Effect of Weekly Teriparatide Administration Followed by Percutaneous Balloon Kyphoplasty on Post-Menopausal Osteoporotic Compression Fracture Treatment / 대한정형외과학회잡지

Purpose@#This study examined the effect of the 3 months use of weekly teriparatide on fracture healing, complications, quality of life improvement, and change in bone turnover markers on postmenopausal osteoporotic vertebral fracture patients who received percutaneous balloon kyphoplasty. @*Materials and Methods@#Using a retrospective study design, 64 patients with osteoporotic vertebral fractures with T-scores≤-2.5, and anterior vertebral compression rates ≥30% were included in this study. 19 patients received weekly teriparatide for three months after kyphoplasty (TPTD group) and 45 patients received calcium and vitamin D supplements (control group). The changes in the anterior vertebral compression rate, rate of adjacent vertebral fracture, visual analogue scale/Oswestry Disability Index (VAS/ODI) score, and bone turnover markers were analyzed statistically. @*Results@#The changes in anterior vertebral compression rate showed significant differences at the 1-month (p=0.002) and 6-month followup (p<0.05, t-test, and two-way mixed ANOVA). The VAS scores showed a significant difference at the 3-month and 6-month followup (p<0.05). The ODI score showed a significant difference at the 3-month and 6-month period (p<0.05). An adjacent vertebral fracture occurred 18.8% (3 cases) in the TPTD group, and 21.6% (8 cases) in the control group, respectively (odds ratio=0.87). Osteocalcin showed a significant difference at 6 month (p=0.04). @*Conclusion@#Weekly teriparatide after percutaneous balloon kyphoplasty has beneficial effects on vertebral body height loss, pain, quality of life improvement, and bone formation.

Intratendinous Tophaceous Gout Mimicking Cellulitis after Achilles Tendon Repair / 대한정형외과학회잡지

A diagnosis of gout is often straightforward because gout has well known clinical presentations, laboratory analyses, and radiologic features. On the other hand, gout can mimic other diseases by showing a range of atypical clinical manifestations. This paper reports a 35-year-old male with no prior history of gout who developed tophaceous gout at his previously repaired Achilles tendon 11 years after surgery. He was initially misdiagnosed with cellulitis because of his atypical clinical features. This case is presented with a review of the relevant literature.

Osteoporotic Vertebral Compression Fracture Associated with Pregnancy and Lactation in Young Women / 대한정형외과학회잡지

Osteoporosis associated with pregnancy and lactation is a rare disease that can cause osteoporotic vertebral compression fracture (OVCF).Patients usually complain of severe back pain, which is easily mistaken for pain due to pregnancy, childbirth, and lactation, making a rapid diagnosis and treatment difficult. The authors diagnosed OVCF related to pregnancy and lactation through a physical examination, simple radiography, whole-body bone scan, magnetic resonance image, bone marrow density, and blood tests in a 29-year-old female patient and a 31-year-old female patient who presented with low back pain. This paper reports two cases of symptom improvement through a teriparatide injection, wearing thoracic lumbar sacral orthosis and taking calcium and vitamin D with a review of the literature.

Minimally Invasive Spine Surgery versus Open Posterior Instrumentation Surgery for Unstable Thoracolumbar Burst Fracture

Methods@#We enrolled 40 patients who underwent either MISS (M group, 20 patients) or open posterior instrumentation surgery (O group, 20 patients) for the treatment of traumatic unstable burst fractures. Clinical outcomes were evaluated based on postoperative back pain, operation time, blood loss, hospital stay duration, and perioperative complications. For radiologic evaluation, preoperative magnetic resonance imaging and plain radiography were performed before and after the surgery to evaluate the changes in the kyphotic angle and fracture union. @*Results@#The change in the kyphotic angle was −8.2°±5.8° in the M group and −8.0°±7.8° in the O group. No significant difference was noted in terms of the change in the kyphotic angle (p=0.94, t-test) after 12 months of surgery. The Visual Analog Scale score was 1.5±0.7 points in the M group, while it was 5.2±1.4 points in the O group. In the M group, back pain has significantly decreased (p<0.01, t-test). The estimated blood loss was 195.5 mL in the M group and 1,077.5 mL in the O group; the operation time was significantly decreased in the O group from 290.7 to 120.7 minutes in the M group (p<0.05, t-test) (p=0.36, t-test). The average duration of hospital stay was 36.0 days in the M group and 41.9 days in the O group (p=0.36, t-test). @*Conclusions@#For the treatment of unstable burst fractures, MISS showed significant differences in terms of postoperative back pain, operation time, and blood loss as compared to open posterior instrumentation surgery.

Lumbar Juxtafacet Cyst Treated with Direct Needle Aspiration Under the Guidance of Image Intensifier / 대한정형외과학회잡지

A lumbar juxtafacet cyst is a rare disease that causes low back pain, radiculopathy and neurological claudication by compressing the nerve roots. A 34-year-old male complained of severe low back pain and radicular pain in the right lower extremity. Magnetic resonance images revealed a cyst at the lateral recess of the spinal canal between the L3-4 disc and posterior facet joint that extended to the L4 body level. Under the guidance of an image intensifier, needle aspiration of the cyst was performed, which extracted 1.5 ml of serous, yellowish colored fluid. After the aspiration, the symptoms subsided dramatically. The follow-up magnetic resonance images showed no recurrence of the cyst. To the best of the author’s knowledge, there are no reports of lumbar juxtafacet cyst treated with needle aspiration in Korea. This case is reported with a review of the relevant literature.

Acute Compartment Syndrome Induced by Rhabdomyolysis Due to Antipsychotic Drug Overuse / 대한정형외과학회잡지

A 49-year-old male was found unconscious at his accommodation and visited the emergency room. He was on antipsychotic and antidepressant drugs (vortioxetine hydrobromide, mirtazapine, sertraline hydrochloride, quetiapine, and alprazolam) for schizophrenia and major depression. At the time of discovery there were signs of overdose of the drugs around the patient. A physical examination revealed, pain, pallor, and edema in the left buttocks and lateral thigh. Active ankle movements below the left ankle were not possible and sensations in the tibia and peroneal nerves were lost. The pressure in the buttock compartment was measured at 42 mmHg. Magnetic resonance imaging revealed edema and high intensity signals in the left hip muscles and surrounding soft tissue. An emergency fasciotomy was performed and partial restoration of the lower extremity sensation and muscle strength were achieved after 24 hours.

Cauda Equina Syndrome Occurred by Adhesive Arachnoiditis of the Lumbar Spine with an Unknown Cause / 대한정형외과학회잡지

Spinal adhesive arachnoiditis is an inflammation and fibrosis of the subarachnoid space and pia mater caused by infection, trauma, spinal vascular anomalies, and iatrogenic (surgery and/or puncture). Adhesive arachnoiditis develops various symptoms and signs (gait disturbances, radiating pain, paralysis, and incontinence). On the other hand, adhesive arachnoiditis associated with cauda equina syndrome has not been reported in Korea until now. The authors experienced cauda equina syndrome caused by adhesive arachnoiditis of the lumbar spine with satisfactory results following decompression. We report this case with a review of the relevant literature.

Cauda Equine Syndrome Induced by Spinal Epidural Hematoma due to a Low-Energy Osteoporotic Vertebral Fracture / 대한정형외과학회잡지

Spinal epidural hematoma (SEH) can occur naturally or traumatically and is most common in patients with an underlying disease of the vascular structure or coagulation disorder. Most SEHs occur naturally for no apparent reason, and epidural hematoma caused by trauma is less common, comprising 1.0%–1.7% of total spinal injuries. Few reports of SEH induced cauda equine syndrome resulting from low-energy injury caused by osteoporotic vertebral compression fractures are available. The authors experienced a case of delayed SEH after hemorrhage due to a low-energy injury in an elderly patient. No cases in Korea have been reported; therefore, this case is reported with a review of the relevant literature.

The Influence of Initial Magnetic Resonance Imaging Findings on the Compression Rate of Thoracolumbar Osteoporotic Vertebral Compression Fracture / 대한정형외과학회잡지

PURPOSE: To investigate the influence of the size of low intensity zone (LIZ) (T1 image) on the vertebral body and the increase in the compression rate in patients with osteoporotic vertebral compression fracture. MATERIALS AND METHODS: In a retrospective study, 187 patients (198 segments) who were followed-up for at least 3 months and diagnosed with thoracolumbar vertebral compression fracture between October 2011 and October 2016, and treated with conservative therapies, such as bed rest and thoraco-lumbar-sacral orthosis. We measured the size of the vertebral LIZ, and fractures on the upper and lower endplates were observed on the initial magnetic resonance imaging. We analyzed the correlation with the increase in compression rate at the last follow-up. Comparisons of the increase in the compression rate were analyzed through a correlation analysis. RESULTS: The larger the size of the LIZ the greater the difference in the increase of the compression rate. The group with the initially LIZ (80%–100%) was significantly increased to 23.87%±17.90% (p=0.007). In case of fracture of upper and lower endplates, an increase in the compression rate was 19.39%±12.59% in the upper endplate fracture, which was significantly higher than that in the absence of endplate fracture (p=0.002). CONCLUSION: The larger the size of the LIZ (T1 image) and superior endplate fracture observed on the initial magnetic resonance imaging after fracture, the greater the increase in the compression rate. In particular, when the size of the LIZ is greater than 80%, the compression rate was significantly increased.

Septic Arthritis after Arthroscopic Meniscal Repair / 대한정형외과학회잡지

The incidence of septic arthritis after knee arthroscopy surgery has rarely been reported in approximately 0.04% to 3.4%. Moreover, septic arthritis after arthroscopic meniscal repair is more rare. There have been some reported cases, but in Korea, it has not been reported thus far. Herein, we report two cases of septic arthritis after arthroscopic meniscal repair with review of literature.

Outcomes of Revision Surgery Following Instrumented Posterolateral Fusion in Degenerative Lumbar Spinal Stenosis: A Comparative Analysis between Pseudarthrosis and Adjacent Segment Disease

STUDY DESIGN: Retrospective study. PURPOSE: We examined the clinical and radiological outcomes of patients who received revision surgery for pseudarthrosis or adjacent segment disease (ASD) following decompression and instrumented posterolateral fusion (PLF). OVERVIEW OF LITERATURE: At present, information regarding the outcomes of revision surgery for complications such as pseudarthrosis and ASD following instrumented PLF is limited. METHODS: This study examined 60 patients who received PLF for degenerative lumbar spinal stenosis and subsequently developed pseudarthrosis or ASD leading to revision surgery. Subjects were divided into a group of 21 patients who received revision surgery for pseudarthrosis (Group P) and a group of 39 patients who received revision surgery for ASD (Group A). Clinical outcomes were evaluated using the visual analogue scales for back pain (VAS-BP) and leg pain (VAS-LP), the Korean Oswestry disability index (K-ODI), and each patient's subjective satisfaction. Radiological outcomes were evaluated from the extent of bone union, and complications in the two groups were compared. RESULTS: VAS-LP at final follow-up was not statistically different between the two groups (p =0.353), although VAS-BP and K-ODI at final follow-up were significantly worse in Group P than in Group A (all p <0.05), and only 52% of the patients in Group P felt that their overall well-being had improved following revision surgery. Fusion rates after the first revision surgery were 71% (15/21) in Group P and 95% (37/39) in Group A (p =0.018). The rate of reoperation was significantly higher in Group P (29%) than in Group A (5%) (p =0.021) due to complications. CONCLUSIONS: Clinical and radiological outcomes were worse in patients who had received revision surgery for pseudarthrosis than in those who had revision surgery for ASD. Elderly patients should be carefully advised of the risks and benefits before planning revision surgery for pseudarthrosis.

Brown-Séquard Syndrome and Cervical Vertebral Fractures after Blunt Cervical Trauma in a Traffic Accident - A Case Report -

STUDY DESIGN: Case report OBJECTIVES: To report a case of Brown-Séquard syndrome after blunt cervical trauma. SUMMARY OF LITERATURE REVIEW: Brown-Séquard syndrome is a rare disease characterized by hemisection of the spinal cord, and it shows the best prognosis of the various types of incomplete spinal cord injuries. MATERIALS AND METHODS: A patient with Brown-Séquard syndrome that occurred after a traffic accident was followed up for 2 years and 6 months. RESULTS: We observed normal recovery of motor strength, but sensory impairment and deep tendon hyperreflexia remained. CONCLUSIONS: Brown-Séquard syndrome is known to have a good prognosis, but in this case, the neurological abnormality did not fully recover; therefore, we report this rare case and present a review of the literature.

Video-Assisted Thoracoscopic Minimally Invasive Anterior Interbody Fusion of the T11-T12 Level Using Direct Lateral Interbody Fusion Devices: A Case Report

STUDY DESIGN: Case report OBJECTIVES: To report a case of video-assisted thoracoscopic (VAT) minimally invasive anterior interbody fusion of the T11-T12 level using direct lateral interbody fusion (DLIF) devices. SUMMARY OF LITERATURE REVIEW: Interbody fusion of the thoracolumbar junction (especially T11-T12) is technically challenging from anterior, lateral, or posterior approaches. A VAT anterior interbody fusion approach using DLIF devices is a safe, minimally invasive alternative approach to the thoracolumbar spine. MATERIALS AND METHODS: A 37-year-old male pedestrian was struck by a car sustaining fracture-dislocation at the T11-T12 level. The accident resulted in complete paraplegia of both lower extremities and multiple lower extremity fractures. A classical instrumented posterolateral fusion from T8 to L3 and staged VAT anterior interbody fusion at the T11-T12 level were performed. RESULTS: At one year postoperatively, he was capable of independent ambulation using a wheelchair without back pain, and plain radiographs and CT scans showed a solid fusion at the T11-T12 level. CONCLUSIONS: VAT anterior interbody fusion using DLIF devices provides excellent access to the anterior spinal column with the added benefits of an improved field of view and can be a safe and effective alternative to open thoracotomy in the management of various thoracolumbar junction problems.

Height Restoration after Balloon Kyphoplasty in Rheumatoid Patients with Osteoporotic Vertebral Compression Fracture

STUDY DESIGN: Retrospective study. PURPOSE: This study was conducted to compare vertebral body height restoration rate in rheumatoid arthritis (RA) patients who had undergone percutaneous balloon kyphoplasty (KP) with that of control group who had matched age, sex, body mass index, and bone mineral density. OVERVIEW OF LITERATURE: There is no report on result of KP in RA patients. METHODS: Postoperative height restoration rate of RA group consisting of 15 patients (18 vertebral bodies) who had undergone KP due to osteoporotic vertebral compression fracture with a 30% or higher vertebral compression rate between May 2005 and January 2013 were compared to control group consisting of 38 patients (39 vertebral bodies) who had matched age, sex, body mass index, and bone mineral density. RESULTS: No statically significant difference in age (p=0.846), sex (p=0.366), body mass index (p=0.826), bone mineral density (p=0.349), time to surgery (p=0.528), polymethylmethacrylate injection time (p=0.298), or amount (p=0.830) was found between the RA group and the control group. However, preoperative compression rate in the RA group was significantly (p=0.025) higher compared to that in the control group. In addition, postoperative height restoration rate showed significant correlation with the RA group (p=0.008). Although higher incidence of recollapse occurred in the RA group compared to that in the control group, the difference was not statistically significant (p=0.305). CONCLUSIONS: Compared to the control group, RA patients showed higher compression rate and higher vertebral restoration rate after KP, indirectly indicating weaker bone quality in patients with RA. Higher incidence of recollapse occurred in the RA group compared to that in the control group, although it was not statistically significant.

Surgical Outcome of Tuberculous Myelitis, Arachnoiditis and Spondylitis after Brain Meningitis: A Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a rare case of a surgically treated tuberculous myelitis and arachnoiditis patient with incomplete paraplegia. SUMMARY OF LITERATURE REVIEW: Tuberculous myelitis and arachnoiditis is a rare disease with a high rate of neurologic deficit. This condition is treated using antituberculous medication and high-dose steroid therapy, but surgical treatment has rarely been reported and the outcomes vary. MATERIAL AND METHODS: A 29-year-old female had tuberculous myelitis and arachnoiditis. The patient was treated with antituberculous medication and high-dose steroid therapy, but the treatment failed and the patient could not walk because of incomplete paraplegia. The surgical treatment was performed twice; we decompressed by total laminectomy and debrided the infected arachnoid membrane. Four months after surgery, we performed anterior interbody fusion due to the development of spondylitis with kyphosis. RESULTS: Three years after the first operation, the patient's neurologic state improved and she could walk 90 m without assistance. CONCLUSIONS: Here, we report a very rare case of surgically treated tuberculous myelitis and arachnoiditis and provide a treatment option for this condition to spine surgeons.

Analysis of Treatment Results of Unstable Distal Clavicle Fractures Using Hook Plate / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to analyze the treatment results and complications in unstable distal clavicle fractures which were treated with a Hook plate, and, in particular, to compare the functional results before and after removal of the Hook plate. MATERIALS AND METHODS: We examined 20 cases in 20 patients who underwent removal of Hook plates after bony union was obtained in an unstable fracture of the distal clavicle (Neer type II) from March 2009 to December 2012. The average follow-up period after initial surgery was 12 months (8-20 months). Plates were removed at 18 weeks (ranged from 10-36 weeks) after initial fixation. University of California at Los Angeles (UCLA) and Korean Shoulder Scoring System (KSS) scores were used for clinical functional evaluation, and plain radiographs were used for radiological evaluation. RESULTS: In radiological evaluation, bony union was obtained at an average of 11.4 weeks (ranged from 8-14 weeks) in all of the 20 patients. All of the 20 patients showed limited range of motion, mild pain, and discomfort of the shoulder before removal of the Hook plate, and all of the 20 patients showed better results in UCLA and KSS score after removal of the plate, when compared to before removal. Stress fracture as a major complication, was united completely with a 'figure of 8' bandage and deep wound infection was resolved after repeated debridement and antibiotic treatment with satisfactory functional results. CONCLUSION: Hook plate in treatment of unstable fracture of the distal clavicle is considered to be a useful method because rigid fixation can be obtained. However, there are some complications, such as limited range of motion, pain, and discomfort of the shoulder joint, before removal of the Hook plate. Therefore, we think that removal of the Hook plate as soon as possible if bony union is obtained would be desirable.

Pseudogout of the Knee after Intraarticular Injection of Hyaluronic Acid / 대한정형외과학회잡지

An 82-year-old woman underwent surgery for the left intertrochanteric fracture. However, during hospitalization, she complained of pain on the right knee. Radiographs showed moderately degenerative arthritis and intrameniscal calcification. Hyaluronic acid was administered by intraarticular injection. After injection, arthritic symptoms improved. Five days after injection, she complained of severe pain, swelling, and heating sensation in the right knee with chills and fever. Blood test showed elevated white blood cell (WBC) count and C-reactive protein. WBC in synovial fluid increased to 47,250/mm3. Antimicrobial therapy was administered under the impression of acute pyogenic arthritis by adverse reaction of hyaluronic acid injection. Polarization microscope showed calcium pyrophosphate dihydrate crystals. Synovial fluid culture was negative. Finally, she was diagnosed as pseudogout. The symptoms improved within one week. To our knowledge, there has been no report of pseudogout following intraarticular injection of hyaluronic acid in Korea. Therefore, we report this case with a review of the literature.

Old and New Fashion: Minimally Invasive Spine Surgery for Adjacent Segmental Spinal Stenosis after Luque Sublaminar Wiring and Posterolateral Fusion: Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a rare case of minimally invasive spine surgery after sublaminar wiring fixation with Luque rods. SUMMARY OF LITERATURE REVIEW: In the past, sublaminar wiring fixation with Luque rods was believed to be an effective fixation method; however, the development of transpedicular fixation resulted in the discontinuation of this method. Currently, instead of classical surgery using a broad incision, minimally invasive spine surgery is performed, which has a multitude of advantages. MATERIALS AND METHODS: Initially, the patient underwent Luque sublaminar wiring and posterolateral fusion. After 25 years, minimally invasive TLIF and percutaneous transpedicular fixation were performed for the adjacent segmental spinal stenosis. RESULTS: A good bone union is developing with an excellent clinical outcome, 14 months after the surgery. CONCLUSIONS: We report a very rare case of a patient who underwent Luque sublaminar wiring and then, 25 years later, had spine surgery with minimally invasive techniques.

Muscular Injury of Iliacus and Gluteus Maximus after Mountain Climbing / 대한스포츠의학회지

Iliacus muscle is the strongest hip flexor of gluteal region that acts with psoas muscle, whereas gluteus maximus muscle is the largest muscle engaged in extension and external rotation of the hip. Mountaineering requires strong contractile force of both flexor and extensor around the hip. A 57-year-old man presented to our hospital with severe pain in left groin after mountaineering for 5 hours without a break. Magnetic resonance imaging revealed incomplete rupture of iliacus muscle and strain of gluteus maximus muscle. Conservative treatment was done. At 3 months of follow-up, he returned to normal life. If we are going to climb mountain, it is important to start warming up with some stretches, take a break while climbing, and use climbing sticks. There have been no report about athletic injury of both iliacus and gluteus maximus after mountaineering. So we report this case with a review of the literature.

The Fate of Neglected Three Column Injuries of the Thoracolumbar Spine / 대한정형외과학회잡지

In a thoracolumbar fracture, accurate diagnosis of spinal stability is necessary in deciding on appropriate treatment options and for prevention of complications that can subsequently occur. In various reports for spinal stability, rupture of the posterior ligament complex is generally accepted as a very important factor of spinal stabiliby. In cases of conservative treatment for unstable thoracolumbar fractures, the progressive kyphotic deformity can cause chronic pain and functional disability, and neurologic deterioration in severe cases. Therefore, the concept of surgical treatment for unstable thoracolumbar fracture has been well established. We report on two cases of neglected three column injury in the thoracolumbar spine, which were treated conservatively due to misdiagnosis at other hospitals, and finally underwent delayed operation in our hospital because of chronic back pain and progressive kyphotic deformity.