Treatment of Intertrochanteric Fracture with Dynamic Hip Screw and Gamma Nail: A Retrospective Matched Pair Study / 대한정형외과학회잡지

PURPOSE: To compare the clinical and radiological results obtained using dynamic hip screws and Gamma nails for the treatment of intertrochanteric fracture of the femur. MATERIALS AND METHODS: We performed a retrospective study of 45 pairs of dynamic hip screw (DHS) and Gamma nail (GN) patients which were matched for sex, fracture type, and Singh index for the treatment of intertrochanteric fracture (matched pair control study). Mean duration of follow-up was 34.5 months (range, 12-62 months). RESULTS: No significant differences were found in terms of operation time, amount of transfusion, neck-shaft angle, sliding of the lag screw, union time, and mechanical complications between the two groups in the cases of stable fractures. For unstable fractures, the operation time of the DHS group was 144.7+/-40.7 minutes and that of GN group was 92.0+/-50.7 minutes (p<0.05) respectively. Mean blood transfusion units of the DHS group were 1.6 pints and of the GN group were 1.1 pints (p<0.05). No statistical differences were found between the two groups in terms of the mean duration of union, the sliding of lag screw or change of neck shaft angle in unstable fractures. Moreover there was no statistical difference between the two groups in terms of mechanical failure according to the Singh index and type of fracture. CONCLUSION: No significant differences were found between the two devices in the treatment of stable fractures. In unstable intertrochanteric fractures, Gamma nail was more useful device but only for in terms of reducing the operative time and blood loss and not in relation to union, fixibility and sliding.

Reconstruction of Neglected Patellar Tendon Rupture with Achilles Tendon Allograft: A case report

Neglected rupture of patellar tendon is an uncommon event. These rupture is often difficult to repair for structural and functional integrity of extensor mechanism because they generally accompanied quadriceps muscle contracture and a great deal of scar tissue formation. We report a case of neglected rupture of patellar tendon that was treated with achilles allograft. The patient who previously treated conservatively by long leg cast immobilization around the knee joint. He had an unstable knee. MRI showed a neglected rupture of patellar tendon, posterior cruciate 1igament and popliteus tendon. At first, patellar tendon was reconstructed using achilles allograft. Secondary operative procedure was necessary for combined pos-tero-lateral corner injuries. 3 years later, he had regained 130 degrees of flexion and full active extension. He had 3cm of thigh atrophy. He had returned to all of his usual activities without significant instability. There were several treatment methods of neglected rupture of patellar tendon. Achilles tendon allograft was one of them. We experienced this method is sufficient for regain usual extensor mechanism of the knee joint.

Radiologic and Clinical Evaluation after Arthroscopic Reconstruction of Anterior Cruciate Ligament Using Autogenous Bone-Patellar Tendon-Bone Graft

PURPOSE: The purpose of this study was to correlate radiological analysis(as divergence of femoral tun-nel and interference screw and tunnel placement) with clinical results(as physical examination, Lysholm knee scoring scale, and side to side difference of anterior displacement in an arthrometer). MATERIALS AND METHODS: This study reviewed radiological and clinical results in 48 endoscopic single-incision ACL reconstruction, using autogenous bone-patellar tendon-bone graft and interference screw fixation, between January 1995 and October 1997. We measured the femoral divergence in antero-poste-rior and lateral views of the knee(APD/LD), the angle between a line through the longitudinal axis of dis-tal femoral shaft, and the axis of femoral tunnel in antero-posterior and lateral views(APFT/LFT). We also measured the placement of a tunnel in antero-posterior and lateral views. RESULTS: Significant correlation was present between APD and APFT(negatively) and between LD and LFT(positively), while other variables had no significant correlation. Furthermore, there was no signifi-cant correlation between divergence and clinical results. Clinical results correlated positively with posteri-or femoral tunnel placement on lateral radiographs and negatively with excessive anterior tibial tunnel placement. Therefore, when femoral tunnels were placed at least 60% posterior along the Blumenssat's line and tibial tunnels were placed at least 20% posterior along the tibial plateau, 77.1% of the patients had good or excellent Lysholm score and 80% of the patients had a KT-2000 Arthrometer maximum manual side-to-side difference of 3 mmor less. When the above criteria were not met, however, only 53.8% of the patients had good or excellent Lysholm score and 53.8% had a KT-2000 Arthrometer maximum manual side-to-side difference of 3 mmor less. CONCLUSIONS: This close correlation indicated that satisfactory radiographic tunnel position influences the outcome of an ACL reconstruction.

Anatomic Variations and Magnetic Resonance Imaging of the Lateral Ankle Ligaments / 대한해부학회지

The lateral ankle ligaments consisted of the anterior talofibular, posterior talofibular and calcaneofibular ligaments. This study was to investigate the dimensions and anatomic variations of these ligaments and correlate with MR images. Sixty seven ankles of Korean adults were used. Among these 37 ankles were only disseted and 30 ankles were dissected after getting MR images. The anterior talofibular ligament consisted of two bands in 72.4%. The length and thickness of this ligament were 20.9mm and 1.8mm, respectively. The widths were 7.0 mm in the upper band and 4.7 mm in the lower band. The talofibular ligament appeared as a hypointense thick band or several lines in MR images. This ligament was observed in 100% of the axial MR sections and 82.8% of the coronal sections. The posterior talofibular ligament showed single thick band in 53.2% while others showed as two bands. The length, width, thickness and the angle between the horizontal plane and the posterior talofibular ligament were 21.8 mm, 7.3 mm, 3.4 mm and 22.6degrees, respectively. In coronal MR images this ligament appeared as a hypointense and heterogeneous thick band between the lateral malleolus and the talus. All anterior and posterior talofibular ligaments were observed in axial MR images with at least one same MR plane showing the two ligaments together. The length, width and thickness of the calcaneofibular ligament were 25.3 mm, 5.2 mm and 2.3 mm, respectively. It was composed of two bands in 8.5%. The angles to the coronal and sagittal planes and this ligament were 20.7degrees(range 5degrees~60degrees) and 27.0degrees(range 7degrees~50degrees), respectively. The calcaneofibular ligament was seen as a hypointense short line or dot depending on the cut plane. It was observed in 72.4% of the axial MR images and in 75.9% of the coronal images but was better imaged in the coronal planes.

PCL Substituting Total Knee Replacement Arthroplasty / 대한정형외과학회잡지

Controversies about the posterior cruciate ligament continue with regards to total knee arthroplasty. There has been a long debate regarding PLC and its importance seems to be overrated in total knee arthroplasty. Twenty four patients had twenty six total knee replacements with insertion of the PCL substituting Press Fit Condylar modular total knee system with cement, and they were enrolled in a prospective study to assess the clinicoradiological results and measure the femoral roll-back postoperatively. Follow-up ranged from twenty four months to fifty months with an average of thirty two months. The mean HSS score was 92.1 points and the mean range of motion was 122.7 degrees. Twenty five cases(96.1%) showed excellent and good clinical results. The radiologic evaluation based on Knee Society roentgenographic system revealed proper alignment of all components and one significant radiolucent area. The mean femoral roll-back was 2.3mm posteriorly. In the present series, total knee arthroplasties with the Press Fit Condylar modular knee system resulted in excellent relief of pain, excellent range of motion and restoration of function.

The Changes of Anterior Displacement in Combined ACL / MCL Injured Knee after MCL Healing / 대한정형외과학회잡지

The medial collateral ligament(MCL) of the knee is the well established secondary restraint to the anterior displacement of the knee joint. However, there has been no report about the estimation of the anterior displacement in combined ACL(anterior collateral ligament) and MCL injures according to period when they were treated with conservative measures. This prospective study evaluated the changes of anterior displacement over time in combined ACL/MCL injury as the MCL injury heals after initial conservative measures. 19 patients who had combined ACL/MCL injury were followed during twelve months after injury. All patient had a positive Lachman test and were evaluated the side to side differences on KT-2000 knee arthrometer(Medmetric, San Diego, California) testing under 20 Ibs anterior tibial loading at 30 degree knee flexion. The stability of the knee was assessed using KT-2000 knee arthrometer every 8 weeks with clinical examination prospectively. They were treated with CI (Combined instability) brace (Smith & Nephew, Carlsbad, California) as conservative measures. Overall, Initial side to side difference of the anterior displacement was averaged 5.21mm (range,4.0-7.0mm) and 3.30mm (range,2.0-5.5mm) finally. According to the classification of MCL injury, in Grade III groups, they had the greatest initial anterior displacement about 6.4mm, but tight- ened the most to 3.08mm finally. In Grade II and Grade I groups they showed 2.97mm and 2.13mm side to side difference (p>0.01). However in Grade I, the anterior displacement were decreased by 4 months after injury but, it were increased at 6 months after injury. In Grade II and III, the decrement of the anterior displacement were continued by 6 months after injury, but they were not changed after that. The data was analyzed by General Linear Model Procedure method. Conclusively, the anterior displacement of knee in patients with combined ACL/MCL injury was diminished with the time in the majority of patients as the MCL healed. It means that the MCL was the stabilizer to the anterior displacement of the knee under the anterior tibial loading.

Lumbar Spinal Stenosis and Diabetes Mellitus: Comparison of Surgical Outcome / 대한척추외과학회지

STUDY DESIGN: This retrograde study was designed to compare the clinical features and postoperative clinical results of diabetic and non-diabetic patients who had undergone decompression and postero-lateral fusion with instrumentation. OBJECTIVE: To determine whether diabetes affected the outcome of surgery and to identify the clinical features associated with a poor outcome. SUMMARY OF BACKGROUND DATA: Symptoms of peripheral angiopathy and neuropathy as long-term complications of diabetes closely mimic those of lumbar stenosis and there may be a risk of inappropriate surgical intervention in patients with both diabetes and spinal stenosis. In the presence of diabetes, a poor surgical outcome might be expected. But only a few literatures have been documented. MATERIALS AND METHODS: We reviewed 21 diabetic(mean age 58.2 years) and 21 non-diabetic patients(mean age 61.3 years) who had undergone decompression and postero-lateral fusion with instrumentation for lumbar spinal stenosis at a mean of 32 months after operation by reviewing the medical records such as clinical symptoms and results of objective examination(including electrophysiologic study). RESULTS: The preoperative symptoms were similar in the two groups except that abrupt onset of symptoms, the presence of night pain and the absence of any posture-related pain relief were recorded only by diabetic patients. The level of decompression, co-morbidity rate, and intra-operative blood loss were similar in two groups, too. Nerve-conduction velocity was lowered in 66.7% of the diabetic and in 25% of the non-diabetic patients. Polyneuropathy, which are highly suspicious of diabetic neuropathy was detected 46.7% in only diabetic group. The long-term result was excellent or good for thirteen(61.9%) of the twenty-one diabetic patients and for nineteen(90.5%) of the twenty-one non-diabetic patients. CONCLUSIONS: Thus diabetic patients who haute spinal stenosis cannot be expected to have same clinical outcome as non-diabetic patients, which is consistent with the general belief of impression. Therefore, the selection of patient according to clinical and electrophysiologic findings would be the most important factor in determining the rate of success of surgical treatment.

Arthroscopic ACL Reconstruction with Quadrupled Semitendinosus Tendon and endobutton / 대한정형외과학회잡지

In anterior cruciate ligament (ACL) deficient knee, several treatment methods were recommended. Recently, arthroscopic reconstruction is widely used as the best treatment method. As the graft materials, bone-patellar tendon-bone (BPB) unit is a gold standard material. Whereas, it has many problems. The purpose of this study was to introduce the new arthroscopic ACL reconstruction technique with quadrupled semitendinosus tendon and Endobutton and to evaluate its results. Twenty one patients were prospectively reviewed after ACL reconstruction with quadrupled semitendinosus tendon and Endobutton at one year post-operation. The surgery was performed in the series of graft tendon harvest, graft preparation, tunnel drilling and Endobutton fixation. The outcomes showed improved knee functions. Endobutton technique with quadrupled semitendinosus tendon is useful method for the arthroscopic ACL reconstruction. Stability and functional outcomes were similar to those with patellar tendon but it showed less donor site morbidity, less pitfall of fixation and simple procedure.

Tibial Tunnel enlargement Following Arthroscopic ACL Reconstruction / 대한정형외과학회잡지

The roentgenograms following arthroscopic ACL reconstruction show the enlargement of bone tunnels. Many authors hypothesized the cause of the tunnel enlargement, either mechanical or biological causes. The purpose of this study was to find the factors which affected the enlargement of the tibial tunnel following arthroscopic ACL reconstruction with bone-patellar tendon-bone or hamstring tendon. Sixty patients were reviewed retrospectively for radiographic measurement of tibial tunnel at post-operative one year (27 patients received bone-patellar tendon-bone autograft, 12 patients received bone-patellar tendon-bone autograft and Kennedy LAD-ligament augmentation device, 21 patients received Semitendinosus and Gracilis tendons with Endobutton). Roentgenographic anteroposterior and lateral films were checked and the tunnel was measured by two independent observers using a digital caliper. Statistical analysis was performed using a one-way analysis of variance (ANOVA) and t-test. The tibial tunnel enlargement was only related to the position of the fixation of the tibial tunnel. We concluded that tibial tunnel enlargement following arthroscopic ACL reconstruction is attributed to the mechanical effect rather than the properties of grafts and the clinical results.

Ossifications of the Ligamentum Flavum and the Posterior Longitudinal Ligament of the Lumbar Spine / 대한척추외과학회지

Ossifications of the ligamentum flavum(OLF) and the posterior longitudinal ligament(OPLL) are uncommon clinical entities as a cause of the progressive compression myelopathy or radiculopathy. Although there are considerable literatures concerning OPLL or OLF in cervical and thoracic spine, there are only a few references about OPLL or OLF in the lumbar spine. OLF and OPLL have been reported that they may lead to severe complication only with a minor trauma or even without trauma, such as paraplegia. The authors have experienced 2 cases of OLF accompanied by OPLL In the lumbar spine, who were treated with decompressive laminectomy and excision of ossified ligaments. For its rarity of OLF and OPLL in the lumbar region, we report here with review of literature.

Lumbar Disc Degeneration and Segmental Instability: A Comparison of Magnetic Resonance Images and Plain Radiographs / 대한척추외과학회지

SUMMARY OF LITERATURE REVIEW: Many authors haute described the association between lumbar disc degeneration and segmental instability but it has not been delineated in detail. OBJECTIVES: To compare the MRI assessment of disc degeneration with the conventional plain X-ray evaluation of the intervertebral disc, in order to study lumbar segmental instability. MATERIALS AND METHODS: In 75 patients with low back pain and/or sciatica, we analyzed disc space height, angular displacement, and horizontal displacement on plain radiographs of the lumbar spine. These parameters were compared with the grade of disc degeneration as evaluated by magnetic resonance Imaging. STUDY DESIGN: We analyzed the association between grade of disc degeneration as evaluated by magnetic resonance imaging assessment and segmental instability as evaluated by plain radiographs of the lumbar spine. RESULTS: Disc space height was decreased In proportion to the grade of disc degeneration. Angular displacement was increased according to the grade of disc degeneration, but significantly less with severe degeneration, accompanied by a tendency to stabilization of the motion segment. Horizontal displacement was not correlated with the grade of disc degeneration CONCLUSIONS: The incidence of lumbar segmental instability increased in proportion to the grade of disc degeneration but significantly decreased with severe disc degeneration.

Segmental Instability in Posterolateral Lumbar Spinal Fusion / 대한정형외과학회잡지

The spinal fusion is used for correcting malformations, stabilizing unstable segments, and suppressing the progression of disease, but it causes more load on the adjacent segment and as a result, the degenerative changes accelerate. Furthermore, the accelerated changes case spinal stenosis, degradation of nucleus pulposus, degenerative spondylolisthesis, acquired isthmus defect, and arthritis of articular facet, it rarely needs surgical treatment. The purpose of this study is to know the effect of the fusion level and range on the adjacent segment, to be a standard for determining the fusion range prior to operation, and to help to find the complication like degenerative changes by measuring the range of motion on the adjacent segment after the spinal fusion. Authors analyzed the result of 29 cases of posterolateral lumbar spinal fusion which were operated from February 1989 and January 1994. The intervertebral angle was measured on the flexion and extension lateral radiographs, and the calculated angular motion and sagittal plane rotation at follow-up periods were compared with those of preoperative values. The results were as follows; 1. Among the adjacent segm0ent, the increment of angular motion of superior adjacent segment was 2.6°(-5°~15°) which was higher than that of inferior one with 1.5°(-3°~7°) 2. The increment of angular motion of superior adjacent segment for 1 segment rather than 2 or 3 segments was more than two times with 3.9°(-2°~15°) 3. Regardless of level and range of fusion, the increment of angular motion was 3.0°(-2°~8°) on 4.5th lumbar segment which was increased mostly and 1.5°(-3°~7°) on 5th lumbar and 1st sacral segment which was increased leastly. 4. There were 3 cases showed instability at the superior adjacent segment and no cases showed instability at the inferior adjacent segment among all the cases showing stability prior to operations. In conclusion, the sagittal plane rotation was increased in adjacent segment after posterolateral spine fusion. So, we would recommend that the adjacent segment is very important to the decision of fusion extent and level.

Clinical study on treatment of spondylolisthesis / 대한정형외과학회잡지

No abstract available.

Piriformis syndrome: a case report

Piriformis syndrome, a term applied to an abnormal condition of the piriformis muscle, is characterized by symptoms and signs due to sciatic nerve entrapment at the greater sciatic notch. Recently we reviewed a case of unusual low back pain, radiating to the left lower extremity with tenderness particular in the left buttock. The patient was successfully treated by sectioning the piriformis tendon. We described the clinical features of a case of piriformis syndrome and reviewed the foreign literature.

The Treatment of Displaced Ankle Fractures with Early Joint Motion and Weight Bearing / 대한정형외과학회잡지

The ankle, which at times bears up to five times the body weight, is the most congruous joint of the lower extremity. Recently, importance of early joint motion and weight bearing after anatomical reduction & rigid internal fixation of the displaced ankle fracture was emphasized. Therefore, we studied prospectively, fifty-two patients with displaced ankle fractures admitted to the Department of Orthopedic Surgery, Severance hospital during a period of 4 years from January 1985 to December 1988. In fifty-two patients, group I (24 cases)were treated with early joint motion and weight bearing without cast immobilization and group II (28 cases) were treated with cast immobilization for long duration after open reduction and rigid internal fixation. The result of an average 15 months follow up of these patients were as follows. l. In displaced ankle fracture, early recovry of joint motion was obtained in early joint motion and weight bearing group after accurate anatomical reduction and rigid internal fixation. 2. In clincal evaluation, 95.8% resulted to satisfactory in group I, whereas 85.8% in group II. 3. In radiologic evaluation, 95.8% resulted to satisfactory in group I, whereas 82.1% in group II. 4. In lateral malleolar fracture, accurate reduction and fixation with plate and screws was important. 5. Syndesmotic ligament should be repaired and weight bearing was allowed without removal of transfixing screw. 6. Reduction of lateral malleolus made reduction and fixation of medial malleolus easy, and thus maintaining talar tilt angle. 7. Anatomical repair of deltoid ligament was needed for stability of ankle joint and prevention of local degenerative change.

Enchondroma of the Hand / 대한정형외과학회잡지

Chondroma is a benign tumor composed of mature hyaline cartilage. Most chondroms are centrally located in bone, and such tumors are called "enchondromas", and comprise 90% of the tumors arising in the skeleton of the hand. Twenty nine patients were admitted to the Department of Orthopedic Surgery, Yonsei University College of Medicine with enchondroma of the hand during a period of 10 years from January 1979 to December 1988. The analysis of results of these patients are as follows. l. Among 29 patients 10 were male, 19 patients were female. 2. The mean age was 26.3 years, range 3 to 61 years. 3. Enchondromal occured most frequently in patient between 10 and 30 years of age. 4. The proximal phalanx was the most commonly involved site by the middle phalanx and metacarpal 5. The ulna three fingers were more often afflicted than the radial two. 6. Among 29 patients, 7 were treated by excision, 18 by curettage and autobone graft, 4 pathologic fractures by curettage, autobone graft after open reduction and internal fixation with Kirschner wire. 7. There were no recurrence, except 1 suspicious recurrence for 8 month later.

Clinical Study on Free Tendon Graft and Staged Tendon Graft for the Flexor Tendon Injury in Zone II / 대한정형외과학회잡지

Nineteen patients with twenty six fingers were admitted to the Department of Orthopedic Surgery, Yonsei University College of Medicine with Zone II flexor tendon injury of the fingers during a period of 9 years from January 1980 to December 1988. 17 cases received free tendon graft and 9 cases received staged tendon graft. The result of long term follow-up of these patients are as follows. 1. The interval from tendon injury to tendon graft did not influence the operational result. 2. The main factor influencing operational result was flexion deformity whieh was in turn deeply related to preoperational passive range of motion. 3. Due to the relative anatomic simplicity, the thumb had better results after treatment than the other fingers. 4. Satisfactory results were obtained with free tendon graft in most of the Pre-operational Grade I group, good soft tissue without scarring or joint contracture, whereas in the Grade II group and above, complicated with scarring, joint damage or nerve injury, free tendon graft resulted only in 33 % success. 5. In Grade II group and above, free tendon graft resulted only in 33% success whereas 71% of staged tendon graft resulted in good or excellent results. This suggested that staged tendon graft had better operational results than free tendon graft in cases of severe tendon injury.