Results of Surgical Treatment for Congenital Vertical Talus / 대한정형외과학회잡지

PURPOSE: We performed clinical and radiological evaluation of surgical outcomes of congenital vertical talus. MATERIALS AND METHODS: Fifteen surgically treated feet in 9 patients (6 bilateral and 3 unilateral) which were followed-up for at least 2 years were included. Mean patient age at the time of surgery was 10.9 months. The surgical technique was a one-stage correction using the Kumar technique with a Cincinnati skin incision. In 7 feet we also transferred half of the tibialis anterior to the talar neck (the Grice technique). Radiologic parameters (talo-calcaneal angle, talo-first metatarsal angle, tibio-talar angle, tibio-calcaneal angle) were analyzed pre- and postoperatively and at the last follow-up, and clinical outcomes by the Laaveg-Ponseti score. RESULTS: Talus orientation was improved in all patients. All radiologic parameters showed statistically significant improvement by the last follow-up. The mean Laaveg-Ponseti score at the last follow-up was 16 for patient satisfaction, 16 for function, and 24 for pain. There was no recurrence, however one case of talar neck fracture occurred during the tibialis anterior transfer. CONCLUSION: One-stage surgical correction for congenital vertical talus at an early age provides satisfactory functional and cosmetic results.

Infiltrating Epidural Angiolipoma Involving Lumbar Spine / 대한정형외과학회잡지

We report on an unusual case with infiltrating extradural spinal angiolipoma. Most spinal angiolipomas involve the thoracic spine and infiltrating ones are also located mainly at the thoracic levels rather than lumbar lesion. In particular, there are few cases of lumbar extradural infiltrating type spinal angiolipoma. One case is that of a 52-year-old female with infiltrating extradural spinal angiolipoma involving lumbar 4 (L4) vertebra, who underwent a L4-5 laminectomy and surgical removal of the tumor. We achieved satisfactory results with surgical treatment of the patient. Spinal angiolipoma has a benign course with a good postoperative outcome.

Results of Treatment for Medial Condyle Fracture of the Distal Humerus in Children

PURPOSE: We evaluated outcomes of treatment in medial condyle fracture of the distal humerus in children. MATERIALS AND METHODS: Seven patients (4 females, 3 males) who were treated at the Pusan National University Hospital and followed-up until skeletal maturity after treatment were included. The average age at the time of fracture was 4.6 years (range, 2 to 10 years). Treatment was performed from 1 day to 6 months after the fracture: 4 patients underwent a surgical treatment for 17 days, 2 months, 2 months and 6 months after fracture, respectively. All fractures were Milch type 1. Five patients had Kilfoyle type 3, and two patients had type 2 fractures. Final outcomes were evaluated by the Mayo elbow performance score and carrying angle. RESULTS: There were 3 excellent, 3 good and 1 fair result at the final follow-up. There was no elbow pain in any of the patients. One of the four patients who underwent a late surgical treatment received corrective osteotomy due to cubitus varus. All four patients had a limitation of elbow motion. The other three patients who had accurate diagnosis and treatment had a full range of motion. CONCLUSION: Diagnosis of medial condyle fracture of the distal humerus based on plain radiograph is difficult in children due to its cartilaginous structures. When a patient shows pain, tenderness and swelling on the medial side of the elbow, an additional examination with magnetic resonance imaging may be required even if no fracture line is found in the radiograph. Accurate diagnosis and early treatment is important for good results.

Efficacy of Short-Term versus Long-Term Post-Operative Antimicrobial Prophylaxis for Preventing Surgical Site Infection after Clean Neurosurgical Operations / 대한신경손상학회지

OBJECTIVE: Surgical site infection (SSI) is a problem constantly uppermost in the minds of all surgeons, although the actual rate of occurrence is only 1-5% in general surgery. In neurosurgical fields, there have been a few papers published about efficacy of post-operative antimicrobial prophylaxis (PAMP) to prevent SSI, compared to well known effectiveness of pre-operative antibiotics. Thus, infection rates of short-term PAMP groups and those of long-term PAMP groups were investigated to evaluate the effectiveness of PAMP and the efficacy of short-term PAMP compared to long-term PAMP for prevention of SSI. METHODS: Between April 2010 and April 2012, we retrospectively analyzed the data of 35 patients in the aneurysmal neck clipping groups (short-term PAMP group: PAMP for 3 days and fewer, long-term PAMP group: PAMP for 10 days and more) and 79 patients in the microdiscectomy groups (short-term PAMP group: 3 days and fewer, long-term PAMP group: PAMP for 6 days and more). RESULTS: In aneurysmal neck clipping groups, SSI occurred 23.1% of short-term PAMP group and 9.1% of long-term PAMP group (p=0.3370). And in microdiscectomy groups, SSI occurred 6.7% of short-term PAMP group and 4.1% of long-term PAMP group (p=0.9840). CONCLUSION: There is no significant difference between the short-term PAMP group and the long-term PAMP group in terms of SSI, regardless of operation type. We therefore suggest that short-term PAMP usage could be an appropriate therapy for preventing SSI in clean neurosurgical operations.

The Effect of Microvascular Decompression for Hemifacial Spasm Caused by Vertebrobasilar Dolichoectasia

OBJECTIVE: Hemifacial spasm (HFS) caused by vertebrobasilar dolichoectasia (VBD) is very rare, and in theses cases, it is difficult to decompress the nerve from its vascular compression. The objective of this study was to investigate the outcome of microvascular decompression (MVD) for HFS caused by VBD. METHODS: There were 10 patients of HFS caused by VBD at our hospital between September 1978 and September 2008. We evaluated magnetic resonance angiography (MRA) and time of flight magnetic resonance imaginge (TOF MRI) findings using the criteria for VBD. We compared the clinical outcomes of MVD for the 10 patients with VBD with the overall outcomes of the total 2058 MVDs performed for HFS. RESULTS: The results of MVD for HFS caused by VBD were successful in 90.9% of cases. The postoperative complication rate in VBD was 45.5%. Offending vessels in patients with VBD were identified visually during surgery. Adverse effects after MVD were found in 4 patients. We found that the diameter of VBD was significantly greater in patients with complications than in those with no complications (p=0.028). CONCLUSION: Our data shows that MVD may be a good treatment modality for HFS caused by VBD but care must be taken to avoid adverse effects from the procedure. It is important to detach the dolichoectatic artery from its surrounding structures sufficiently to allow it to be easily movable. In addition, attempts should be made to lessen the retraction of the cerebellum during release of the dolichoectatic artery.

New Bone Formation Following Transplantation of Stem Cells and Nanoscale Hydroxyapatite Scaffold Materials into Rabbit Long Bone Defects / 대한정형외과학회잡지

PURPOSE: We observed new bone formation following the transplantation of allogenic periosteum-derived stem cells and different sizes of hydroxyapatite (HA) scaffold materials into rabbit long-bone defects. MATERIALS AND METHODS: Thirty-two white rabbits were grouped according to the material transplanted into their tibial bone defects: group 1 (microscale HA only); group 2 (nanoscale HA only); group 3 (microscale HA plus stem cells); and group 4 (nanoscale HA plus stem cells). Viscosity was controlled by the relative amounts of HA and agar. After surgery, radiologic, microscopic, and biochemical observations were performed weekly for 8 weeks. RESULTS: Nanoscale HA (groups 2 and 4) provided better bone formation than microscale HA (groups 1 and 3). The rabbits that had been transplanted with nanoscale HA plus stem cells (group 4) had more homogeneous bone formation during the natural repair process than the other groups. CONCLUSION: Further study is required using nanoscale HA plus organic substance and stem cells, which are more similar to human bone structure, for better bone formation.

Mediastinoscopic Bilateral Bronchial Release for Long Segmental Resection and Anastomosis of the Trachea

The extent of resection and release of the trachea is important for successful anastomosis. Bilateral bronchial dissection is one of the release techniques for resection of the lower trachea. We present the experience of cervical video-assisted mediastinoscopic bilateral bronchial release for long segmental resection and anastomosis of the lower trachea.

Efficacy of Low Dose Barbiturate Coma Therapy for the Patients with Intractable Intracranial Hypertension Using the Bispectral(TM) Index Monitoring

OBJECTIVE: Barbiturate coma therapy (BCT) is a useful method to control increased intracranial pressure (IICP) patients. However, the complications such as hypotension and hypokalemia have caused conditions that stopped BCT early. The complications of low dose BCT with Bispectral(TM) index (BIS) monitoring and those of high dose BCT without BIS monitoring have been compared to evaluate the efficacy of low dose BCT with BIS monitoring. METHODS: We analyzed 39 patients with high dose BCT group (21 patients) and low dose BCT group (18 patients). Because BIS value of 40-60 is general anesthesia score, we have adjusted the target dose of thiopental to maintain the BIS score of 40-60. Therefore, dose of thiopental was kept 1.3 to 2.6 mg/kg/hour during low dose BCT. However, high dose BCT consisted of 5 mg/kg/hour without BIS monitoing. RESULTS: The protocol of BCT was successful in 72.2% and 38.1% of low dose and high dose BCT groups, respectively. The complications such as QT prolongation, hypotension and cardiac arrest have caused conditions that stopped BCT early. Hypokalemia showed the highest incidence rate in complications of both BCT. The descent in potassium level were 0.63 +/- 0.26 in low dose group, and 1.31 +/- 0.48 in high dose group. The treatment durations were 4.89 +/- 1.68 days and 3.38 +/- 1.24 days in low dose BCT and high dose BCT, respectively. CONCLUSION: It was proved that low dose BCT showed less severe complications than high dose BCT. Low dose BCT with BIS monitoring provided enough duration of BCT possible to control ICP.

Effectiveness of Multiple Burrhole Operation in Adult Moyamoya Disease / 대한뇌혈관외과학회지

OBJECTIVE: Most of the studies that have described surgical procedures for moyamoya disease(MMD) have had the aim to improve the blood flow mainly in the middle cerebral artery(MCA) territory. The purpose of this study is to clarify the good indications for a multiple burrhole operation to treat MMD. METHODS: With the patient under local anesthesia, burrhole trephination with a diameter of 1.5 to 2cm at 3 to 5cm lateral to the midline was performed in a total of 18 hemispheres during 12 procedures. The burrholes were opened in the frontal lobe at 19 sites in 10 patients and in the parietal lobe at 22 sites in 12 patients. Revascularization through multiple burrholes and arachnoid openings was performed in 12 patients who suffered from MMD. RESULTS: As seen on the follow up angiograms, good revascularization was achieved in 27 of 41 burrholes, and mainly from the middle meningeal artery and then from the superficial temporal artery. The moyamoya vessels were decreased in four patients. The neovascularization covered 68.4% of the frontal lobe and 63.5% of the parietal lobe. Compared with the preoperative 99mTc-HMPAO-SPECT, 6 patients showed improvement of cerebral blood flow on the postoperative 99mTc-HMPAO-SPECT. Transient ischemic attack disappeared in three of the four patients who presented with this symptom, and the preoperative symptoms improved in both of the patients who presented with headache and cerebral infarction. CONCLUSIONS: A multiple burrhole operation is a simple technique. The results of our series suggest that the revascularization obtained for adult MMD patients who underwent a multiple burrhole operation is similar to that obtained with other indirect surgeries, but long term follow up studies are needed.

Surgical Treatment of Partial Closure of Growth Plate: Physeal Bar Resection and Free Fat Graft / 대한정형외과학회잡지

PURPOSE: To evaluate the results of physeal bar resection and free fat graft as a treatment method for partial epiphyseal closure. MATERIALS AND METHODS: Thirteen cases of partial epiphyseal closure (4 of the distal femur, 8 of the distal tibia and one of the distal radius) were subjected to physeal bar resection. All of the cases were caused by trauma. The physeal bar was central in 3 cases, peripheral in 9, and mixed (central-peripheral) in 1. Mean patient age at surgery was 10.7 years and mean follow-up period was 47 months. Final results were evaluated by a modified Williamson-Staheli classification. RESULTS: Results at final follow-up were as follows: 6 satisfactory (3 excellent and 3 good) and 7 unsatisfactory (5 fair and 2 poor). Satisfactory results according to location and region of the physeal bar were as follows: distal tibia, 5 of 8 cases; distal femur, 1 of 4; central, 1 of 3; peripheral, 4 of 9; and mixed, 1 of 1. When considered by areal extent, physeal bars occupying 30% or less of the bone's cross-sectional area showed satisfactory results in 5 of 7 cases, while in 6 cases with the physeal bar over 30%, 5 were unsatisfactory. CONCLUSION: Accurate preoperative evaluation of the size and type of the physeal bar, and meticulous surgical technique, are important predictors of satisfactory outcome of physeal bar resection. Cases where the physeal bar extent exceeded 30% had mostly unsatisfactory results.

Practical role of TCD and 3D-CTA in planning the angioplasty for the treatment of DIND after aneurismal subarachnoid hemorrhage / 대한뇌혈관외과학회지

OBJECTIVE: We evaluated the relationship between transcranial Doppler sonography (TCD) and three-dimensional computerized tomography angiography (3D-CTA) under delayed ischemic neurologic deficit (DIND) with angioplasty following vasospasm. MATERIALS & METHODS: Twenty consecutive patients with DIND following vasospasm who received sequential TCD and CTA were analyzed. On TCD, vasospasm was defined as anterior circulation peak mean velocity>120 cm/s, daily increases of 50cm/s, and a Lindegaard ratio (LR)degrees root 3. On 3D-CTA data were subdivided into local and combined types according to the position where vasospasm occurred, and into mild, moderate, and severe by the blood vessel diameter. RESULTS: Among the 20 consecutive patients with DIND, 13 of them received angioplasty. On TCD, the angioplasty group had more frequent vasospasm and tended to have an LR higher than 3. The mean blood flow velocity of MCA in the angioplasty group was 40 cm/sec higher than the group without angioplasty. On CTA, the angioplasty group showed combined, moderate types more frequently. After 3D-CTA evaluation, TCD sensitivity, specificity, positive predictive value and negative predictive value, analyzed with the index of diminished vessel diameter that was more than moderate, were 92.6%, 83.3%, 72.2% and 50.0%, respectively. CONCLUSION: TCD and 3D-CTA could be useful tools for evaluation and management planning of critical patients suspected of having DIND by vasospasm.

Treatment of Ulnar Impaction Syndrome using Arthroscopy and Ulnar Shortening Osteotomy / 대한정형외과학회잡지

PURPOSE: To retrospectively analyze the follow-up results of patients with ulnar impaction syndrome, who were treated with arthroscopic debridement, thermal shrinkage and a simultaneous ulnar shortening osteotomy. MATERIALS AND METHODS: Eleven wrists from ten patients with ulnar impaction syndrome, which were diagnosed by the clinical history, physical examination, radiological evaluation and arthroscopic findings, and were treated by arthroscopic debridement, thermal shrinkage and ulnar shortening osteotomy were enrolled in this study. The minimum duration of the follow-up was one year. The ulnar variance was measured using Kreder's method, and the follow-up results were analyzed radiographically as well as clinically using the Chun and Palmer wrist score. RESULTS: According to the wrist scoring system, seven wrists were fair and four poor preoperatively. However, after surgery, eight wrists were excellent and three good. The average wrist score increased from 62 preoperatively to 93 at the last follow-up. The mean ulnar variance decreased from +3.3 mm (+0.4-+6.4 mm) preoperatively to +0.1 mm (-0.8-+1.3 mm) at the last follow-up. Radiological union of the osteotomy site was achieved after an average of 12 weeks. There were no cases of nonunion or malunion. CONCLUSION: When ulnar impaction syndrome is diagnosed by the clinical, radiological and arthroscopic findings, arthroscopic debridement, thermal shrinkage and simultaneous ulnar shortening osteotomy are useful treatments for relieving the patients symptoms.

Periosteum-Derived Mesenchymal Stem Cells and Scaffolds Transplanted into Long-Bone Defects of Rabbit / 대한정형외과연구학회지

PURPOSE: To observe the changes in periosteum-derived mesenchymal stem cells and different scaffold materials transplanted into rabbit long-bone defects. MATERIALS AND METHODS: Thirty-five white rabbits were grouped according to the material transplanted into their tibial bone defects: Group 1 (control group); Group 2-A (agar plus mesenchymal stem cells); Group 2-B (agar only); Group 3-A (Biocompatible Osteoconductive Polymer plus mesenchymal stem cells); Group 3-B (BOP(R) only); Group 4-A (xenograft plus mesenchymal stem cells); Group 4-B (xenograft only). After surgery, radiologic and microscopic observation were performed weekly for 8 weeks. RESULTS: Rabbits transplanted with mesenchymal stem cells showed better bone formation than those without. Mesenchymal stem cells transplanted with agar had better results than mesenchymal stem cells plus BOP(R). Rabbits receiving xenografts showed severe inflammatory reactions. CONCLUSION: Further research is needed on rigid scaffold materials which minimize immune reaction, and on how to ensure uniform distribution of mesenchymal stem cells within such materials.

Dislocation of the Carpometacarpal Joint of the Thumb in Ehlers-Danlos Syndrome: A Case Report / 대한정형외과학회잡지

A subluxation or dislocation of the carpometacarpal joint of the thumb is a rare injury, which usually occurs from trauma. There is a relative dearth of literature about the results of hand surgery for the treatment of Ehlers-Danlos syndrome. To the best of our knowledge, there has been no report on capsular ligament reconstruction in the hand using an autogenous tendon graft for the treatment of Ehlers-Danlos syndrome. We describe a case of atraumatic dislocation of the carpometacarpal joint of the thumb that had gradually progressed in a patient with Ehlers-Danlos syndrome; and which was treated with capsular ligament reconstruction by use of a portion of the flexor carpi radialis tendon. Six months after surgery, a trapeziometacarpal arthrodesis was performed secondarily, because of subluxation and pain in the carpometacarpal joint of the thumb, with a pinching motion.

Surgical Treatment of Cavernous Malformation of Pineal Region

The main causes of pineal apoplexy are hemorrhage associated with pineal region tumors, vascular malformations, and pineal cysts. Cavernous malformations rarely occur in the pineal region, with only fifteen cases reported previously. Hemorrhage associated with cavernous malformation causes apoplectic event in the pineal region. We report two surgically treated cases of pineal hemorrhage associated with cavernous malformation and discuss the consideration in management of the pineal apoplexy.

Surgical Treatment of Cavernous Malformation of Pineal Region

The main causes of pineal apoplexy are hemorrhage associated with pineal region tumors, vascular malformations, and pineal cysts. Cavernous malformations rarely occur in the pineal region, with only fifteen cases reported previously. Hemorrhage associated with cavernous malformation causes apoplectic event in the pineal region. We report two surgically treated cases of pineal hemorrhage associated with cavernous malformation and discuss the consideration in management of the pineal apoplexy.

The Effectiveness of Osteoplasty System (Vertebroplasty using Large Cannula-low Pressure Delivery System) in Compression Fracture and other Spinal Pathology

OBJECTIVE: The vertebroplasty is an excellent procedure in spine compression fracture, but there are some problems such as cement leakage and difficulties in bone biopsy. Recently, the osteoplasty system is developed to solve these problems, so we will report the usefulness of the osteoplasty system. METHODS: From January 2003 to November 2003, there are 9patients with simple osteoporotic spine compression fracture, 2 compression fracture patients combined with suspicious spinal metastasis, 1patient with suspicious primary bone tumor, and 2patient with infection on spine. All patients were treated using the osteoplasty system. RESULTS: All 11 compression fracture patients were relived the back pain after the osteoplasty and there is no complication. The bone biopsies in 3 suspicious cancer patients were also effectively performed using the osteoplasty system; negative result in 2patients and positive result in 1patient. The culture result of spontaneous discitis was no growth for 48hours. The spine tuberculosis was confirm using the osteoplasty system. CONCLUSION: The osteoplasty system has distinguished advantages in comparison with the vertebroplasty. That is, the risk of cement leakage is lower than vertebroplasty because of low pressure delivery system. And we can obtain the specimen effectively in bone biopsy because of large cannula. In conclusion, we emphasize that the osteoplasty system is a more useful procedure in spine compression fracture especially in the patient needed bone biopsy for diagnosis.

A Case of Benign Metastasizing Pulmonary Leiomyoma / 결핵및호흡기질환

A benign metastasizing pulmonary leiomyoma (BMPL) is a rare disease that usually occurs in women with a prior or coincident history of uterine leiomyoma. Although leiomyoma is histologically benign, it has the potential to metastasize to a distant site such as the lung. A 35 year old woman who had undergone a hysterectomy due to uterine leiomyoma 5 years prior was admitted for an investigation of multiple pulmonary nodules on a routine chest roentgenogram. An open lung biopsy was taken to make a pathological diagnosis. The microscopic finding of the nodules was leiomyoma and was similar to those of the uterine leiomyoma that had been resected 5 years ago. The woman underwent wedge resections of all pulmonary nodules. This is the first case of BMPL in Korea, which was treated with wedge resections of all multiple pulmonary nodules.

Head Tilt and Facial Asymmetry in Congenital Muscular Torticollis / 대한정형외과학회잡지

PURPOSE: To analyze head tilt and facial asymmetry in congenital muscular torticollis. MATERIALS AND METHODS: The 37 cases (mean age: 8.5 years) of congenital muscular torticollis [23 operative cases (14 bipolar release, 9 unipolar release) and 14 non-operative cases] were reviewed. Measurements included: head tilt, horizontal facial asymmetry angle, midfacial asymmetry angle on photographs; craniovertical angle, orbital plane-cranial horizontal line angle on cephalograms; and the angle between two reference lines connecting the mastoid processes and the spinous processes on C-spine radiographs. RESULTS: The results in both operative/non-operative groups were measured as follows: mean head tilt of 6.6 degrees/4.3 degrees, mean horizontal facial asymmetry angle of 3.4 degrees/1.9 degrees, mean midfacial asymmetry angle of 3.2 degrees/2.4 degreeson photographs; mean head tilt of 17.1 degrees/4.7 degreeson C-spine radiographs; mean craniovertical angle of 2.9 degrees/2.1 degrees, mean orbital plane-cranial horizontal line angle of 3.3 degrees/2.0 degreeson cephalograms. CONCLUSION: The facial asymmetry in congenital muscular torticollis become more severe with increased age at treatment and with a more severe head tilt. Horizontal facial asymmetry around the orbits is more distinctive than midfacial asymmetry in torticollis-related facial asymmetry.

Clinical Review of Primary Chest Wall Tumors / 대한흉부외과학회지

BACKGROUND: Primary chest wall tumors originate from soft tissue, bone or cartilage of the chest wall and it comprises 1~2% of all primary tumors. Resection of tumor is often indicated for chronic ulceration or pain, and long-term survival might be achieved after surgery depending on the histology and the surgical procedure. MATERIAL AND METHOD: Retrospective study of 125 primary chest wall tumors (86 benign, 39 malignant) operated between Sep. 1976 to Mar. 2001 were reviewed and their clinical outcomes were analyzed. Follow-up data were collected at the outpatient clinic. RESULT: All patients with benign tumors were treated by excision without recurrence or death, and most malignancies were treated by wide resection. Malignant fibrous histiocytoma and chondrosarcoma constituted 46.2% of the malignant neoplasm. There was no operative death. The overall 3-year survival for patients with primary malignant neoplasm was 76.0%, and the 10-year survival was 60.5%. All deaths were disease-related and the tumor recurred in 11 patients. There was no significant difference in survival between patients with resection margins less than 4 cm and those with resection margins greater than 4 cm. CONCLUSION: Chest wall resection offers excellent results for benign chest wall tumors and substantial long-term survival for malignant diseases. Safe resection margin of 4 cm or more did not correlate with the survival rate although the tumor recurrence correlated with poor survival.