Delayed Vertebral Collapse in Osteoporotic Vertebral Compression Fractures: Risk Factors and Treatment Strategies

STUDY DESIGN: Literature review. OBJECTIVES: To review the complications of osteoporotic vertebral compression fractures (OCFs) with regard to risk factors and treatment strategies. SUMMARY OF LITERATURE REVIEW: Understanding the complications and treatment methods of OCFs is important given their increasing prevalence. MATERIALS AND METHODS: Review of the literature. RESULTS: The complications of OCFs include kyphotic deformity due to a delayed collapse of the vertebral body and neurologic deficits. The pathophysiologic mechanism of these complications has not been established; however, the most accepted theory is posttraumatic avascular necrosis of the vertebral body. The risk factors for these complications include fracture at the thoracolumbar junction, systemic usage of steroids, severe osteoporosis, and radiological intravertebral vacuum cleft. Most of these complications require surgical treatment, the indications for which include progressing axial back pain, pseudarthrosis, kyphotic deformity, and neurologic deficits. Surgical approaches for treating the complications of OCFs include anterior, posterior, and combined anterior-posterior approaches. Osteotomies should be done when deformity correction is needed. The decision among these various surgical methods should be made considering patient factors and the surgeon's ability to achieve the best outcomes with solid fusion. CONCLUSIONS: complications of OCFs include kyphotic deformity due to delayed collapse of the vertebral body and neurologic deficits. Most of these complications require surgical treatment, in which achieving solid fusion at the fracture site is the ultimate goal. Patient-related factors and the surgeon's ability should be considered prior to making decisions regarding surgery.

Amyloid Arthropathy of the Hip Joint Associated with Multiple Myeloma: A Case Report / 대한고관절학회지

Amyloidosis is a disease characterized by the deposition of non-soluble fibrous protein in multiple tissues with a number of possible causes. This protein deposition can occur in any tissue, yet is most commonly seen in kidneys, heart, and gastrointestinal tracts. However, invasion to bone tissues is not often reported. The deposition of amyloid proteins in bone tissues may result in joint pain and pathological fractures; it is important to elucidate the causes and detect early to determine prognosis and treat optimally. In the present case report, with relevant literature review, the authors report a case of total hip arthroplasty in an amyloidosis patient.

The Relationship between the Progression of Kyphosis in Stable Thoracolumbar Fractures and Magnetic Resonance Imaging Findings

STUDY DESIGN: Retrospective study. PURPOSE: To investigate the relation between the progression of kyphotic deformity and magnetic resonance imaging (MRI) findings in conservatively treated stable thoracolumbar fractures. OVERVIEW OF LITERATURE: When treated conservatively, excessive progression of kyphotic deformity and vertebral compression can emerge during follow-up. We sought to identify predictors of vertebral body deformation using MR images. METHODS: The presence in MR images of anterior longitudinal ligament (AL) or posterior longitudinal ligament (PL) injury, superior or inferior endplate disruption, superior or inferior disc injury in fractured vertebral bodies, the existence of low signal intensity on T2 weighted images, and bone edema of intravertebral bodies were assessed. RESULTS: The presence of superior endplate disruption and a higher level of bone edema were found to cause the progressions of kyphotic angle (KA), wedge angle (WA), and anterior vertebral compression (AVC) rate. When AL or superior disc injury was observed, only KA increased meaningfully. When low signal intensity was present on T2 weighted images WA and AVC increased significantly, but PL injury, inferior endplate disruption, and inferior disc injury showed no notable correlation with kyphotic deformity progression. The risk factors found to be associated with an increase of KA to >5degrees were AL injury, superior endplate disruption, superior disc injury, and a bone edema level of over 1/3, and their associated risks versus no injury cases were 14.1, 3.7, 6.8, and 10.4-fold, respectively. CONCLUSIONS: AL injury, superior endplate and disc injury, or a high level of bone edema, were critical factors that determine kyphotic deformity progression.

Radiological and Clinical Comparison of 1 Cage versus 2 Cages for Posterior Lumbar Interbody Fusion with PEEK Cage and Local Bone Graft / 대한척추외과학회지

STUDY DESIGN: This is a retrospective study. OBJECTIVES: We wanted to compare and evaluate the results of using one cage and two cages with local bone grafting for each segment when performing posterior lumbar interbody fusion (PLIF). Summary of Literature Review: Some authors have reported that unilateral one-caged PLIF with local bone grafting and posterior instrumentation was no difference from bilateral two-caged PLIF regard to the fusion rates and the radiologic or clinical results. MATERIALS AND METHODS: From March 2005 to February 2006, PLIF was performed on 36 patients who had lumbar degenerative disease. They were categorized as the cases for which one cage was used for a segment and the cases for which 2 cages were used for a segment. The clinical and radiological results in each group were compared. RESULTS: There was complete union in 11 segments with using one cage (55%), complete union in 12 segments using two cages (77%) and incomplete unions in 9 segments with using one cage (45%) and incomplete union in 4 segments with using 2 cages (25%), and there wasn't any case of nonunion (p>0.05). The postoperative changes of the intervertebral disc space were a 2.0 mm increase with using one cage and a 2.2 mm increase with using two cages, yet these values decreased by 0.4 mm and 0.3 mm, respectively, on the last follow-up. The mean operation time was 89 minutes for one segment with one cage and 105 minutes for one segment with two cages. The blood loss was a mean of 602 ml with one cage and 802 ml with two cages (p<0.05). There was no significant difference between the one cage group and the two cages group for the Kirkadly-Willis criteria. CONCLUSION: Posterior decompression and PLIF with one PEEK cage for treating degenerative lumbar disease was more effective for the operation time and the amount of blood loss than that with two cages, but the fusion rate, the alteration of the intervertebral disc space, the improvement of pain and the clinical results were no different. However, these results are from short term follow up, so continuous follow up will be necessary in the future for assessing the long term prognosis.

The Value of Local Flaps in Lower Extrimity Reconstruction

PURPOSE: The aim of this study was to evaluate the outcome and the effectiveness of local flaps in lower extremity reconstruction. MATERIALS AND METHODS: We have performed lower extremity reconstruction with local flap in 14 cases (10 males and 4 females) from May 2006 to February 2008. The mean age was 40.1 years (range, 16~67). The defect site was the tibia in 5 cases, the ankle in 1 case and the foot in 8 cases. The local flaps were reverse flow sural artery flap in 7 cases, gastrocnemius flap in 3 cases, lateral supramalleolar flap in 2 cases, dorsalis pedis flap in 1 case and medial hemisoleus flap in 1 case. RESULTS: All flaps were survived. Venous congestion was developed in 1 case of the rerverse flow sural artery flap but healed with secondary rotational flap. Other flaps were good without any complications. CONCLUSION: If we choose precisely indicated local flap in lower extremity reconstruction, the resultant coverage of defect would be excellent.

The Usefulness of Bone Scan in the Osteoporotic Vertebral Compression Fracture Patients Treated With Kyphoplasty / 대한척추외과학회지

STUDY DESIGN: Retrospective study. OBJECTIVES: To compare the clinical results of kyphoplasty between osteoporotic patients with compression fractures and rib hot uptake on bone scan and patients without rib hot uptake. SUMMARY OF LITERATURE REVIEW: The incidence of osteoporotic rib fractures is 0.3% in postmenopausal women. MATERIALS AND METHODS: Between July 2005 and July 2006, 72 kyphoplasties for osteoporotic vertebral compression fractures were performed, and all patients had a bone scan study. On bone scan study, 41 patients (57.7%) had hot uptake in their ribs. Results were assessed by visual analog scale (VAS). RESULTS: The incidence of hot uptake was 67.8% in thoracic fractures, 40.0% in lumbar fractures, and 72.7% in thoracolumbar fractures. Hot uptake was significantly more common with thoracic and thoracolumbar fractures than with lumbar fractures (p0.05). CONCLUSIONS: Thoracic and multiple osteoporotic compression fractures are often accompanied by rib fractures. Bone scan is a useful tool to detect rib fractures and predict the prognosis of kyphoplasty.

Comparison of Unipedicular versus Bipedicular Kyphoplasty for Osteoporotic Vertebral Compression Fractures / 대한척추외과학회지

STUDY DESIGN: A retrospective study OBJECTIVES: To compare the radiological and clinical results of the unipedicular and bipedicular approach of kyphoplasty for osteoporotic vertebral compression fractures. SUMMARY OF LITERATURE REVIEW: A unipedicular rather than a bipedicular technique has been suggested to decrease the risks associated with surgical procedures. MATERIALS AND METHODS: Between July 2005 and May 2006, 136 vertebrae of 97 patients, who underwent kyphoplasty for osteoporotic vertebral compression fractures, were analyzed. Group 1, with the bipedicular approach, consisted of 86 vertebrae of 67 patients with a mean age of 72.2 years. Group 2, with unipedicular approach, consisted of 50 vertebrae of 30 patients with mean age of 73.4 years. The plain radiographs, MRI and surgical records were reviewed. RESULTS: The mean operation time of the single vertebral body in group 2 was statistically lower than in group 1(p0.05). CONCLUSION: There were no significant differences in clinical satisfaction and radiological results between the unipedicular and bipedicular kyphoplasty. The advantage of a unipedicular approach is the shorter procedure time than the bipedicular approach. This is particularly useful in multi-level compression fractures. The rate of the unipedicular approach in upper and mid thoracic spine is higher because of the higher convergence of the pedicle and the lower volume of vertebral body despite the disadvantages of instrument insertion through the medial pedicle wall.

Analysis of the Calcaneocuboid Joint Involvement in Intraarticular Calcaneal Fractures / 대한족부족관절학회지

PURPOSE: This study was performed to analyze the characteristics of calcaneocuboid joint involvement in intraarticular calcaneal fractures. MATERIALS AND METHODS: Total number of 92 patients (111 cases) who underwent operation for intraarticular calcaneal fractures between Jan. 2000 and Oct. 2005 were included in this study. The preoperative computed tomographs of the subjects were retrospectively reviewed to analyze calcaneocuboid joint involvement. RESULTS: It was revealed that 63 cases (56.8%) involved calcaneocuboid joint; 29cases (46.0%) showed type 1 (undisplaced or minimally displaced type, articular gap or =2 mm), 7 cases (11.1%) were included in type 3 (comminuted type) and 11 cases (17.5%) belonged to type 4 (fracture and dislocation). 48 out of 63 cases belonged to Sanders classification II and III that involved calcaneocuboid joint and included 25 cases (52.1%) of type 1 and 14 cases (29.2%) of type 2. Among 15 out of 63 cases included in Sanders classification IV, 4 (26.7%) showed type 1 and 6 (40.0%) belonged to type 4. According to our results, Sanders classification allowed to predict pattern of the involvement of calcaneocuboid joint (P0.05). CONCLUSION: Calcaneocuboid joint involvement in intraarticular calcaneal fractures was common and more than half showed severe injuries. We concluded that further studies on the involvement of calcaneocuboid joint should be performed prior to surgical treatment of intraarticular calcaneal fractures.

The Effect of Pedicle Screw Instrumentation on Fractured Vertebrae in Unstable Thoracolumbar Burst Fractures with Canal Encroachment and Clinical Result / 대한척추외과학회지

STUDY DESIGN: A retrospective study. OBJECTIVES: To evaluate the canal encroachment of fractured bony fragments and neurological deficits of pedicle screw instrumentation for the treatment of unstable thoracolumbar burst fractures with pedicle screws inserted into the fractured vertebrae. MATERIALS AND METHODS: The authors evaluated 18 patients treated surgically with posterior fusions using pedicle screws for unstable thoracolumbar burst fractures, from March 2000 to September 2004. The ratios of the areas occupied by the fractured bony fragments in the canals were analyzed, before and after pedicle screw insertion, by computed tomography scans of the fractured vertebrae. The kyphotic angles, anterior vertebral heights, and neurological deficits were evaluated. RESULTS: The areas occupied by the fractured fragments in the canals were improved significantly after surgery and there were no neurological complications resulting from the placement of pedicle screws or fragment displacements. The kyphotic angles and anterior vertebral heights at the last follow-up visits were improved significantly compared with the preoperative radiographs. The neurological deficits were not aggravated after pedicle screw insertion. CONCLUSION: Our results suggest that pedicle screw instrumentation in fractured vertebrae is safe and effective for the treatment of unstable thoracolumbar burst fractures.

Thoracolumbar Fracture with Posterior Ligament Complex Injury

PURPOSE: To evaluate the clinical features and radiographical landmarks of patients who has a thoracolumbar fracture combined with posterior ligament complex injury retrospectively. MATERIALS AND METHODS: The preoperative plain radiographys, axial CT, MRI and medical records of 27 patients were reviewed who were confirmed the posterior ligament complex injury in operation from January, 2002. to December, 2004. RESULTS: The patients were from 15 years to 75 years of age (mean 39.1 years), 20 males and 7 females. The mechanisms of injury were 17 falls from a height, 7 traffic accidents and 3 direct blow injuries. There were 17 cases (63%) in thoracolumbar transitional zone, such as 11 cases in T11-T12, 6 cases T12-L1. There were 9 cases of compression fracture and 18 cases of burst fracture according to the shape of fractured vertebra. In the plain radiograph, the degree of kyphotic angle was between 6~49 degrees (mean 22 degrees), anterior vertebral height loss was 7~70% (mean 39%), and posterior vertebral height loss was 0~8% (mean 3%). 21 cases (78%) were the anterior vertebral height loss below 50%, 23 cases (85%) were the degree of kyphotic angle below 30 degrees. Neurological deficits were not registered. 23 cases (85%) were positive in MRI and 24 cases (89%) were positive in direct focal tenderness in the view of posterior ligament complex injury. Conclusions: The posterior ligament complex injury is common finding of the thoracolumbar fracture. The high resolution MRI findings and direct focal tenderness are very importance in identifying the posterior ligament complex injury that is important prognostic factor particularly in mild anterior vertebral height loss and mild kyphotic angle in the plain radiograph.

MR Predictors of Bone Cement Leakage in Percutaneous Vertebroplasty and Kyphoplasty for Painful Osteoporotic Vertebral Compression Fracture / 대한척추외과학회지

STUDY DESIGN: Retrospective study OBJECTIVES: To determine MR findings that affect the bone cement leakage in patients with osteoporotic compressive fractures who are receiving percutaneous vertebroplasties and kyphoplasties. MATERIALS AND METHODS: A retrospective review was conducted on 105 patients with 131 vertebrae treated by percutaneous vertebroplasties (group 1: 66 patients and 78 cases) and kyphoplasties (group 2: 39 patients and 53 cases) from October 2001 to October 2005. The study was performed to determine whether cement leakage was related to any of the following MR findings: level of injured vertebra, severity of anterior height loss, posterior cortical disruption, endplate disruption, presence of either vacuum or cystic portions, linear sclerosis that was low in signal intensity in T1 and T2-weighted images. RESULTS: Bone cement leakage was detected in 51 (65.3%) of 78 treated vertebrae in group 1 and 18 (33.9%) of 53 treated vertebrae in group 2. There was a statistically significant difference between the incidences (p<0.05). Vertebral endplate disruption had a positive correlation in both groups (p<0.05). There was more cement leakage in group 1 (48.5%) than in group 2 (18.1%) in cases of endplate disruption (p<0.05). Vacuum or cystic change had negative correlations to bone cement leakage in group 1 (p<0.05). No other MR findings demonstrated a statistically significant correlation with bone cement leakage. CONCLUSION: On the MR findings, vertebral endplate disruption and vacuum or cystic change in fractured vertebrae demonstrated a significant correlation with bone cement leakage in group 1. There was relatively less cement leakage into the intervertebral spaces with kyphoplasties than with vertebroplasties in the cases of vertebral endplate disruption.

Partial Thickness Tear of the Deep Surface of the Subscapularis Tendon: Its Relationship to the Anterior Internal Impingement / 대한정형외과학회잡지

PURPOSE: The purposes of this study were to investigate the relationship between partial thickness articular side tear of the subscapularis tendon and anterior internal impingement, and to evaluate the clinical outcomes. MATERIALS AND METHODS: We reviewed 27 cases who underwent surgery for tears in the deep surface of the subscapularis tendon. On arthroscopic examination, fraying or tear less than 10% thickness of the subscapularis tendon was observed in 9 cases, 10-30% in 5, more than 30% in 5, and longitudinal tear in 8. Tears were treated with debridement only in 21 cases, arthroscopic repair in 5, and open repair in 1. Labral or SLAP repair was also performed in 6 cases. Analysis was done by the preoperative clinical test, coracoid index and coracohumeral distance from the MR images, associated lesion and the presence or absence of anterior internal impingement on arthroscopic evaluation. Clinical results were assessed using the University of California at Los Angeles shoulder rating scale. RESULTS: Anterior labral lesions were present in 59% of the cases. Hawkins test was positive in 16 cases (59%). Among these cases, labral lesions were seen in 14 (88%). The results were satisfactory in 81%. CONCLUSION: We thought that anterior internal impingement between the partial thickness tear of the subscapularis tendon and the anterior glenoid labrum may cause shoulder pain and possibly induce progression of tear in deep surface of the subscapularis tendon, and Hawkins test is helpful for diagnosis. Satisfactory outcomes could be obtained with debridement or repair in partial tear of the deep surface of the subscapularis tendon.

Surgical Treatment of the Irreducible Hohl and Moore Type 2 Proximal Tibia Fracture-Dislocation 3 Years Follow up Study: 1 Case Report

Intraarticular proximal tibia fracture and dislocation patterns, that were proposed by Hohl and Moore, are generally caused by high energy mechanism . These fracture and dislocation patterns are known to be combined with injuries of popliteal artery, peroneal nerve and cruciate ligament in many cases. We experienced a case irreducible Hohl and Moore fracture-dislocation patterns type 2, in which posterior dislocation with medially displaced entire lateral condyle that could not be reduced by closed mean for fibular head blocking the proper reduction. Additionally, popliteal artery was entrapted into the fracture site. We carried out open reduction and screw fixation via posterior approach and with fibular osteomy. We followed the patient for 3 years.