Erratum to "Effects of Multiple Drilling on the Ischemic Capital Femoral Epiphysis of Immature Piglets" by Gong SY, et al. (Yonsei Med J 2011;52:809-17.)

No abstract available.

Changes of the Muscle-tendon Lengths in a Three-dimensional Musculoskeletal Model according to the Hip Transverse Angle in Cerebral Palsy Patients with Crouch Gait / 대한정형외과학회잡지

PURPOSE: Crouch gait is one of the common pathologic gaits in children with cerebral palsy. Hamstring lengthening for alleviation of knee flexion is often considered as a first choice for the treatment of crouch gait. However, there have been a variety of reports about the lengths of the hamstring muscle. The purpose of this study was to classify the crouch gait on the transverse plane and to suggest a guide line for hamstring lengthening by analyzing the length of these muscles. MATERIALS AND METHODS: The subjects for this study were selected in ambulatory spastic diplegia patients with crouch gait. A total of sixty-two patients (124 cases) were included. The gait parameters and the muscle lengths were compared. The range of +/-1 standard deviation of the normal middle stance hip rotation was considered as the normal range. The subjects were divided into three groups as hip external rotated (group I), normal (group II) and hip internal rotated (group III) according to the hip rotation. RESULTS: The flexion of the knee and hip was the greatest in group III and dorsiflexion of the ankle was the least in group I. On comparison of moment and power on the sagittal plane, there was no significant difference among the groups. In group III, the percent lengths of the adductor, biceps femoris and gracilis muscles were increased the most, whereas the percent length of the semimembranosus was decreased the most. There was no statistical difference between groups I and II and the normal control group. CONCLUSION: Irrespective of the hip rotation, the length of the hamstring muscle in patients with crouch gait did not differ compared to that of the normal control. But if rotational osteotomy is done for the correction of the increased femoral anteversion in group III, then we should consider lengthening the semimembranosus muscle.

Effects of Multiple Drilling on the Ischemic Capital Femoral Epiphysis of Immature Piglets

PURPOSE: This study investigated the effects of multiple drilling on the immature capital femoral epiphysis following ischemic injury in a piglet model. MATERIALS AND METHODS: Ischemic necrosis of capital femoral epiphysis was induced bilaterally in 12 piglets using a cervical ligation method. Three weeks later, medial, central, and lateral 3 drill holes were made on the left femoral head using 0.062" K-wire. At 3, 6, 9, and 12 weeks following the multiple drilling, femoral heads were harvested from each three piglets. On histologic examination, percent of revascularization, percent of osteoblast surface, capital femoral epiphyseal quotient and proximal femoral growth plate height were evaluated. Untreated right femoral heads served as control. RESULTS: While percent of revascularization of left capital femoral epiphysis with multiple drilling was significantly higher than untreated control side (p<0.001), percent of osteoblast surface, capital femoral epiphyseal quotient and proximal femoral growth plate height showed no significant difference. CONCLUSION: This study indicates that multiple drilling could promote revascularization of ischemic capital femoral epiphysis, and multiple drilling does not appear to produce bony physeal bars at short-term, if using small diameter drill. However, multiple drilling alone does not seem to prevent femoral head deformity or to promote new bone formation.

Combined Therapy of Orthopedic Surgery after Deep Brain Stimulation in Cerebral Palsy Mixed Type: A Case Report

Dystonia is a symptom defined by involuntary and irregular contractions of the muscles, which cause movement disorders and postural problems. Deep brain stimulation (DBS) in globus pallidus interna (GPi) is a good option for controlling dystonia. DBS has already been shown to have significant effects on primary dystonia as well as Parkinson's disease. Dystonia is very difficult to manage, as seen in cerebral palsy (CP) mixed with spasticity. As CP patients grow, their musculoskeletal problems may require orthopedic surgery. However, the outcome of orthopedic surgery is not usually suitable due to dystonia. Therefore, we attempted to control dystonia through DBS initially and perform orthopedic surgery to correct musculoskeletal deformities after treatment of dystonia. Herein, we report a case that showed remarkable improvement in terms of the dystonia rating scale and gait pattern after combined therapy of DBS and orthopedic surgery.

Limb Angular Deformity Correction Using Dyna-ATC: Surgical Technique, Calculation Method, and Clinical Outcome

PURPOSE: Dyna-ATC is a unilateral external fixator with angulator, lengthener, and translator, which allows for angular correction and compensation of the secondary displacement during angular correction. The purpose of this study is to introduce surgical technique and calculation methods and to evaluate the clinical outcome of angular deformity correction using Dyna-ATC. MATERIALS AND METHODS: The amounts of secondary displacement were calculated with the distances between axis of correction of angulation, Center of Rotational Angulation, and osteotomy and the amount of angular deformity. The rate of angular correction was determined to distract the corticotomy at 1 mm/day. Clinical and radiographic evaluation was performed on 13 patients who underwent deformity correction using Dyna-ATC. There were 8 proximal tibia vara, 1 tibia valga, 2 varus and 4 valgus deformities on distal femur. One patient underwent pelvic support femoral reconstruction. Concomitant lengthening was combined in all femur cases. Mean age at surgery was 17.5 years (7 to 64). RESULTS: All but one achieved bony healing and normal alignment with the index procedure. Mean mechanical axis deviation improved from 31.9 mm to 3.0 mm. The average amount of angular correction was 11.0degrees on tibiae and 10.0degrees on femora. The average length gain on femora was 6.4 cm, and the healing index averaged to 1.1 mo/cm. One patient underwent quadricepsplasty and one patient had three augmentation surgeries due to poor new bone formation. CONCLUSION: We believe that Dyna-ATC is a useful alternative to bulky ring fixators for selective patients with angular deformity less than 30 degrees in the coronal plane around the knee joint.

Surgical Treatment for Planovalgus Foot in Children with Generalized Ligamentous Laxity / 대한정형외과학회잡지

PURPOSE: Planovalgus deformity in children with generalized ligamentous laxity is usually asymptomatic, but it sometimes causes severe deformity and functional problems. The aim of this study was to evaluate, post-operatively, functional outcomes, plantar pressure and radiographic results of symptomatic planovalgus with generalized ligamentous laxity. MATERIALS AND METHODS: This retrospective study included a total of 42 feet of 24 patients that had undergone a calcaneal lengthening osteotomy or an extra-articular subtalar arthrodesis. The mean age of the patients at the time of the index operation was 10.5 years (range, 6-15.6 years), and the mean duration of follow-up was 51 months (range, 18-92 months). Patients were evaluated clinically and radiographically using the Oxford Ankle Foot Questionnaire, AOFAS score, Mosca criteria, standard radiographs and dynamic pedobarographs. RESULTS: Functional outcomes at the latest available follow-up were excellent except for three feet. No foot had a significant limitation affecting the patient's daily activities. Both surgical treatments improved radiographic parameters. The parameters of dynamic pedobarographs, including the relative vertical impulse and the peak pressure, decreased for the medial aspect of the forefoot and midfoot, while they increased for the lateral aspect of the forefoot, midfoot and calcaneus after surgical treatment. The change in the center of pressure indicated a significant lateral shift in the weight-bearing surface of the foot. CONCLUSION: Calcaneal lengthening osteotomy and extra-articular subtalar arthrodesis appear to be effective means for pain relief and clinical improvement in children with symptomatic planovalgus deformity and generalized ligamentous laxity. Further follow-up evaluation is needed to obtain long-term clinical and radiographic results with regard to skeletal maturation and changes in generalized ligamentous laxity.

Effects of Heat Shock and Antioxidant on the Growth Plate of Unloaded Rats / 대한정형외과연구학회지

PURPOSE: This study was performed to examine any histopathological changes occurring in the growth plate when the rats were subjected to be deprived of normal weight bearing using the hindlimb suspension model, and to search for any countermeasures for improving and/or recovering the chondrocyte activities within the growth plate. MATERIALS AND METHODS: Sixty male Sprague-Dawley rats, aged 6 weeks, were divided into 10 groups each: Group I-control to unloading; Group II-unloading 3 weeks only; Group III-unloading+application of heat shock; Group IV-unloading+application of antioxidant; Group V-unloading+application of heat shock and antioxidant; Group VI-control to reloading; Group VII-reloading 1 week only; Group VIII-reloading+application of heat shock; Group IX-reloading+application of antioxidant; Group X-reloading+application of heat shock and antioxidant. The animals were double labeled with 5-Bromo-2'-deoxydiuridin (BrdU) and BrdU immunohistochemistry was performed for the cellular kinetic analysis. Transferase-mediated deoxyuridine triphosphate-biotin nick end labeling (TUNEL) assay was done for the investigation of apoptotic changes in the growth plate, and the positive cells were counted in each zones of the growth plate in both TUNEL and BrdU immunohistochemistry. Heat shock protein (HSP), indian hedgehog (Ihh), and vascular endothelial growth factor (VEGF) were immunolocalized to assess the chondrocytic activities in terms of production of extracellular matrix protein. RESULTS: Non-weight bearing induced a reduction of height of the growth plate, reduced cellular proliferation of chondrocytes, reduced expression of Ihh and VEGF, and altered expression of heat shock protein. When heat shock and/or antioxidant were applied to the unloaded and reloaded rats, only rats in the group of application of both heat shock and antioxidant showed normal cellular activities in terms of cellular proliferation and the production of extracellular matrix protein. CONCLUSION: The present results suggest that application of heat shock and antioxidant would be a countermeasure for the restoration of chondrocytic activities when the normal weight-bearing is deprived of.

Effect of Curettage and DBM-CaSO4 Graft for the Treatment of Ischemic Necrosis of the Capital Femoral Epiphysis in Immature Pigs / 대한정형외과연구학회지

PURPOSE: The purpose of this study was to determine the effect of curettage and DBM complex graft as a new treatment modality for LCP disease using piglet capital femoral epiphysis ischemic necrosis model. MATERIALS AND METHODS: Five to six weeks old piglets were used for the experiment. Ischemic necrosis of the capital femoral epiphysis was surgically induced by cervical ligation on both sides. Three weeks following ischemic insult, the left hip joint was approached medially. About 15% of the necrotic capital femoral epiphysis was curetted through a window which was opened at medial cervical cortex, then, demineralized bone matrix complex was engrafted. The right femoral heads served as controls. Piglets were sacrificed three, six, nine, and twelve weeks following were harvested for histologic examination. RESULTS: In control group, photomicrographs of specimens showed central necrosis and fibrovascular invasion in capital femoral necrosis at three weeks after ischemic insult. Six, nine, and twelve weeks following ischemic insult, fibrovascular invasion advanced without noticeable new bone formation and collapse of femoral head progressed. At twelve weeks, definite coxa plana developed. In curettage and DBM complex graft group, there was evident new bone formation observed in the site of DBM complex graft. At three weeks, new bone formation along with fibrovascular invasion was observed around the engrafted DBM complex mainly in the cervical metaphyseal area. At six and nine weeks, new bone formation progressed into the engrafted DBM complex in the cervical metaphysis and around the engrafted DBM complex in the capital femoral epiphysis. At twelve weeks, new bone along with new cartilage formation was observed in the capital femoral epiphysis. CONCLUSION: In conclusion, curettage and DBM complex graft is thought to be an effective treatment modality that promote regeneration of ischemic necrosis of capital femoral epiphysis.

Altered Synthesis of Cartilage-Specific Proteoglycans by Mutant Human Cartilage Oligomeric Matrix Protein

BACKGROUND: The mechanism by which mutant cartilage oligomeric matrix protein (COMP) induces a pseudoachondroplasia phenotype remains unknown, and the reason why a mutation of a minor protein of the growth plate cartilage causes total disruption of endochondral bone formation has not yet been determined. The current study was performed to investigate the effects of mutated COMP on the synthesis of the cartilage-specific major matrix proteins of Swarm rat chondrosarcoma chondrocytes. METHODS: The Swarm rat chondrosarcoma chondrocytes transfected with a chimeric construct, which consisted of a mutant gene of human COMP and an amino acid FLAG tag sequence, were cultured in agarose gel. Formation of extracellular proteoglycan and type-II collagen by the cells was evaluated by immunohistochemical staining and measuring the (35)S-sulfate incorporation. RESULTS: No difference was observed for the detection of type-II collagen among the cell lines expressing mutant COMP and the control cell lines. Histochemical staining of sulfated proteoglycans with safranin-O showed that lesser amounts of proteoglycans were incorporated into the extracellular matrix of the chondrocytes transfected with the mutant gene. (35)S-sulfate incorporation into the cell/matrix fractions demonstrated markedly lower radiolabel incorporation, as compared to that of the control cells. CONCLUSIONS: Mutation of COMP has an important impact on the processing of proteoglycans, rather than type-II collagen, in the three-dimensional culture of Swarm rat chondrosarcoma chondrocytes.

Gastrocnemius Muscle Length and Velocity During Gait in Patients with Planovalgus Foot Deformity in Cerebral Palsy / 대한정형외과연구학회지

PURPOSE: Patients with planovalgus show various abnormal gaits and these are affected by the different length and velocity of the muscles around knee and ankle. The purpose of study is to compare the length and velocity of gastrocnemius in cerebral palsy with planovalgus by ankle plantarflexion-knee extension couple. MATERIALS AND METHODS: 22 patients with spastic diplegia who have planovalgus were included. The mean age was 12 years (5 years~18 years). Group I consisted of 7 patients with knee flexion more than 30 degrees and Group II consisted of 15 patients with knee flexion less than 15 degrees during mid-stance phase. Normal groups were consisted of 15 normal children. RESULTS: In patients with planovalgus, ankle dorsiflexion during stance was decreased but ankle plantarflexion was not different compared to normal. There is no difference in the percent length of gastrocnemius compared to normal, but the velocity was decreased. The percent length of gastrocnemius was decreased in group I, but there were no difference in the velocity. CONCLUSION: The decreased velocity of gastrocnemius is the cause of disability of ankle plantarflexion-knee extension couple and the variable length of gastrocnemius is the cause of variability of abnormal gait.

In Situ Late Metaphyseal Osteosynthesis for the Fractures of the Lateral Humeral Condyle in Children

PURPOSE: To evaluate the efficacy of the in situ late osteosynthesis for slightly displaced fractures of the lateral humeral condyle. MATERIALS AND METHODS: From 2000 to 2004, 12 patients (8 boys and 4 girls) were managed with in situ late osteosynthesis for fractures of the lateral humeral condyle. The average age at the time of operation was 6 years 1 month (1 year 7 months~9 years 1 month), and the mean amount of fragment displacement was 3.3 mm (2.0~4.5 mm). The operative procedure included curettage and in situ fixation of the fragment RESULTS: Bony union was achieved in all cases after avg. 48 months (33~73 months) follow-up assessment. According to the score system of Dhillon et al, 7 patients had excellent, 3 had good, 2 had fair results. None of the patients developed avascular necrosis or premature closure of the epiphysis. CONCLUSION: We suggest that in situ fixation is an effective method for the late treatment of slightly displaced fracture of the lateral humeral condyle.

Outcome Results of Ilizarov Osteosynthesis for Congenital Pseudarthrosis of the Tibia : An Interim Report / 대한정형외과학회잡지

PURPOSE: This study evaluated the efficacy of the Ilizarov technique for the treatment of patients with congenital pseudoarthrosis of the tibia (CPT). MATERIAL AND METHODS: Twenty-two patients with CPT, who underwent osteosynthesis using the Ilizarov technique and were followed-up for more than 3 years, were enrolled in this study. The clinical and radiological data were reviewed to evaluate the outcomes of the Ilizarov technique. RESULTS: The initial osteosynthesis was carried out successfully with the Ilizarov method at average age of 4.6 years. Twenty refractures occurred in 12 patients, who were also treated successfully using the Ilizarov method. Tibial lengthening (27 cases), medial tibial hemiepiphysiodesis (23 cases), distal tibiofibular synostosis (17 cases) were combined with a total of 42 Ilizarov osteosyntheses. After an average 8.1 years follow-up, the mean limb length discrepancy was 1.6 cm, and average anterior apex and valgus angulation of the tibial shaft were 6.3degrees and 7.3degrees, respectively. The mean ankle alignment was valgus 1.9, and the mean range of motion of the ankle joint was 21degrees dorsiflexion and 33degrees plantar flexion. CONCLUSION: The Ilizarov technique combined with tibial lengthening, distal tibiofibular synostosis and/or medial tibial hemiepiphysiodesis is an effective procedure that can achieve bony union as well as a functional limb.

Physeal Defect Model of Rabbit's Tibia : Conventional Curettage vs Box Osteotome Method / 대한정형외과연구학회지

PURPOSE: In many previous animal studies on cell therapy to the physeal defect, the defect was made by curetting the physeal cartilage with a scalpel, a syringe needle, or a curette. Authors questioned the validity of this method because it may be accompanied by the risk of incomplete removal of physis. MATERIALS AND METHODS: Eight-week-old New Zealand White rabbits were used. In the scalpel group(n=32), a physeal defect was made on the medial half of the bilateral proximal tibiae by the conventional curettage method as previously described. In the box osteotome group (n=16), physis and adjoining eiphyseal and metphyseal bone segments were removed with a box osteotome and a motorized burr. RESULTS: Histological examination showed that, in the scalpel group, incomplete removal of physeal cartilage was observed in 14 of 38 (37%) tibiae sacrificed between Day 1 and 7, while all of the 20 (100%) in the box osteotome group showed complete removal of physeal cartilage. CONCLUSION: The results show the high risk of incomplete removal of physeal cartilage with the conventional curettage method. We believe that our method using a box osteotome and a motorized burr is better in terms of ease and validity in creating physeal defect.

Bone Graft Substitute

No abstract available.

The Effect of Chemical Sympathectomy on Moxibustion-Induced Immunomodulation in the Rat Spleen

BACKGROUND: To investigate the role of sympathetic nervous system (SNS) in moxibustion-induced immunomodulation, the effects of chemical sympathectomy on moxibustion-induced changes in splenic NK cell cytotoxicity, T and B cell proliferation were studied in Sprague-Dawley male rats. METHODS: Chemical sympathectomy was achieved with intraperitoneal injection of 6-hydroxydopamine 50 mg/kg/day for 3 successive days. Direct moxibustion (6-minute interval, 9 moxa ball, each of which weighing 0.007 g and burning for 40 seconds) was applied on unilateral anterior tibial muscle region where Zusanli (ST36) acupoint is located, once a day for 7 successive days. NK cell cytotoxicity was measured by 4hr-51Cr release assay. Mitogen-induced lymphocyte proliferation was analyzed by [3H]-thymidine incorporation assay. RESULTS: NK cell cytotoxicity was suppressed by moxibustion, more in sympathectomized rats than in vehicle-treated rats. T cell proliferation induced by concanavalin A was not affected by moxibustion. B cell proliferation induced by lipopolysaccharide showed no significant change in vehicle- treated rats, but an increase in sympathectomized rats by moxibustion. Sympathectomy alone induced augmentation of NK cell cytotoxicity and suppression of T cell proliferation. CONCLUSION: These results suggest that SNS has no direct relation with moxibution-induced immunomodulation but has an important role in the mechanism to keep the homeostasis of immune system by tonically inhibiting excessive changes of various immune components.

Clinical Application of Unilateral-Ring Hybrid Fixation Using DynaExtor(R) / 대한정형외과학회잡지

PURPOSE: We have used a hybrid fixation, in which DynaExtor(R) and Ilizarov rings are connected each other with special connectors. Here, we report upon the technical tips learned and the clinical outcomes of the first twenty five consecutive cases treated using this method. MATERIALS AND METHODS: Between May 1997 and December 1999, 25 patients were treated using hybrid fixation aimed at simple lengthening (8 patients), concomitant deformity correction and lengthening (12), deformity correction alone (3), and fracture fixation (2). RESULTS: In the group requiring simple lengthening, the healing index (H.I.) was 38.3 day/cm (23.6-66.8 day/cm). For concomitant deformity correction and lengthening, the mean amount of angular correction was 33.8degrees (15-75degrees) and the length gain, 4.7 cm (2.2-8.9 cm). For deformity correction alone, the amount of angular correction was 50.1degrees (15-120degrees). For fracture fixation, the mean external fixation time was 59.5 days (26-93 days). Complications included mild pin-tract infection in 8 patients, a temporary stiff joint in 5, and equinus of the foot and delayed union in one patient each. CONCLUSION: The DynaExtor(R) hybrid-fixation system is an effective and convenient method that can be selectively applied to cases that need deformity correction, lengthening, or fixation of the long bone.

Biomechanical Analysis of Unilateral-Ring Hybrid External Fixation / 대한정형외과연구학회지

The mechanical stiffness of Unilateral-Ring Hybrid External Fixation(URHEF) was analyzed and compared with conventional Ilizarov circular external fixation system and unilateral fixation with DynaExtor(R). Our URHEF is basically a unilateral external fixation system which affords easier incorporation and removal of the Ilizarov rings(200mm in diameter) coupled with connecting clamps at anytime, if needed. It allows controlled axial micromotion in due time. For mechanical test, URHEF system was constructed using a DynaExtor(R) fixed with two or three half pins(6 mm in diameter) attached with two proximal and distal Ilizarov rings fixed with an olive pin and a half pin on each ring. Unilateral fixation system was constructed with a DynaExtor(R) fixed with 2 or 3 half pins. Ring fixation system was constructed with four Ilizarov rings(140mm in diameter). Ilizarov system were assembled into 90degrees-90degrees and 45degrees-13 5degrees configurations with 2 olive pins, respectively. The distance between the center of pylon and the pin-clamp interface was equalized, being 70mm, in all the systems. Stiffness in axial compression, anteroposterior and lateral bending was measured. On axial compression and lateral bending tests, URHEF was stiffer than DynaExtor(R) and Ilizarov systems. On anteroposterior bending test, URHEF was less stiff than 90degrees-50degrees configuration of the Ilizarov system but stiffer than 45degrees-135degrees configuration. Considering the fact that instead of 90degrees-90degrees transfixing pin fixatin system, 45degrees-135degrees configuration system is generally used in clinical practice, URHEF appears to be significantly stiffer than unilateral(DynaExtor(R)) and circular (Ilizarov)fixation systems. This mechanical study implicates that URHEF can be beneficially applied in the clinical use with assurance of mechanical stability.