point in the posterior cortex of upper vertebra, with the other extending passed the mid point of posterior cortex in the upper vertebra to the dorsal margin of the retroperitoneal fat or peritoneum. The maximal distance for a safe approach was measured from the end of spinous process to the point where the extended former second line crosses the skin. The minimal angles and maximal distances for safe approaches in males and females, from the right and left sides, at each level of the intervertebral space and in groups according to the BMI were compared. RESULTS: Females had a larger mean minimal angle for a safe approach (14.7 degrees) than that for males (9.6 degrees). However, no differences were observed between the right (12.0 degrees) and left sides (12.4 degrees). At each vertebral level, L2-3(16.4 degrees), L3-4(11.3 degrees) and L4-5(8.8 degrees), significant differences were observed. However, obesity had no influence on the different angles for a safe approach. The maximal distances for safe approaches were 12.9 and 12,6cm in males and female, 12.8 cm in for both of the right and left sides, and 11.8, 13.0 and 13.6cm in L2-3, L3-4 and L4-5, respectively. No differences were observed in any of the above group, but the more obese group had a longer distance. CONCLUSIONS: Females and the upper level of the intervertebral space had larger minimal angles for a safe approach, but there were no differences in relation to gender, direction and obesity. All the maximal distances for safe approaches were the same in males, females, right and left, and at each level of the intervertebral space, but the more obese group had a longer distance. A safer zone for the approach in a percutaneous endoscopic lumbar discectomy can be taken, considering the gender, vertebra level and obesity.

Safe Approaching Angle and Distance in Percutaneous Endoscopic Discectomy / 대한척추외과학회지

STUDY DESIGN: A retrograde study, using Computerized Tomography (CT), to evaluate a safer approaching angle and distance for a percutaneous endoscopic discectomy. OBJECTIVES: To measure the safest approaching angle and distance in a percutaneous endoscopic discectomy at each vertebra level in Koreans. LITERATURE REVIEW SUMMARY: Some authors have shown an approaching angle of between 25 to 30 degrees, but reports on Koreans patients are very rare. MATERIALS AND METHODS: 200 cases of abdomino-pelvic CT were investigated. The minimal angle of safe approach was composed of two lines, one horizontal line passing through the mid point in the posterior cortex of upper vertebra, with the other extending passed the mid point of posterior cortex in the upper vertebra to the dorsal margin of the retroperitoneal fat or peritoneum. The maximal distance for a safe approach was measured from the end of spinous process to the point where the extended former second line crosses the skin. The minimal angles and maximal distances for safe approaches in males and females, from the right and left sides, at each level of the intervertebral space and in groups according to the BMI were compared. RESULTS: Females had a larger mean minimal angle for a safe approach (14.7 degrees) than that for males (9.6 degrees). However, no differences were observed between the right (12.0 degrees) and left sides (12.4 degrees). At each vertebral level, L2-3(16.4 degrees), L3-4(11.3 degrees) and L4-5(8.8 degrees), significant differences were observed. However, obesity had no influence on the different angles for a safe approach. The maximal distances for safe approaches were 12.9 and 12,6cm in males and female, 12.8 cm in for both of the right and left sides, and 11.8, 13.0 and 13.6cm in L2-3, L3-4 and L4-5, respectively. No differences were observed in any of the above group, but the more obese group had a longer distance. CONCLUSIONS: Females and the upper level of the intervertebral space had larger minimal angles for a safe approach, but there were no differences in relation to gender, direction and obesity. All the maximal distances for safe approaches were the same in males, females, right and left, and at each level of the intervertebral space, but the more obese group had a longer distance. A safer zone for the approach in a percutaneous endoscopic lumbar discectomy can be taken, considering the gender, vertebra level and obesity.

Retrograde Pin Fixation with Tension Band Wiring for the Proximal Humeral Fractures / 대한정형외과학회잡지

PURPOSE: To introduce a surgical technique of retrograde pin fixation with tension band wiring for the proximal humeral fractures and to evaluate the clinical results. MATERIALS AND METHODS: The clinical results of thirty-two patients who underwent surgical treatment for the proximal humeral fractures, during the period from June 1996 to June 2001, using a retrograde pin fixation with tension band wiring were reviewed. The mean followup was 2.5 years (1-5 years) Twelve patients had a two-part fracture, and twenty patients had a three-part fracture with Neer's classification. We analyzed the clinical results using Neer score and radiological state using Zyto's three-point graded scale. RESULTS: By clinical evaluation, eighteen cases (56%) were excellent, twelve cases (38%) were satisfactory, one case (3%) was unsatisfactory and one case (3%) was failure. By radiological evaluation, twenty-one cases (66%) were good, nine cases (28%) were acceptable and two cases (6%) were poor. Three unsatisfactory cases were a case with pin migration, loss of reduction or avascular necrosis. There was not a case of delayed union, nonunion or infection. CONCLUSION: Retrograde pin fixation with tension band wiring for the proximal humeral fractures was considered to be a useful method, which is easy and induces limited soft tissue injury, and provides enough stability for postoperative rehabilitation in majority cases such as surgical neck or three-part fractures.

Culture of Rabbit Chondrocytes Using Chitosan Bead / 대한정형외과연구학회지

PURPOSE: To confirm the adhesion and matrix formation of chondrocytes which were cultured on chitosan beads and to elucidate the difference between the porous chitosan beads and non-porous chitsan beads as scaffold for chondrocytes. MATERIALS AND METHODS: Chondrocytes isolated from rabbit articular cartilage were cultured in vitro on porous and non-porous chitosan bead for 2 weeks. Histochemical (H&E stain, Toluidin blue stain) and scanning electromicroscopic approaches were used to compare the differences between two groups. RESULTS: In both groups, adhesion and proliferation of chondrocytes were observed on scanning electron microscopy. which were more active in the porous chitosan bead group. On histochemical staining with toluidine blue, the porous chitosan bead group showed stronger metachromasia than that of the non-porous chitosan bead. CONCLUSION: It is concluded that both chitosan beads could work as an effective scaffold for culturing chondrocytes, and that porous chitosan bead may be a better scaffold than non-porous chitosan bead because of cavities in former bead.

Discomfort in Winter Season after Fixing Lateral Malleolar Fracture with Plates: A comparison between stainless steel and titanium plate / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to find a method of proving cold discomfort in patients who complain during the winter seasons, after receiving an internal fixation with a metal plate, and to determine the different in the developments of cold discomfort according to the type of metal plate used. MATERIALS AND METHODS: Among 26 cases of lateral malleolar fracture, 16 stainless-steel plates and 10 titanium plates were compared. Discomfort was induced by placing ice over both lateral malleoli (ice provocation test), and the side on which discomfort was induced first was recorded. RESULTS: Ten patients who felt discomfort in the winter, among which 8 cases stainless-steel plate and 2 cases titanium plate. The degree of pain was rated as 3.6 on average (ranging 2-4) on the VAS (visual analogue scale). CONCLUSION: Cold discomfort during the winter season can be confirmed by using the ice provocation test (p=0.0004). The frequency of discomfort during the winter season was higher (p=0.126) in cases filted with stainless-steel plate (50%) than in those with a titanium plate (20%).

Bankart Procedure through Lateral Capsulotomy in Traumatic Anterior Instability of the Shoulder / 대한정형외과학회잡지

PURPOSE: To determine the outcome of the Bankart procedure through lateral capsulotomy approach by objective and subjective evalua-tion in traumatic anterior instability of the shoulder. MATERIALS AND METHODS: Thirty-seven patients with traumatic anterior instability, who underwent the Bankart procedure through lateral capsulotomy, were investigated with an average follow-up of 23 months. Every effort was made to maximize the range of motion by repairing the Bankart lesion and closing the capsulotomy to allow as much external rotation as feasible. In 18 cases, superior capsular shift (13) or Neer 's capsular shift (5) were combined to deal with capsular redundancy. Outcome was assessed using range of motion, Pennsylvania Shoulder Function Score, pain, residual symptom and satisfaction. RESULTS: Recurrence of instability was not encountered. Function score increased significantly and all patients were satisfied with the results. However, 8 patients (22%) complained of feeling apprehensive about sports activities. CONCLUSION: The Bankart procedure through lateral capsulotomy appears to minimize unwanted external rotation limitations and enable capsular redundancy to be dealt with adequately.

One-Stage Reconstruction with Pericraniosubgaleal Flap after Removal of Skin Involved Severe Paraffinoma

Paraffinoma on nose from injection of paraffin by the quack doctor for the purpose of augmentation rhinoplasty has so many problem, especially when invaded overlying nasal skin. 6 cases of skin involved severe paraffinoma were treated by one step reconstruction with pericraniosubgaleal flap and follow up periods was 2 to 17 months. All patients were successfully treated without any complications and had satisfactory results. In cases of three telangiectasis among six patients, the severity of telangiectasis was improved, but not completely. We believe that the advantages of this method are one step reconstruction and good vascularity, which prevent infection and enable easy to make variable shape. When the overlying skin loss was developed, the flap became tolerable graft bed. The authors conclude that the pericraniosubgaleal flap is one of the reliable surgical options for treatment of the skin involved severe nasal paraffinoma.

Optic Nerve Injury Associated with Facial Trauma

The traumatic optic neuropathy occurs in 0.5 to 5% of closed head trauma cases. Because it may cause permanent blindness, the early diagnosis and proper treatment are very important. We have treated 6 traumatic optic neuropathy patients among 433 head trauma cases from Sep, 1997 to Aug, 1998. Four patients showed visual recovery with steroid therapy. The diagnosis can be made clinically when the patient suffers from acutely decreased vision, Marcus-Gunn pupil, with its relatively normal fundoscopic finding, is considered as the most sensitive indicator and the first herald of visual tract injury, even though visual acuity is normal at the initial stage. The megadose steroid therapy must be diagnosed for the recovery of incompletely injured axons rather than regeneration. The optic canal decompression surgery must be spared for the delayed onset optic neuropathy patients who do not respond to the steroid therapy. In a case of indirect optic neuropathy, the associated orbital fracture reduction should not be undertaken until the optic neuropathy has stabilized. But severely displaced blow-in fracture of the orbit that decreases orbital volume should repaired early for orbital decompression.

A Clinical Analysis of Recurrence and Lymphatic Metastasis in Early Gastric Cancer

BACKGROUND: Among all gastric cancers, the most frequent malignant tumor in Korea, the proportion of early gastric cancer is increasing. This increase is bringing about controversy on the necessity of gastrectomy with extensive lymph node dissection for treatment. METHODS: Of 923 gastric cancer cases operated on at EulJi Medical Hospital from Jan. 1988 to Dec. 1996, we observed retrospectively 198 cases diagnosed as early gastric cancer on pathological biopsies. We performed this study in order to analyze the prognostic factors affecting recurrence and survival rate and to determine which characteristic of early gastric cancer influences lymph node metastasis. RESULTS: The rate of lymph node metastasis of early gastric cancer was 9.5% and it was revealed that depth of tumor invasion (p2 89.6%) and lymph node metastasis (n 96.3%, n 88.9%). CONCLUSIONS: Lymph mode metastasis is the most influential factor in the survival rate and the recurrence rate of early gastric cancer. We conclude that limited surgery is a reasonable treatment for differentiated mucosal cancers less than 5 cm and selectively for submucosal cancers less than 2 cm with elevation, which have the least possibility of recurrence and lymph node metastasis. However, a gas-trectomy with extensive regional lymph node dissection is still considered to be essential for either submucosal cancer with a depression or the submucosal cancer measuring more than 2 cm in size with elevation since recurrence and lymph node metastasis were frequently seen with these variants.

Fournier's Gangrene: A report of one case

Fournier's gangrene is a rare infection with high mortality rate. it consists of a mixed bacterial infectin of the skin, subcutaneous tissues and superficial fascia of the perinium and genitalia. Old patients especially with diabetes mellitus, alcoholism and maligancy are more affected. This disease requires prompt treatment: early diagnosis, broad spectrum antibiotic therapy, nutritional support and immediate extensive surgial debridement are necessary We report one case of Fournier's gangrene associated with diabetes mellitus.