Monitoring Radiation Doses during Diagnostic and Therapeutic Neurointerventional Procedures: Multicenter Study for Establishment of Reference Levels / 신경중재치료의학

Purpose@#To assess patient radiation doses during diagnostic and therapeutic neurointerventional procedures from multiple centers and propose dose reference level (RL). @*Materials and Methods@#Consecutive neurointerventional procedures, performed in 22 hospitals from December 2020 to June 2021, were retrospectively studied. We collected data from a sample of 429 diagnostic and 731 therapeutic procedures. Parameters including dose-area product (DAP), cumulative air kerma (CAK), fluoroscopic time (FT), and total number of image frames (NI) were obtained. RL were calculated as the 3rd quartiles of the distribution. @*Results@#Analysis of 1160 procedures from 22 hospitals confirmed the large variability in patient dose for similar procedures. RLs in terms of DAP, CAK, FT, and NI were 101.6 Gy·cm2, 711.3 mGy, 13.3 minutes, and 637 frames for cerebral angiography, 199.9 Gy·cm2, 3,458.7 mGy, 57.3 minutes, and 1,000 frames for aneurysm coiling, 225.1 Gy·cm2, 1,590 mGy, 44.7 minutes, and 800 frames for stroke thrombolysis, 412.3 Gy·cm2, 4,447.8 mGy, 99.3 minutes, and 1,621.3 frames for arteriovenous malformation (AVM) embolization, respectively. For all procedures, the results were comparable to most of those already published. Statistical analysis showed male and presence of procedural complications were significant factors in aneurysmal coiling. Male, number of passages, and procedural combined technique were significant factors in stroke thrombolysis. In AVM embolization, a significantly higher radiation dose was found in the definitive endovascular cure group. @*Conclusion@#Various RLs introduced in this study promote the optimization of patient doses in diagnostic and therapeutic interventional neuroradiology procedures. Proposed 3rd quartile DAP (Gy·cm2) values were 101.6 for diagnostic cerebral angiography, 199.9 for aneurysm coiling, 225.1 for stroke thrombolysis, and 412.3 for AVM embolization. Continual evolution of practices and technologies requires regular updates of RLs.

Source Image Based New 3D Rotational Angiography for Differential Diagnosis between the Infundibulum and an Internal Carotid Artery Aneurysm : Pilot Study

Objective@#: Distinguishing between an infundibulum and a true aneurysm is clinically important. This study aimed to evaluate whether using source image based new three-dimensional rotational angiography (S-n3DRA) can increase the rate of aneurysm detection and improve distinction between a true aneurysm and an infundibulum. @*Methods@#: Twenty-two consecutive patients with 23 lesions, were evaluated by time-of-flight (TOF) magnetic resonance angiography (MRA), S-n3DRA, and digital subtraction angiography (DSA). The data were retrospectively and independently reviewed by two neurointerventionists, and the diagnoses based on TOF MRA, S-n3DRA, and DSA were compared. The diagnostic efficacy (interobserver agreement and diagnostic performance) of S-n3DRA was compared with that of TOF MRA. @*Results@#: S-n3DRA showed higher interobserver agreement (κ=0.923) than TOF MRA (κ=0.465) and significantly higher accuracy than MRA in distinguishing an aneurysm from an infundibulum (p=0.0039). @*Conclusion@#: Compared to MRA, S-n3DRA could provide better screening accuracy and information for distinguishing an aneurysm from an infundibulum. Therefore, S-n3DRA has the potential to reduce the need for DSA.

Source Image Based New 3D Rotational Angiography for Differential Diagnosis between the Infundibulum and an Internal Carotid Artery Aneurysm : Pilot Study

Objective@#: Distinguishing between an infundibulum and a true aneurysm is clinically important. This study aimed to evaluate whether using source image based new three-dimensional rotational angiography (S-n3DRA) can increase the rate of aneurysm detection and improve distinction between a true aneurysm and an infundibulum. @*Methods@#: Twenty-two consecutive patients with 23 lesions, were evaluated by time-of-flight (TOF) magnetic resonance angiography (MRA), S-n3DRA, and digital subtraction angiography (DSA). The data were retrospectively and independently reviewed by two neurointerventionists, and the diagnoses based on TOF MRA, S-n3DRA, and DSA were compared. The diagnostic efficacy (interobserver agreement and diagnostic performance) of S-n3DRA was compared with that of TOF MRA. @*Results@#: S-n3DRA showed higher interobserver agreement (κ=0.923) than TOF MRA (κ=0.465) and significantly higher accuracy than MRA in distinguishing an aneurysm from an infundibulum (p=0.0039). @*Conclusion@#: Compared to MRA, S-n3DRA could provide better screening accuracy and information for distinguishing an aneurysm from an infundibulum. Therefore, S-n3DRA has the potential to reduce the need for DSA.

Endovascular Treatment for Intracranial Aneurysms: A Nationwide Survey in Korea / 신경중재치료의학

Purpose@#In Korea, endovascular treatment (EVT) for intracranial aneurysms (IAs) has increased steadily. We conducted a nationwide survey to evaluate the current status of EVT for IAs and to identify treatment preference in the real world. @*Materials and Methods@#A Google online survey was distributed to representative clinicians at hospitals treating IAs, where members of Korean Society of Interventional Neuroradiology (KSIN). The data was collected from October 2017 to December 2017. The responding hospitals were divided into 2 groups (tertiary and non-tertiary hospitals). And variable factors involved in decision making for treatment were evaluated. @*Results@#In total, 73 hospitals (tertiary: 37, non-tertiary: 36) responded to the survey. Most hospitals that responded had over 100 cases of diagnostic angiography (93%) and over 50 cases of EVT for IAs (74%) performed in 2016. The proportion of EVT for ruptured aneurysms in non-tertiary hospitals was significantly higher than tertiary hospitals (49% vs. 9%). The proportion of EVT for unruptured aneurysms at non-tertiary hospitals was significantly higher than tertiary hospitals (66% vs. 44%). Most physicians tended to make decision for treatment on location, shape, and size of unruptured IAs and patients’ age, more than the results from previous clinical trials for unruptured IAs. Although EVT was preferred for older patients (age >70) with unruptured IAs (99%), surgical clipping was still considered as the first treatment of choice for younger patients (age 30 to 50 years) at considerable rates (56%). Over two-thirds of respondents preferred surgical clipping for middle cerebral artery aneurysms, while EVT was preferred initially at other locations. @*Conclusion@#This nationwide survey showed that EVT is considered as the first treatment modality for IAs and there is a discrepancy between current guidelines and real-world practice for decision making of treatment options.

Symptomatic Sinus Pericranii with Adult Onset Headache: A Case Report with Pathologic Perspective

Sinus pericranii (SP) is a rare vascular anomaly of the scalp that consists of an abnormal pericranial venous channel connected to adjacent dural venous sinuses. Most SP are asymptomatic and are found in the pediatric age group. We aim to report a case of symptomatic SP in adult and describe the clinical, radiological, and pathohistological findings to help understand and differentiate this lesion from other scalp lesions. A 40-year-old man with a scalp mass was admitted to our hospital complaining of headache. The lesion enlarged when the patient was in a recumbent position or during Valsalva maneuver. The radiologic imaging suggested its diagnosis as an accessory type of SP with bone erosion. Surgical resection and cranioplasty were successfully performed, and the related headache also gradually subsided. At the 3-year follow-up, there was no recurrence on magnetic resonance imaging.

Management of Polytrauma / 대한정형외과학회잡지

To optimize results for polytrauma patients, prompt evacuation and early management are critical. These patients also require a multidisciplinary team effort, involving multiple departments, as they are likely to have not only musculoskeletal injuries but also specific organ injuries or compromised general status. In the 1980s, the goal was definitive fracture fixation in the early stages after injury (early total care). Since the 1990s, however, the goal has shifted to temporary fixation, with a delay of several days prior to definitive fixation (damage control orthopedics). Recently, the timing and extent of treatment have been determined by the condition of patients based on objective indicators. Because surgery may result in secondary damage, it is desirable to minimize potential tissue injury with either temporary fixation or a delay in definitive fixation.

Stoppa Approach for Anterior Plate Fixation in Unstable Pelvic Ring Injury

BACKGROUND: The Stoppa (intrapelvic) approach has been introduced for the treatment of pelvic-acetabular fractures; it allows easy exposure of the pelvic brim, where the bone quality is optimal for screw fixation. The purpose of our study was to investigate the surgical outcomes of unstable pelvic ring injuries treated using the Stoppa approach for stable anterior ring fixation. METHODS: We analyzed 22 cases of unstable pelvic ring injury treated with plate fixation of the anterior ring with the Stoppa approach. We excluded cases of nondisplaced rami fracture, simple symphyseal diastasis, and parasymphyseal fractures, which can be easily treated with other techniques. The average age of the study patients was 41 years (range, 23 to 61 years). There were 10 males and 12 females. According to the Young and Burgess classification, there were 12 lateral compression, 4 anteroposterior compression, and 6 vertical shear fracture patterns. The fracture location on the anterior ring was near the iliopectineal eminence in all cases and exposure of the pelvic brim was required for plate fixation. All patients were placed in the supine position. For anterior plate fixation, all screws were applied to the anterior ramus distally and directed above the hip joint proximally. Radiologic outcomes were assessed by union time and quality of reduction by Matta method. The Merle d'Aubigne-Postel score was used to evaluate the functional results. RESULTS: The average radiologic follow-up period was 16 months (range, 10 to 51 months). All fractures united at an average of 3.5 months (range, 3 to 5 months). According to the Matta method, the quality of reduction was classified as follows: 16 anatomical (73%) and 6 nearly anatomical (27%) reductions. There were no cases of screw or implant loosening before bone healing. The functional results were classified as 7 excellent (32%), 12 good (55%), and 3 fair (13%) by the Merle d'Aubigne-Postel score. There were no wound complications, neurovascular injuries, or other complications related to the surgical approach. CONCLUSIONS: Stable anterior ring fixation placed via the Stoppa approach can result in excellent reduction and stable screw fixation with a low complication rate.

Measurement of Optimal Insertion Angle for Iliosacral Screw Fixation Using Three-Dimensional Computed Tomography Scans

BACKGROUND: Percutaneous iliosacral screw fixation can provide stable fixation with a minimally invasive surgical technique for unstable posterior pelvic ring injuries. This surgical technique is not limited by cases of difficult fracture patterns, sacral dysplasia, and small sacral pedicles that can occur in Asians. The purpose of this study was to investigate the incidence of the sacral dysplasia in the Korean population and determine the optimal direction of iliosacral screws by analyzing pelvic three-dimensional computed tomography (3D-CT) scans. METHODS: One hundred adult patients who had pelvic 3D-CT scans were evaluated. The upper sacral morphology was classified into three groups, i.e., normal, transitional, and dysplastic groups; the cross-sectional area of the safe zone was measured in each group. S1 pedicle with a short width of more than 11 mm was defined as safe pedicle. The incidences of safe pedicles at different angles ranging from 0° to 15° were investigated in order to determine optimal angle for screw direction. RESULTS: The incidence of normal, transitional, and dysplastic group was 46%, 32%, and 22%, respectively. There were significant increases of the cross-sectional area of the safe zones by increasing the angles from 0° to 15° in all groups. The incidence of safe pedicles increased similar to the changes in cross-sectional area. The overall incidence of safe pedicles was highest at the 10° tilt angle. CONCLUSIONS: The incidence of sacral dysplasia in Koreans was 54%, which is higher than previous studies for Western populations. The cross-sectional area of the safe zone can be increased by anteromedial direction of the iliosacral screw. Considering the diversity of sacral morphology present in the Korean population, a tilt angle of 10° may be the safest angle.

The Character of Reverse Obliquity Intertrochanteric Fractures in Elderly Patients

PURPOSE: To discriminate the characteristics between reverse obliquity fractures in the elderly and that of young adults using three-dimensional computed tomography (3D CT). MATERIALS AND METHODS: Eighteen patients who had reverse obliquity intertrochanteric fractures were enrolled from January 2007 to March 2012. The fracture pattern was analyzed using the 3D CT. The area showing low density (bone defect) of trochanter and femoral neck region was measured. Patients were divided into two groups: Group I, less than 65 years old and Group 2, 65 years and over. RESULTS: In all 9 cases of group 1, the proximal fragment had a 'V' shape with an average of 5.6 cm below the vastus ridge; however, the fracture of 8 cases (88.97%) in group 2 had a 'Lambda' shape of the distal fragment at the level of vastus ridge and an additional fracture line extending to the greater trochanter tip. The bone defect volume of the trochanter and femoral neck region was larger significantly in group 2 than in group 1. CONCLUSION: Reverse obliquity intertrochanteric fracture in the elderly demonstrated a pattern of bursting fracture with 4 parts, which had different patterns from that of young patients. We believe that the larger volume of bone defects resulted in the difference of fracture patterns between the two groups.

Comparison of the Mortality Rate according to the Presence of Trauma Team in Hemodynamically Unstable Patients with Pelvic Ring Injury / 대한정형외과학회잡지

PURPOSE: To compare the clinical results of hemodynamically unstable patients diagnosed with pelvic ring injury according to the presence of a trauma team. MATERIALS AND METHODS: Patients with hemodynamically unstable pelvic fracture were enrolled in the study and were divided into two groups: Group I, patients who were managed before March 2009, when there was no trauma team; and Group II, patients who were managed after March 2009, when emergent trauma team began to work. Data were collected regarding the time the trauma team began patient management, the treatment modality used to control bleeding, transfusion requirement, and patient mortality. RESULTS: The time when the trauma team began patient management was five hours and 48 minutes in Group I and 57 minutes in Group II. The time to definitive treatment in order to control bleeding in Group I and Group II was 14.4 hours and 4.2 hours, respectively. The amount of the transfusion was 41.1 unit in Group I and 13.2 unit in Group II patients. In Group I, four patients (57.1%) died, although only one of the seven patients in Group II (14.3%) died. CONCLUSION: Using a multidisciplinary approach, the trauma team has only a short amount of time to determine their treatment strategy and to achieve prompt management of bleeding, with the final objective to decrease the mortality rate in patients with hemodynamically unstable pelvic fractures.

Incidence and Prevention of Venous Thromboembolism in Severely Injured Patients with Lower Extremity Fracture / 대한정형외과학회잡지

PURPOSE: To compare the incidence of venous thromboembolism (VTE) in severely injured patients with lower extremity fracture in a prophylactic group with that in a non-prophylactic group during a retrospective study. MATERIALS AND METHODS: Severely injured patients with lower extremity fracture were enrolled in this study and were divided into the following two groups: Group I, non-prophylactic group, and Group II, prophylactic group using anticoagulants and mechanical prophylaxis. RESULTS: Symptomatic VTE occurred in 5 cases (16.1%) among the 31 cases in Group I; i.e., deep vein thrombosis in one case and pulmonary embolism (PE) in four cases, including life threatening PE 2 cases. There were no patients with symptomatic VTE among the 32 cases in Group II. CONCLUSION: The incidence of symptomatic VTE without the use of prophylaxis was 16.1%. This rate dramatically decreased with the use of prophylaxis. Therefore, we believe that prophylaxis with anticoagulants and mechanical device is necessary in order to prevent VTE in severely injured patients with lower extremity fracture.

Treatment of Distal Femur Fracture

No abstract available.

Radiation Exposure to the Orthopaedic Surgeon during Fracture Surgery / 대한정형외과학회잡지

PURPOSE: To assess the risk of radiation exposure by measuring the equivalent dose during fracture surgery. MATERIALS AND METHODS: Two orthopedic trauma surgeons were enrolled in this study from April to June 2009. The equivalent dose was measured using thermoluminiscent dosimeters placed at the left (in and out of the lead apron). RESULTS: The equivalent dose measured from the apron over the 3 month period were 5.22 mSv, 4.34 mSv(outside), and 1.83 mSv and 0.71 mSv(inside). The rate of radiation reduction was 64.9% and 83.6% respectively. CONCLUSION: The estimated annual equivalent dose outside the apron was close to or higher than the maximum limit of radiation exposure. These findings highlight the need for surgeons to be more cautious about radiation exposure during fracture management and take active steps to minimize radiation exposure, such as wearing a radio-protective apron.

Bowel Entrapment by Fragments of Acetabular Fracture: A Case Report

Abdominal injuries are common in patients with pelvic or acetabular fracture. However intestinal entrapment or perforation caused by fragments of a pelvic or acetabular fracture is rare and to date there has been no report of this occurring in Korea so far. As it is difficult to diagnose intestinal entrapment caused by fragments of pelvic or acetabular fracture, the entrapment therefore results in intestinal perforation, sepsis, and a high mortality rate in the absence of early detection. We present a case of intestinal entrapment and perforation caused by fragments of acetabular fracture as well as a literature review.

Clinical Results of Femoral Subtrochanteric Fractures

PURPOSE: This study examined the clinical course of subtrochanteric fractures of the femur as well as the risk factors of complications. MATERIALS AND METHODS: A retrospective study was performed on 56 patients with femoral subtrochanteric fractures who were treated at our hospital from 2004 to 2008. Risk factors, such as the type of fracture, type of implant, soft tissue dissection at the fracture site, communition of the medial cortex and degree of fracture displacement after the reduction, were compared to determine their effect on the rate of complications, such as nonunion and implant failure. Open reduction with a soft tissue dissection at the fracture site was performed in 34 cases, and a closed reduction was performed in 22 cases. Thirty five cases had medial cortex communition and 21 cases did not. RESULTS: There were 8 cases of nonunion(14.3%). There was a positive correlation between the degree of fracture displacement after the reduction and the union time (P=0.017). The union time was longer when there was communition of the medial cortex. A subtrochanteric fracture using an open reduction tended to have a long union time but this was not statistically significant. There was no correlation between the type of implant and union time. CONCLUSION: The union time is longer in subtrochanteric fractures with communition of the medial cortex. Therefore, it is important to preserve the blood supply at the fracture site using a closed reduction and restore the fracture reduction accurately.

Outcomes of Treatment for Femoral Head Fractures with Hip Dislocation: Review of 20 Cases

PURPOSE: We wanted to assess the clinical results and the complications of treating femoral head fractures. MATERIALS AND METHODS: Twenty patients with femoral head fractures and who had a minimum 1 year follow up were enrolled in this study from April 2004 to June 2008. The clinical outcomes were evaluated according to the mechanism of injury, the reduction time, the Pipkin classification, the treatment methods, the surgical approach and the complications. RESULTS: There were 5 cases of Pipkin type I and 2 cases of Pipkin type II, 1 case of Pipkin type III and 12 cases of Pipkin type IV. All the patients underwent operation except 1 patient; there were 5 excisions, 7 internal fixations, 1 prosthesis, and 6 internal fixations of combined acetabular fixation without surgery for the femoral head fractures. The average Harris hip score at 1 year after operation was 80.0 (range: 57~99): there were 4 excellent, 7 good, 5 fair and 4 poor results. The complications of the femoral head fractures were 2 cases of avascular necrosis and 2 cases of posttraumatic osteoarthritis. CONCLUSION: Internal fixation of the femoral head with using Herbert screws showed a favorable outcome, while excision of the femoral head fragments did not. Internal fixation of Pipkin type 1 or 2 fractures could be performed by the anterior approach. The posterior approach combined with surgical dislocation is especially useful in internal fixation of concurrent posterior acetabular fractures, and it has the advantage of preserving the blood supply to the femoral head.

Bursting Fracture of the Proximal Femur during Insertion of Unreamed Femoral Nail for Femur Shaft Fracture: A Case Report

When treating femur shaft fracture in adults, undreamed nail can be an option in order to avoid systemic complications. To appropriately insert unreamed intramedullary nail, an accurate entry point and sufficient reaming of the entry portal is essential. The intramedullary canal of the proximal femur must be reamed over than the diameter of the proximal end of the nail. If the proximal reaming is not sufficient, complications such as bursting fracture of proximal femur can occur. We present two cases of bursting fracture of proximal femur following insertion of undreamed intramedullary nail as well as a literature review.

Subtrochanteric Fracture: Intramedullary Nailing

No abstract available.

The Importance of the Trauma Surgeon: A Reflection on the Management of Hemodynamically Unstable Pelvic Trauma Patients

PURPOSE: Pelvic trauma is a serious skeletal injury with high mortality. Especially in cases of severe injury trauma, treatment outcomes depend on early diagnosis and intervention. We expect trauma surgeon to play an important role in the management of severe multiple trauma patients. METHODS: A retrospective study was performed on pelvic trauma patients with hemodynamic instability between March 2005 and September 2009. We divided the time period into period I (March 2005~Feburary 2009) and period II (March 2009~September 2009). The trauma surgeon and team started to work from period II. Data were collected regarding demographic characteristics, mechanism of injury, type of pelvic fracture, ISS (injury severity score), treatment modality, transfusion requirement, time to definitive treatment, and mortality. RESULTS: During period I, among 7 hemodynamically unstable patients, 4(57.1%) patients died. However during Period II, only one of 6(16.6%) patients died. The demographic data and injury scores showed no differences between the two time periods, but the time to definitive treatment was very short with trauma team intervention( 14.4 hrs vs. 3.9 hrs). Also, the amount of transfusion was less(41.1 U vs. 13.9 U). With arterial embolization, early pelvic external fixation led to less transfusion and made patients more stable. CONCLUSION: This study demonstrated the importance of the trauma surgeon and the trauma team in cases of hemodynamically unstable pelvic trauma. Even with the same facility and resources, an active trauma team approach can increase the survival of severely injured multiple trauma patients.

HIF-1alpha and VEGF Expression in Fracture Healing / 대한정형외과학회잡지

PURPOSE: To elucidate the relation between fracture healing and angiogenesis, we checked expression of Hypoxia-inducible factor (HIF) and Vascular endothelial growth factor (VEGF) in hypoxic cell cultures and the callus from a rat femur fracture model. MATERIALS AND METHODS: Human osteoblasts, chondrocytes, and rat ST2 cells were cultured in DME/F12 media with 10% FBS. Hypoxic DME/F12 media (PO2<60 mmHg) was generated by bubbling with 95% N2 and 5% CO2 and added to cells. After 2, 6, and 24 hours, RNA and proteins were collected for reverse transcription - polymerase chain reaction (RT-PCR) and Western blot. In addition, immunocytochemistry and siRNA treatment for HIF-1alpha were performed. Next, femurs from 9-week SD rats were fractured after fixation with needles. The rats were sacrificed at post-fracture day (PFD) 3, 5, 7, 10, 14, 21 and calluses were collected for RT-PCR and Western blot. RESULTS: HIF-1alpha and HIF-2alpha expression were not increased in RT-PCR but protein levels were increased. VEGF expression in RT-PCR was increased. Treatment with siRNA directed towards HIF inhibited VEGF expression. In the rat fracture callus, HIF-1alpha and VEGF expression peaked between PFD 5 and 7 and decreased after PFD 10. In contrast to cell culture, mRNA expression of HIF-1alpha was increased at PFD 7. CONCLUSION: HIF-1alpha and VEGF peaked early in fracture healing. With expression decreasing as O2 tension increased. Further study is needed to identify other factors affecting chondrogenic differentiation.