Comparison of Tissue Perfusion Measured by ST Segment Resolution between Thrombolysis and Primary Stenting in Acute ST Elevation Myocardial Infarction

BACKGROUND AND OBJECTIVES: The primary objective of reperfusion therapy in the acute ST elevation myocardial infarction (STEMI) is the recovery of myocardial perfusion in infarct tissue, as well as the restoration of epicardial blood flow. ST segment resolution on the ECG is an index, which represents adequate myocardial tissue perfusion following treatment. SUBJECTS AND METHODS: Patients with acute STEMI, arriving within 12 hours of the onset of symptom underwent either thrombolysis (n=40) or primary stenting (n=51) were used for this study. ST segments on the ECG were measured with hand-held electronic callipers and the results were analysed by a single observer. RESULTS: Thrombolysis therapy was started earlier than primary stenting, although this was not statistically significant (311+/-171 minutes vs 399+/-251 minutes, p=0.61). After treatment, thrombolysis achieved a higher rate of complete ST segment resolution (>or=70%) compared to primary stenting (20/40;50.0% vs 13/51;25.4%, p=0.016). However, when the data was corrected for time, the difference between the two modalities was not significant (p=0.119). ST segment resolution varied significantly (p=0.026) according to treatment time, regardless of treatment modality. At the 6 month follow up, patients with complete ST segment resolution had a lower rate of major cardiac event (2.1% vs 13.8% p=0.094). CONCLUSION: In this study, thrombolysis achieved a higher rate of complete ST resolution compared with primary stenting in acute STEMI. By ad hoc analysis, this result was attributed to the difference in treatment time between the two groups, suggesting successful tissue reperfusion in acute STEMI is determined primarily by the rapidity, rather than the type, of treatment.

Plasma Homocysteine Concentration and Genotype Variation of Enzymes as Risk Factors in Patients with Coronary Artery Disease

BACKGROUND AND OBJECTIVES: Increased plasma homocysteine(tHcy) has been implicated as an independent risk factor for coronary artery diseas(CAD), but the relationship has not been firmly established. Present study aimed to determine the difference of plasma homocysteine between patients with CAD and normal control, and to identify the relation between plasma homocysteine and genotype variation of its metabolic enzymes, and serological characteristics. METHODS: Plasma homocysteine, fasting and post-methionin loading, folate and vitamin B12 were measured among 149 patients and 80 control subjects. Both group consisted of those younger than 65 years. Frequencies of prevalent mutations of enzymes involved in homocysteine metabolism, cytosine to thymidine transition (C(677)T) of methylentetrahydrofolate reductase (MTHFR) was determined by polymerase chain reaction (PCR) in 85 patients and 47 control. RESULT: There was no significant difference in homocysteine level between patients and control group (fasting tHcy; 10.4 +/- 3.6 vs 11.4 +/- 8.4 ng/ml, post-methionine loading tHcy; 18.8 +/- 4.9 vs 17.2 +/- 9.5 ng/ml, p> 0.05 respectively). Genotype frequency of MTHFR C(677)T was similar between two groups. Plasma homocysteine level did not appear to vary with genotypes of MTHFR both in patients and control subjects. Multiple linear regression analysis identified smoking as the most significant factor affecting plasma homocysteine level, followed by age, MTHFR genotype, obesity, and folate level. CONCLUSION: Homocysteine concentration was not different between controls and patients with CAD. Significant variation of homocysteine level according to genetypic polymorphism of metabolism enzymes was not observed. On multiple linear regression, several factors were identified to be related to homocysteine level, including MTHFR genotype. Further study is warranted to clarify the significance of homocysteine in the development of CAD.

Anomalous Origin of the Left Main Coronary Artery from the Right Sinus of Valsalva

We present a case, previously not reported, of anomalous origin of the left main trunk from the right aortic sinus with anterior course, in which anomalous left main trunk bifurcated and traversed anterior to the pulmonary artery. Moreover, ostial spasm was combined and resulted in hemodynamic instability in the presence of infarcted right coronary artery.

Coronary Angiographic Features and Clinical Significance of Inferior ST segment Elevation during Acute Anterior Myocardial Infarction

BACKGROUND AND OBJECTIVES: Inferior ST elevation during anterior acute myocardial infarction(AMI) was not widely investigated. We investigated the frequency, causes, angiographic and clinical significance of simultaneous precordial and inferior ST elevation. MATERIALS AND METHOD: We compared clinical, electrocardiographic and angiographic features of 49 patients with anterior AMI according to the presence(group A) or absence(group B) of inferior ST elevation. Results : 1) ST segment elevation in inferior leads was found in 19(21%) of 89 patients with anterior AMI. The sum of ST elevation in precordial leads and lateral limb leads was smaller in group A than in group B(174 vs 248 mV, 01 vs 57 mV, respectively). 2) Wrapped left anterior descending artery(LAD)(94% vs 26%), 2-vessel disease(50% vs 19%), and collaterals to inferior wall(17% vs 0%) were more common in group A than in group B. Occlusion of middle or distal LAD(83% vs 58%) and patent diagonal or septal branches proximal to occlusion site(21 vs 10) were also more common in group A than in group B. 3) By left ventriculogram, anterolateral involvement was lower(38% vs 82%) and diaphragmatic involvement higher(56% vs 11%) in group A than in group B. 4) The two groups did not differ regarding cardiac enzymes and left ventricular ejection fraction. CONCLUSION: Inferior ST elevation during anterior AMI results from a smaller mass of ischemic anterolateral myocardium combined with simultaneous inferior wall ischemia (i.e., a middle or distal occlusion of wrapped LAD) or multivessel disease. In patients with occlusion of wrapped LAD, deterioration of ventricular function is not worse than in anterior AMI without inferior ST elevation.

Congenital Absence of Left Circumflex Coronary Artery: Circumflex Artery Extended from Right Coronary Artery

Nonvisualization of left circumflex coronary artery from the left coronary artery is commonly due to anomalous origin of circumflex artery from the right coronary artery or right sinus of Valsalva. However, complete ostial obstruction of circumflex artery, circumflex artery extended from the right coronary artery, anomalous origin of circumflex artery from the pulmonary artery may be the cause. We report two cases of absent left circumflex artery from the left coronary artery, in which the circumflex artery arose as a terminal extension of the right coronary artery. Angiographic features of absent left circumflex artery from the left coronary artery were described.

The Feasibility and Safety of Transradial Coronary Stenting Using 6 French Guiding Catheter / 대한내과학회지

OBJECTIVES: Powerful anticoagulant and antiplatelet therapies after coronary stenting may carry the risk of increased bleeding complications if large-bore guiding catheters are introduced via the femoral artery. Recently smaller radial artery is introduced as an entry site for coronary interventions owing to miniaturization of equipments, easy hemostasis and lower access site complications, and little hand ischemia. The purpose of this study is to evaluate the feasibility and safety of coronary stent implantation via the radial artery. METHODS: After a learning curve for transradial diagnostic coronary angiography, stent implantation was attempted in 131 consecutive patients, 135 lesions. Immediately after procedure, the introducer sheath was withdrawn and mobilization was initiated. Clinical follow-up was done for punctured radial arteries. RESULTS: Procedural success and uncomplicated clinical course was achieved in 129(98%) patients, 133(99%) lesions. No stent embolization or migration within the coronary artery, and no procedure-related death, Q wave myocardial infarction or emergent bypass surgery were happened. No stroke or severe arm vessel complications were happened except 4(3%) cases of moderate hematoma. Failed 2 cases were in early period and stents did not pass the lesions due to inappropriate selection and poor backup of guiding catheters. During follow-up of 124+/-36 days, punctured radial arteries showed weak or absent radial pulse in 10(7%) patients, but no claudication or ischemia of hand was observed. CONCLUSION: Transradial coronary stenting was performed safely with high success rate and low complication rate. This study supports that transradial approach is a promising primary route for coronary stenting.

Transradial Stenting of an Anomalous Right Coronary Artery Originating from the Left Sinus of Valsalva

Anomalous right coronary artery arising from the left sinus of Valsalva is rare, but not protected from ather-osclerotic disease. Major factor determining successful angioplasty is the selection of the appropriate guiding catheter to provide optimal coaxial backup support. We report the first case of successful transradial stenting of an anomalous right coronary artery originating from the left sinus of Valsalva.

Anomalous Origin of the Left Circumflex Coronary Artery: A Report of 2 Cases and Echocardiographic Features

Anomalous origin of the left circumflex coronary artery(LCx) from the right sinus of Valsalva is the most common coronary anomaly and, generally, is considered to be benign. Nevertheless, myocardial infarction or sudden death in young patients with this coronary anomaly has infrequently been described. The LCx arises from the right sinus of Valsalva or proximal right coronary artery, courses posterior to the aorta to enter the left atrioventricular groove, and provide branches to the left lateral wall of heart. Transthoracic or transesophageal echocardiography may provide a useful diagnostic clue although coronary angiography is the standard diagnostic method. We report 2 cases of anomalous origin of the LCx from right aortic sinus with typical echocardiographic images.

Radiologic study of abduction-posterior tilt type in supracondylar fracture / 대한정형외과학회잡지

No abstract available.

Anteromedially Displaced Supracondylar Fracture of the Humerus in Children / 대한정형외과학회잡지

1. Fifteen cases of anteromedial supracondylar fracture of the humerus in children were treated during a 15-year-period since 1975. 2. The anteromedial fracture were classified into flexion-varus and adduction-antilt type and subdivided into angulation and shear fracture. 3. The characteristic roentgenographic manifestations of the anteromedial fracture are: 1) Flexion varus fracture:Segmental fracture of the wall of the olecranon and coronoid fossa with fracture of the anterior and posterior cortex of metaphysis on lateral view. 2) Adduction-antilt fracture:The longitudinally split fracture of the anterior and posterior cortex of the metaphysis and tension fracture on the posterior fragment with medial impaction of the distal fragment. 4. Adduction-antilt fracture should be treated by manipulative reduction and fixation in plaster in abduction of the elbow. The full extension is necessary to fix the elbow which can afford to abduct the forearm securely to definite direction. 5. Anteromedially displaced fracture can be fixed by two percutaneous K wire pinning. On the lateral side, the pin is directed upward and medially at an angle of 45 degrees to the fracture line and intramedullary vertical to the coronal plane of the humerus. On the medial side the pin is directed upward along the axis of the medial column and inserted into medullary canal (vertical pin). On the lateral projection, the pin is introduced through the distal fragment and the anterior distal end of the proximal fragment, contact point between fragments to penetrate the opposite cortex. The pin is securely fixed at the two point-opposite cortex and anterior distal end of the proximal fragment.

Supracondylar Fracture of Humerus in Children : Radiologic Study of Flexion / 대한정형외과학회잡지

1. The author found that the characteristic radiologic finding of the flexion-valgus type of supracondylar fracture of humerus in children is Y shape bifurcation of the distal end of proximal fragment on lateral view. 2. Thirteen cases were identified as the flexion-valgus type from among the 224 cases of supracondylar fracture. 3. Thirteen cases of flexion valgus type were classified into five types. 1) Dome shape fracture, along the upper border of the olecranon fossa-5 cases. 2) Transverse fracture, proximal to the olecranon fossa-2 cases. 3) Oblique fracture, through the posterior wall of supraconlylar-2 cases. 4) Oblique fracture, through the distal end of lateral column-3 cases. 5) Oblique frarture with partial injury of epiphyseal line of lateral condyle-1 case.

Radiologic Study of Torsion Type of Supracondylar Fracture of Humerus in Children / 대한정형외과학회잡지

1. The author found that the periosteal callus was formed on lateral side of the fracture in two cases of three posteromedially displaced supracondylar fracture of the humerus associated with fracture of distal end of ipsilateral forearm which were considered as the torsion fracture. 2. The above result was peculiar out come of the torsion fracture. 3. The characteristic radiologic findings of the torsion fracture are. 1) The fracture line of the proximal fragment is transverse and irregular(bursting). 2) Multiple longitudinal splitting and waving on entire fracture line of distal fragment. 4. Twenty eight cases of 236 cases of extension varus fracture supracondylar fracture of humerus were identified with torsion fracture. 5. The torsion fracture was combined with hyperextension fracture in 3 cases, extension-adduction fracture in 6 cases, shearing fracture by direct blow on anterior aspect of flexed elbow in 12 cases, and shearing fracture by backward thrust of forearm in 4 cases.

Interlocking Intramedullary Nailing Versus conventional Kuntscher Intramedullary Nailing for Fracture of the Femoral Shaft / 대한정형외과학회잡지

We studied 75 cases of conventional Kuntscher intramedullary nailing and 52 cases of interlocking intramedullary nailing from July 1980 to October 1988 for femur shaft fractures. The conventional Kuntscher intramedullary nailing was used for fresh fracture and the interlocking intramedullary nailing was used not only fresh fracture, but also unstable fracture, nonunion and pathologic fracture. The conventional Kuntscher intramedullary nailing was frequently used in middle one-third level, but the interlocking intramedullary nailing could be applied widely from subtrochanteric area to supracondylar level in femur. The average operation time in patient who had no associated injury was 3.6 hours in conventional Kuntscher intramedullary nailing and 3.25 hours in interlocking intramedullary nailing. Time period for union was much less in interlocking intramedullary nailing than conventional Kuntscher intramedullary nailing. Some kinds of immobilization was needed shortly in conventional Kuntscher intramedullary nailing but immediate postoperative ambulation was possible in interlocking intramedullary nailing. Interlocking intramedullary nailing can prevent the angulation, shortening and trochanteric bursitis due to migration of the intramedullary nail.

The Interlocking Kuntscher IM Nailing for Femur Shaft Fracture / 대한정형외과학회잡지

The intramedullary nailing is a good method of treatment in femur shaft fracture but it is not available in some fracture pattern or fracture level. And it is very difficult with conventional Kiintscher nailing to prevent torsional stress and fix rigidly in unstable fracture of the femur shaft. The unstable fracture by comminuted fracture or segmental fracture, nonunion and pathologic fracture needed the rigid fixation. Interlocking Kuntscher IM nailing can provide antitorsional stability, good axial alignment and prevent shortening of the fracture site, also allow early ambulation and joint exercise. We analysed 51 patients 52 cases of interlocking Kiintscher IM nailing from May 1981 to March 1988. The interlocking Kuntscher IM nailing prevents the rotational and axial roading. The interocking Kuntscher IM nailing has expanded its application in fracture pattern and fracture site. The interlocking IM nailing provides rigid fixation in severe comminuted fracture. segmental fracture, long spiral fracture, and other several unstable fractures and eliminates splinting or external supports, so it is possible doing early joint exercise. The interlocking Kuntscher IM nailing was also considered best internal fixation method in pathologic fracture or sever osteoporosis. The static interlocking for rigid fixation and the dynamic interlocking method for axial compression to fracture site during weight bearing can be adapted appropriately to fracture pattern. Radiation hazard during the interlocking nailing is not considerable.

Surgical Treatment of the Trochanteric Fracture of the Femur / 대한정형외과학회잡지

The authors have treated 30 cases of trochanteric fracture of the femur from June 1987, to July 1988 at Dong Suwon General Hospital. The 30 cases included, 8 Condylocephalic Kuentscher nailing, 9 Ender nailing, 7 Multiple pinning, 5 Antegrade Kuentscher nailing and 1 Row plating. 1. The shape of condylocephalic Kuentscher nail should be designed differently, contoured circular arc in anteroposterior and angled in lateral plane. In the anteroposterior plane : The length of the radius of the arc is measured by following way. 1) Design the shape of the nail on the X-ray film of the normal femur which was taken in full internal rotation of the leg. 2) Make three points in the femoral film. One is A, midcentral point of the femoral canal of the isthmus. Point B is center of upper lateral quadrant of the femoral head. Point C is apart from medial cortex 5-7mm at the level of entry portal of the nail. 3) Make point D: Draw the perpendicular lines from the right middle of the AB and AC. These lines meet at the point D. AD is radius of the arc of nail. Draw an arc measuring by the length of AD and mold the nail following the arc. In the lsteral plane ; The nail is bent into three or four segments and the length of the longest segment should not be exceeded the permissible length of straight nail, the latter is distance from entry portal of the nail to anterior cortex of the femur where the tip of the inserted nail is impinged, about 15cm. 2. Two different types of the Ender nailings are used depend on the type of the fracture. In intertrochanteric fracture, the trochanter is remained in the distal fragment and acts as the crane post to fix the proximal fragment(interfragmental compression screw fixation) by horizontal screw inserted through the lateral cortex of the distal fragment into medial cortex of the proximal fragment and fixed with another screw inserted into the distal fragment by tension band wiring. In transtrochanteric frscture, the proximal fragment is fixed by two different kinds of the nails, prior to the nailing medial displacement of the distal fragment is not reduced. The first nail is driven along the medial wall of the medullary canal of the distal fragment, the tip of the nail comes out of the fracture site and impinges to the inferomedeial aspect of the head along the out side of the neck. The nail is inserted into the head after correction of nail direction. The second and third nails are inserted through the medullary canal of the fragments. The proximal fragment is fixed between two nail groups. 3. Antegrade Kuentscher nailing is used for undisplaced trochanteric fracture with segmental fracture or comminuted, segmental subtrochanteric fracture. The open reduction and fixation is preferable in comminuted segmental subtrochanteric fracture for its accurate reduction. The authors msde additional several holes, transverse, sagittal (at the dorsum of the nail) oblique holes around the nail, so the interlocking screw can be easily inserted to the nail when the insertion of the screw through the transverse holes are difficult. 4. It's extremely important to study the fracture carefully when the surgeon plans to use the multiple pinning for trochanteric fracture. The fracture configuration has to be determined in regard to expect stability after local pinning especially in lateral plane. The fracture is fixed by horizontal pin, low angle pin, curved buttress pin(or screw) solidly, not parallel as in neck fracture. The curved buttress rush pin should be inserted as acting as the anteromedial or posteromedial buttress.

A Clinical Study of the Operative Treatment for the Spondylolisthesis / 대한정형외과학회잡지

We reviewed 35 patients who received an operation for the Spondylolisthesis from July 1980 to July 1985. The follow-up period between operation and evaluation was at least 14 months and average 32 months. we obtained the following results. 1. The age distribution was from 23 years of age to 70 years of age and the prevalent decade was at the 5th. 2. Sex difference showed male 9 cases and female 26 cases, that is, female preponderance about 3 times. 3. 24 cases were isthmic type and 11 cases were degenerative type. The ratio between isthmic type and degenerative type was about 2: l. 4. Isthmic type was found at the 4th and 5th decades frequently and degenerative type was at 5th and 6th decade frequently. 5. The displacement between L4 and L5 was 21 cases and the displacement between L5 and sacrum was 14 cases. 6. In isthmic type, the displacement between L4 and L5 was 11 cases and the displacement between L5 and sacrum was 13 cases. In degenerative type, the displacement between L4 and L5 was 10 cases and the displacement between L5 and sacrum was 1 case. So the isthmic defect occurred at 2 levels almost equally and degonerative type occurred at L4-5 predominantly. 7. Overall results are excellent 2 cases(6%), good 29 cases(82%), fair 2 cases(6%), and poor 2 cases (6%).

Supracondylar Fractures of the Femur Treated by Interlocking Nailing / 대한정형외과학회잡지

Between Jan. 1976 and May 1987, Sixteen supracondylar fractures of the femur were treated by interlocking nailing. Of the 16 cases, 7 cases were intercondylar, 12 cases were segmental fractures of the femur, 4 cases were open fractures in the type of wound. 1. The simple supracondylar fracture involving the distal 9cm of the femur can be treated by interlocking nailing which makes firm fixation and allows early ambulation. 2. If the supracondylar fracture is accompanied with intercondylar fracture, careful reduction and transcondylar fixation by means of tibial bolt or cancellous screws are essential before the insertion of the nail. 3. The shape of the bent nail must be depended on the type of the fracture. If the nail is to be inserted into the anterolateral aspect of the distal fragment, the degree of bending of the nail is 400cm, and posteromedial is 110cm in radius. 4. The authors made several sagittal holes the at dorsum of the nail. So the screw can be easily inserted to the nail perpendicularly or obliquely, when the insertion of the screw through the transverse holes is difficult. 5. Of the 15 cases treated by interlocking nailing, 5 cases were excellent, 4 cases were good, 2 cases were fair, 4 cases were failure by schatzker assessment.

Supracondylar Fracture of the Humerus in Children: Part I : Extension / 대한정형외과학회잡지

The authors made an attempt to classify the supracondylar extension-valgus fracture according to the direction and location of the fracture line based on the radiographic manifestation. This new classification helps to dictate the model of treatment, possible sequence of reduction and the causes of deformity of the elbow after treatment. During the last 12 years of this study, 200 supracondylar fractures of the humerus were treated in the Kyung Hee University Hospital. Of the cases 82 were extension-valgus fractures. The results were as follows: 1. The supracondylar extension-valgus fracture were classified into 5 types: Type I: fish-tail fracture (14 cases) Type II : obtuse fish-tail fracture (27 cases) Type III: oblique fracture (16 cases) Type IV: oblique fracture with comminution of lateral column (14 cases) Type V: Transverse fracture (11 cases) 2. The displacement of the distal fragment in the fish-tail fracture is severe but it can be reduced easily by manipulation. Once reduction has been obtained, the fracture is stable and maintained by a long arm cast with acute flexion of the elbow alone. There is no need of percutaneous pinning. Among 14 cases of type I fracture there was no cubitus varus deformity. 3. The line of the obtuse fish-tail fracture lies distal to fish-tail fracture. This is unstable so it is necessary to percutaneous pinning. 4. The oblique fracture is produced by the hyperextension of the elbow and degrees of the obliquity of the fracture line were 12 to 20 degrees (Av. 14 degrees). The valgus angles in opposit elbows were 9 to 25 degrees (Av. 16 degrees). The forearm must be pulled into valgus position during the reduction of the fracture. 5. Type IV fracture occures under 4 years old, and more commonly in girls. This is unstable, so it is necessary to percutaneous pinning.

Arthroscopic Adhesiolysis of Knee Ankylosis / 대한정형외과학회잡지

Severe limitation of knee motion is a complication of operative procedures or trauma about the knee. Physical therapy and occasionally manipulation of knee with anesthesia may improve results when performed soon after the onset of motion limitation. When performed later, these have been proven less useful. This is a review of 15 patients who had severe limitation of knee motion following open operative procedures or trauma about knee and were treated by percutaneous release of adhesions under arthroscopic control. There were eleven males and four females, ranging in age from 23-67years(mean 38 years). The interval between the last open operative procedure or trauma and arthroscopic adhesiolysis ranged from three and half months to four years(mean 11.5 months). The interval between arthroscopic adhesiolysis and final follow-up evaluation ranged from 6 months to 3 years(mean 1.5 years). Average preoperative knee motion was 38.2 degrees. After arthroscopic adhesiolysis, maximum knee motion under anesthesia was 120.3 degrees and average final motion at follow-up was 101.2 degrees. The results of treatment of treatment of Tbc knee sequalae with secondary osteoarthritis and pyogenic arthritis were less favorable for motion improvement. Arthroscopic adhesiolysis seems to be a useful method of treatment in knee ankylosis. Morbidity was low, complications were few and the duration of hospital stay was short.

The Shape of Küntscher nail for Treatment of Tibial Shaft Fractures / 대한정형외과학회잡지

We have experienced 40 cases of the tibial shaft fractures treated with Küntscher nail from 1979 to 1986. Authors analysed these cases and our own experimental study concerned with the shape of Küntscher nail. The shape of Küntscher nail for the tibial shaft fractures should be designed according to the type and location of the fracture. The proximally bent and distally straight nail is used for the extension fracture, proximally and distally bent nail or entirely bent nail is inserted for the flexion fracture of the tibia. The large nail(over 13 mm in diameter) may produce injury to the patella because it has minimal flexibility. In order to permit easy driven down of nail and prevent this injury, the nail should b. bent into three to four segments and the length of the longest segment should not exceed the permissible length of straight nail (Permissible length is distance from entrance of nail to posterior cortex of the upper fragment, where tip of the (nail impinged-about 12cm) The midpoint of the middle segment of dual dent nail is placed at the fracture site. The middle segment of the nail may bent anteriorly for flexion fracture and posteriorly for extension fracture, securing the dynamic fixation of the fracture.