Long Term Follow up Results of the Operative Treatment of the Acromioclavicular Joint Dislocation with a Wolter Plate

PURPOSE: To evaluate the long-term clinical and radiological results of the operative treatment of the acromioclavicular dislocation with a Wolter plate. MATERIALS AND METHODS: We reviewed clinical and radiological data of twenty patients (mean age: 37 years) who underwent the operative treatment of acromioclavicular joint dislocation using a Wolter plate from September, 1999 to December, 2002 with minimum of five years follow-up (average 6 years 7 months). The clinical outcomes of twenty patients were evaluated by UCLA scoring and radiological results of fifteen patients with available radiograph were evaluated by Zanca view and stress view. RESULTS: The mean UCLA score was mean 33 points (range, 27~35) at final follow up. By clinical evaluation, twelve cases (60%) were excellent, six cases (30%) were good and two cases were poor (10%). By radiological evaluation, eight cases (54%) were excellent (without displacement), five cases (33%) were good (displacement 5 mm). Erosive change in acromioclavicular joint was seen in poor case. CONCLUSION: Wolter plate fixation may be a useful modality for treating acromioclavicular joint dislocation. Great care should be taken to make the hook hole at the appropriate position during operation for long-term prognosis.

The Effect of COX-2 Inhibitor on the Expression of MMP-13 during Early Fracture Healing Phase in Rats

PURPOSE: This study investigated the effect of COX-2 inhibitor on the expression of MMP-13 in the healing process of fracture. MATERIAL AND METHODS: Adult Sprague-Dawley rats were divided into two groups of twenty five rats each. Unilateral femoral shaft fractures were created artificially under displacement in all two groups. COX-2 inhibitor was only given to the experimental group from the postoperative day 1. At 2 weeks after fracture the rats were sacrificed and the callus from each group was used for histologic examination and real time RT-PCR for MMP-13 expression. RESULTS: Histologically, proliferation of osteoblasts and formation of osteoid was less abundant in the experimental group. In real time RT-PCR, the mean expression of MMP-13 is 2.84+/-2.50 in the control group compared with 1.16+/-1.05 in the experimental group. CONCLUSION: In the early stage of fracture healing, COX-2 inhibitor suppress the expression of MMP-13.

Comparative Evaluation of Percutaneous Endoscopic Discectomy and Microdiscectomy Using Tubular Retractor System at L4-5 Level / 대한척추외과학회지

STUDY DESIGN: A prospective, non-randomized study OBJECTIVES: To evaluate the early clinical results of percutaneous endoscopic lumbar discectomy (PELD) and microdiscectomy (MD) using a tubular retractor. SUMMARY OF THE LITERATURE REVIEW: There are few reports comparing the clinical results of different minimal invasive surgical procedures for disc herniation. MATERIALS AND METHODS: Out of 41 patients who underwent a discectomy at the L4-5 level, 16 patients (Group I) underwent PELD and 25 patients (Group II) underwent MD. The surgical techniques were based on the patient's selection. The characteristics of the operation(operation time, time for C-arm, amount of removed disc) were compared with the clinical outcomes by evaluating the SLR (straight leg raising test), leg VAS (visual analogue scale), ODI (Oswestry Disability Index), hospital day, changes in disc height. RESULTS: Group I showed a larger amount of disc removed and exposure time for the C-arm than group II (p<0.05). However, the hospital day was shorter in group I than in group II (p<0.05). There were no differences in the leg VAS, ODI, the change in disc height and surgery time between the two groups at the last follow up. One case in group I had a neuropraxia of the L5 root that had recovered fully at postoperative 3months. In group II, there was one case of a postoperative hematoma and 2 cases of a dural tear. CONCLUSION: Although the early clinical outcomes were similar in both groups, group I showed a larger amount of disc removed and more exposure time to radiation but a shorter hospital stay.

Neurolymphomatosis Involving Sciatic Nerve: A Case Report / 대한정형외과학회잡지

The term "Neurolymphomatosis" includes the infiltration of the peripheral nervous system by lymphoma and nontumor lymphocytes. A neurolymphomatosis has not been classified as a distinct entity. Hence, its characteristic symptoms are often missed, and oncologists or neurological consultants fail to obtain an accurate diagnoses. We encountered a case of non-Hodgkins lymphoma involving the sciatic nerve, which has never been reported in the orthopedic literature in Korea. We report a case of neurolymphomatosis with a brief review of the literature.

Primary Repair in Tears Affecting Two or More Rotator Cuff Tendons

PURPOSE: The current study assessed the factors affecting outcomes of primary repair procedures in tears of multiple rotator cuff tendons. MATERIALS AND METHODS: Among the cases of rotator cuff tears involving two or more tendons receiving operations between 1997 and 2003, The clinical results of 19 cases with more than 2 years follow-up were evaluated by the UCLA score. We evaluated the correlation of trauma, active motion, acromiohumeral distance, tear size, and surface area with the UCLA score using Pearson's linear correlation coefficient (PLCC). RESULTS: UCLA scores increased significantly in all cases, from 9 to 26.1 on average. However, the results were good in 53%, and poor in 47% according to Ellman's criteria. Trauma, active elevation, acromiohumeral distance, and tear size did not correlate with the UCLA score, but the tear surface area was inversely correlated with the score (PLCC=- 0.696). Cases with degeneration of the infraspinatus muscle above Goutallier grade III on MRI showed worse results than cases with less degeneration. CONCLUSION: The clinical results of primary repair of rotator cuff tears involving multiple tendons were satisfactory in 53% of patients. Large tear surface area and severe degeneration of the infraspinatus were poor prognostic factors.

The Effect of Hyaluronic Acid on the Expression of MMP-13 in Healing Process of Bone Defect in Rats / 대한정형외과학회잡지

PURPOSE: Matrix metalloproteinase (MMP)-13 has a degradation effect on type II collagen and is expressed in osteoblastic cells and hypertrophic chondrocytes. However, the role of MMP-13 is not completely understood. This study investigated the effect of exogenous Hyaluronic acid (HA) on the expression of MMP-13 in the healing process of bone defects. MATERIALS AND METHODS: After making a bone defect in the metaphysis of the distal femur in rats, HA was instilled into the defect in the experimental group. In the control group, a bone defect was made but HA was not instilled. Two weeks after the experiment, the rats were sacrificed and the callus that filled the bone defects was obtained. A histological examination and real time reverse transcription polymeric chain reaction (RT-PCR) were performed to investigate the healing response and expression of MMP-13. RESULTS: Histologically, the proliferation of osteoblasts and the formation of osteoid were more active in the experimental group. Nevertheless, the level of MMP-13 expression was significantly lower in the experimental group than in the control group. CONCLUSION: From the results of this study, it appears that exogenous HA inhibits the expression of MMP-13 at the early stage of bone healing.

Mode of Fixation Failures of Dynamic Hip Screw with TSP in the Treatment of Unstable Proximal Femur Fracture: Biomechanical Analysis and a Report of 3 Cases / 대한정형외과학회잡지

There are few reports of the failure mode of a dynamic hip screw with a trochanteric stabilizing plate (TSP) in the treatment of unstable proximal femur fractures. We present 3 cases of fixation failure of a TSP used to treat unstable intertrochanteric fractures. All cases had the same type of failure mode, which represented a fatigue fracture of the distal screw at the junction of a plate and screw. Non-union occurred in 2 cases, and one case was an incidental finding 4 years after union. Biomechanical analysis and SEM (scanning electron micrograph) examination was also performed. Adding TSP to the plate might increase the level of shear stress and slip motion in the distal screw followed by a fatigue fracture. SEM of the surface of the broken screw revealed a multiple cycle and low stress fatigue fracture. Recommendations are made regarding the implant design and surgical technique.

Repair of Osteochondral Defect Using Chitosan-collagen Sponge intheRabbit's Knee / 대한정형외과학회잡지

PURPOSE: To determine the suitability of using a chatoyant-collagen sponge as a scaffold for transplanting a chondrocyte into a full-thickness articular cartilage defect. MATERIALS AND METHODS: The in vitro characterization of a chatoyant-collagen sponge infiltrated with the chondrocyte was combined with an in vivo assessment of the early articular cartilage repair in a rabbit's knee by H&E and MTT staining. These porous chatoyant-collagen sponges were implanted into the osteochondral defects made in the left patellofemoral grooves of 12 rabbits. The osteochondral defects were untreated in the right side and used as controls. The experimental animals were sacrificed 1, 3, 6 and 12 weeks after implantation and the repaired tissue was evaluated by a gross and histological evaluation using the Wakitani score. RESULTS: More primary cells cultured from the articular cartilage of the rabbit's knee were found to attach to and survive within a porous chatoyant-collagen sponge than with a chatoyant sponge. In gross and histological examination, the experimental group showed indications of repair, which appeared similar in color and texture to the surrounding articular cartilage. The Wakitani scoring in the experimental group at 6 (Ave. 10.7) and 12 (Ave. 7.3) weeks were superior to those in the control group at 6 (Ave. 8.7) and 12 (Ave. 3.7) weeks (6 wk: p=0.03, 12 wk: p=0.02). CONCLUSION: Scaffolds composed of porous a chatoyant-collagen sponge enhance the growth of cartilaginous repair and make a milieu for the survival of chondrogenic cells both in vitro and in vivo.

Analysis of the Orientation of Lumbar Isthmic Defect / 대한정형외과학회잡지

PURPOSE: We analyzed angles of defect planes of spondylolysis from coronal plane using axial computed tomography to identify the problem of 45degrees oblique plain radiograph by which we routinely has used and to suggest an appropriate radiological diagnostic tool for spondylolysis. MATERIALS AND METHODS: From January 2001 to July 2002, 84 cases of spondylolysis from 44 patients were studied. The diagnosis of spondylolysis was confirmed with axial computed tomography in all cases and angles of isthmic defect from coronal plane were measured. We intended to assess the distribution of angles of isthmic defect and analyzed the result of plain radiographs which were obtained in the direction parallel to the angle of the mean value. RESULTS: Although angles of lumbar isthmic defects have a wide distribution, the mean value was 20.9+/- 9.5degrees which was nearer to coronal plane than 45degrees oblique plane. Fifty eight cases were distributed within 23degrees from coronal plane. A diagnostic sensitivities were 88.1% in lateral view, 78.6% in 45degrees oblique view and 100% in 20degrees oblique view, so a 20degrees oblique view seemed to be more sensitive in diagnosis of lumbar isthmic defect. CONCLUSION: Because the mean angle of lumbar isthmic defects from coronal plane was about 21degrees, obliqueview with 20degrees was more appropriate and sensitive diagnostic tool for spondylolysis than oblique view with 45degrees which have been used routinely.

The Usefulness of Non-operative Treatment of Distal Radius Fracture in Elderly Patients

PURPOSE: To disclose the correlation between the functional and radiologic results of the treatment of distal radius fracture in elderly patients by non-operative versus operative treatment. MATERIALS AND METHODS: From January 1995 to December 2000, 36 patients, more than 60 years old with fractures of distal radius were treated and followed up for more than one year. We classified them using the Fernandez classification and evaluated functional and radiological results according to the subjective point system of Cole & Obletz and objective evaluation by Scheck. RESULTS: In functional result, excellent to good results were obtained in 12 cases (71%) in the non-operative group and 14 cases (74%) in the operative group, there were no evidence of statistical difference between two groups (p>0.05). In radiographic results, mean radial inclination, loss of radial length and volar tilt were 13degree, 12.3 mm, 7.2degrees in the non-operative goup and 5.2degrees, 5.1 mm, 3.3degrees in the operative group on last follw-up radiographs, there were evidence of statistical difference between two groups (p<0.05). CONCLUSION: Operative treatment is radiographically better result in distal radius of elderly patients but functional satisfaction is not significantly related with radiographic result. When we decide the treatment of elderly patients, non-operative treatment can be useful method, considering with patient's age and activity status.

Anatomical Assessment of the Proper Insertion Site for a Tibial Nailing

PURPOSE: To investigate the proper insertion site for a tibial intramedullary nail in the Korean. MATERIALS AND METHODS: Forty volunteers without trauma below knee joint were studied to determine relationship between central axis of medullary canal and lateral tibial spine, patellar tendon and the proper insertion site, and to evaluation changes of proper insertion site during rotation of knee and effective diameter. RESULTS: The proper insertion site located average 4.3+/-0.9 mm medial to the lateral tibial spine. The proper insertion site was in the medial 1/3 of patellar tendon in 6 knees, middle 1/3 of patellar tendon in 20 knees, and lateral 1/3 of patellar tendon in 14 knees. The proper insertion site might be changed two times in internal rotation more than in external rotation. The effective diameter was more narrow in medial slope than in lateral slope at proximal tibia. CONCLUSION: The study indicates the ideal insertion site of tibial nail is the medial aspect of the lateral tibial spine in Korean. To reduce the mal-reduction from a improper insertion site, lateral insertion site might be safer than medial one. However, individual variations in the relationship between the patellar tendon and tibial medullary canal should be considered.

Surgical Treatment of Intercondylar Fracture of the distal Humerus through the Modified Triceps Sparing Approach / 대한정형외과학회잡지

PURPOSE: We evaluated the therapeutic results of intercondylar fractures of the distal humerus that were treated through the modified tricepssparing approach. MATERIALS AND METHODS: From February, 1997 to september, 2001, we reviewed sixteen cases of intercondylar fracture of the distal humerus, which were treated by surgical treatment. The follow up period ranged from one year to three years, averaging 1 year 8 months. The articularsurface of the distal humerus was exposed through elevation of the triceps from the medial and the lateral intermuscular septum. Theulna nerve was identified and protected, and then, the fracture sites were fixed with double plates. The functional results were evaluated using Broberg and Morrey's functional scale. RESULTS: All united at 14.5 weeks in an average. The functional results were as follows; three excellent, ten good, two fair and one poor. The range of the elbow joint motion was flexion contracture 11 degree to further flexion 130 degree in average. The one patient presented poor result had coronal shear fracture of the capitulum combined with severe comminution. The incomplete ulnar nerve palsy developed in one case. CONCLUSION: The modified triceps sparing approach provided sufficient exposure for rigid fixation of intercondylar fracture of the humerus. But in cases with severe comminution or coronal shear fracture, additional anterior approach or olecranon osteotomy should be considered.

Operative Treatment of Complete Dislocation of the Acromioclaviclar Joint with a Wolter Plate / 대한정형외과학회잡지

PURPOSE: We studied to analyse the results of Wolter plate fixation for the treatment of complete acromioclavicular joint dislocation. MATERIALS AND METHODS: From September 1999 to August 2000, 20 patients with complete dislocation of the acromioclavicular joint were treated by Wolter plate fixation. The radiologic and clinical outcomes were evaluated by UCLA scoring. The mean duration of follow up was fifteen months. RESULTS: Functional outcomes at the last follow up were excellent in eleven (55%), good in seven (35%) and poor in two cases (10%). The mean preoperative coracoclavicular interval on the injured side was 200% versus the normal side, and after operation this was 15%. In one case of an elderly patient, the plate was removed at 6 weeks due to loss of fixation. CONCLUSION: The Wolter plate fixation for complete acromioclavicular joint dislocation was considered as one of the effective method. But careful attention should be taken to prevent possible acromial fracture in the elderly.

Bankart Procedure through Lateral Capsulotomy in Traumatic Anterior Instability of the Shoulder / 대한정형외과학회잡지

PURPOSE: To determine the outcome of the Bankart procedure through lateral capsulotomy approach by objective and subjective evalua-tion in traumatic anterior instability of the shoulder. MATERIALS AND METHODS: Thirty-seven patients with traumatic anterior instability, who underwent the Bankart procedure through lateral capsulotomy, were investigated with an average follow-up of 23 months. Every effort was made to maximize the range of motion by repairing the Bankart lesion and closing the capsulotomy to allow as much external rotation as feasible. In 18 cases, superior capsular shift (13) or Neer 's capsular shift (5) were combined to deal with capsular redundancy. Outcome was assessed using range of motion, Pennsylvania Shoulder Function Score, pain, residual symptom and satisfaction. RESULTS: Recurrence of instability was not encountered. Function score increased significantly and all patients were satisfied with the results. However, 8 patients (22%) complained of feeling apprehensive about sports activities. CONCLUSION: The Bankart procedure through lateral capsulotomy appears to minimize unwanted external rotation limitations and enable capsular redundancy to be dealt with adequately.

Surgical Treatment of Malleolar Fracture with or without Use of a Tourniquet / 대한정형외과학회잡지

PURPOSE: To determine the advantage and disadvantage of using tourniquet in the malleolar fracture treated with open reduction and internal fixation. MATERIAL AND METHOD: Randomized 12 patients were operated on with use of a tourniquet (Group T), and 12 patients without use of a tourniquet (Group NT). The operation time, the technical difficulty during operation, the incidence of postoperative complication and the intensity of postoperative pain were compared between the two groups. RESULT: The demographic of the two groups, including age, sex, fractire type, and delay after injury were similar. The average duration of the operation and the technical difficulty during operation were similar between the both group (76min. in Group T, 81min in Group NT, p=0.28) There were no severe complications, however, Four patients had local redness and oozing (3 in group T, 1 in group NT). The patients in group T had higher VAS (Visual Analogue Scale, p=0.014) and more frequencies of analgesic injection (p=0.03) than within 24 hours after operation than those in Group NT, which difference was more significant in male patients and the patient of more than 40-year old. CONCLUSION: Open reduction and internal fixation of the malleolar fracture without use of a tourniquet can be performed with little difficulty and the severity of postoperative pain and the incidence of postoperative complication can be reduced.

Tardy Ulnar Nerve Palsy after Olecranon Fracture: 3 Cases Report / 대한정형외과학회잡지

There has not been reported that the tardy ulnar nerve palsy could be developed as a sequelae of the olecranon fracture. The purpose of this paper is to report our experience of diagnosis and treatment of tardy ulnar nerve palsy, developed in three patients who had managed for non-union and malunion of olecranon fractutre, with a review of the literature.

Protective Effect of Ischemic Preconditioning on Rabbit Skeletal Muscle / 대한정형외과학회잡지

Ischemic preconditioning (IP), a brief period of flow interruption prior to a prolonged ischemic period, increases tolerance to ischemia and improves function during reperfusion in the heart. The aim of the present study is to determine whether IP attenuates and protects against ischemia-reperfusion injury in the skeletal muscle of rabbits. Normal sham control (NC) group was the leg muscles which had no procedures taken after anesthesia. Ischemic control (ICH) group was the leg muscles with ischemia taken for 180 min. followed by reperfusion for 60 min, after anesthesia. Ischemic preconditioning 1 (IP 1) group, IP 2 group and IP 3 group were the leg muscles taken 1, 2 and 3 cycles of ischemia for 10 min. and reperfusion for 10 min. respectively, prior to same procedures as ICH group. The ischemic injury of skeletal muscles was assessed using transmission electron microscope and biospectrophotometric method. The triphenyltetrazolium chloride (TTC) reduction activity was measured, and concentrations of the ATP and its metabolites were also measured. The ICH group showed severe to irreversible changes of the myocytes homogenousely in contrast to the IP 1 group in which irreversible change was only focal and not homogenous. The TTC reduction assay significantly demonstrated that the IP 1 and IP 2 group showed higher reduction activity than the ICH group (p<0.05). The ATP content of muscles was maintained higher in the IP 1 group than in the ICH group (P<0.05). The protective effect of ischemic preconditioning can be induced in the rabbit skeletal muscles, and its effect is associated with lower energy metabolism during sustained ischemia.

Intraradicular Lumbosacral Disc Herniation: A Case Report And Review of the Literature / 대한척추외과학회지

Intraradicular disc herniation is a very rare form of disc herniation because the disc should migrate distally and laterally to enter the nerve root sheath. No case has been diagnosed before surgery. We descibe a 72-year-old woman who has an intraradicular disc herniation into the S1 nerve root and summarize the common features of the past reported 12 cases and this one. MRI showed enlarged nerve sleeve simulating root cyst at the S1 body level. At surgery, fusiform swelling of S1 nerve root adhered to anterior structure was seen and root tumor was suspected. Through the incised opening of the root sheath, two pieces of disc fragment were removed and final diagnosis of intraradicular disc herniation was made. Biopsy of extracted frag-ments revealed degenerative collagenous tissue. Patient's symptom was relieved almost immediately after surgery. An unusual form of intraradicular disc herniation is presented with review of the English language literatures.

Dynamic Instability of Lumbar Spine without Spondylolisthesis / 대한정형외과학회잡지

Although flexion and extension lateral views were known the most preferable diagnostic method of instability of lumbar spine, many authors had reported that there were some findings which suggested instability of lumbar spine in plain films. This study was undertaken to analyze clinical aspect and plain film findings of dynamic instability of lumbar spine and to suggest indication of dynamic X-ray to find out the causes of low back pain. A retrospective analsysis was perfomed on 30 patients who had dynamic instability of lumbar spine without spondylolithesis between January 1996 and March 1997. They were reviewed in sex, age, symptom duration and instability level, etiologic factor etc. And then their plain films and flexion and extension lateral views were reviewed. Following results were obtained. Dynamic instability was more frequent in women than in man and occured younger age in women. The mean symptom duration was 5 years and 10 months and simple degenerative change was the most common etiologic factor. In plain films, traction spur and dome shaped end plate were common findings and the L4-5 intervertebral disc space was most frequently involved(23/30 cases). Translation was occured more frequently in flexion position(23/30 cases). The mean dynamic translation distance was 4.7mm, the mean sagittal rotational angle was 16.2degreesand the mean angular displacement was 3.2degrees. Conclusively, among the diagnostic criteria af instability of lumbar spine, translational distance was the most common finding. Flexion and extension lateral views have diagnostic value in patients who complaint back pain from unknown origin, in old age, for prolonged symptom duration, or those who have findings associated with instability in plain films.

Locking of the Metacarpophalangeal Joint of the Thumb: Report of Two Cases and an Anatomic Study of the Heads of the First Metacarpals / 대한정형외과학회잡지

Locking of the metacarpophalangeal(MP) joint of thumb in mild hyperextension is relatively uncommon problem. The most frequently recognized cause appears that proximal palmar ligament or volar plate were ruptured tranversely with its distal part riding over the volar prominence of the radial condyle of the first metacarpal head. We experienced two cases of locking of the MP joint of the thumb due to volar plate injury. Closed reduction was failed in both cases and open reduction was done by cutting the constricted ligament hundle over the radial condyle of the first metacarpal head. Our description of this mechanism is supported by expeimental evidence that we obtained from the cadeveric specimens. The height of radial side condyle of first metacarpal head is higher than ulna side of that by 1.76mm in both hands of 16 cadeveric specimen. So we are going to report these cases with a review of the literature, and suggest that the preferable location of surgical incision in open reduction is radial side of metacarpal head.