Symptomatic Os Infranaviculare

The author observed a new accessory bone of the foot in the distal portion of navicular, which articulated with the medial cuneiform and the intermediate cuneiform, and named it os infranaviculare. A degenerative change was observed between the accessory bone and the navicular; this caused midfoot pain to the patient during weight-bearing. Thus, the patient was treated by excision of the accessory bone. The symptom was relieved at one-year postoperative.

Coracoclavicular Ligaments Reconstruction for Acromioclavicular Dislocation using Two Suture Anchors and Coracoacromial Ligament Transfer

PURPOSE: This study examined the outcomes of reconstruction of the coracoclavicular ligaments with using two suture anchors and performing coracoacromial ligament transfer in patients with acromioclavicular dislocation. MATERIAL AND METHODS: Forty patients with complete acromioclavicular dislocation were included in this study. According to the preoperative radiographs, 5 patients with AC dislocations were diagnosed as type III, 4 patients as type IV and 31 patients as type V. Two 3.5mm suture anchors with four strands of nonabsorbable sutures were separately placed on the anterolateral and posteromedial portion of the base of the coracoid process to stabilize the distal clavicle. The coracoacromial ligament was then transferred to the undersurface of the distal end of the clavicle for augmentation. RESULTS: At a mean follow-up of 28 months, the average Constant score improved to 97 points. All the patients returned to normal life at an average of 3.2 months postoperatively. At the last follow-up, 37 patients achieved anatomical reduction and three patients showed complete redislocation. However, the clinical results of the patients with redislocation were satisfactory. CONCLUSION: Anatomical coracoclavicular reconstruction using two suture anchors and coracoacromial ligament transfer for treating complete acromioclavicular dislocation is a safe, effective procedure for restoring a physiologically stable acromioclavicular joint.

Radiological Landmarks for the Assessment of the Alignment in the Use of the LCP-PLT (Locking Compression Plate-Proximal Lateral Tibia): An Anatomical and Radiological Study

PURPOSE: To evaluate the conformity of the anatomically pre-shaped LCP-PT to the tibias of the Korean adult and to identify radiological guidelines to assist intraoperative assessment of correct alignment. MATERIALS AND METHODS: 30 adult femur obtained from the Korean adult cadaver were used. A nine or eleven-hole LCP-DF was applied to the lateral surface of the tibia according to the contour. Then the distance from the inner surface of the plate to the lateral condyle was measured at the sites of mismatch. The angle between the most proximal screw and the articular surface was measured with the image intensifier. RESULTS: The LCP-PT showed good conformity to the tibia in general. The distance from the inner surface of the plate to the lateral condyle was 3.5mm in average (range 0~9). The angle between the most proximal locking screw and the joint line was 1.16 degrees in average (range 0~7 degree). CONCLUSION: The LCP-PT showed good conformity to the tibia in general. Malposition of the most proximal screw which is not paralleling to the joint line may herald a coronal plane malalignment.

Treatment of Complex Tibial Plateau Fractures: A Modified Patient Positioning for the Combined Anterior and Posterior Approaches

We have treated thirteen complex plateau fractures involving both condyles with one of the following conditions with the use of the combined anterior and posterior approaches in a modified supine position. Associated PCL avulsion fracture, displacement of major fracture plane dominantly at the back, large coronal fracture fragment involving medial or lateral condyles. A patient is placed on an operation table in supine position with a bump under the contralateral buttock. The well leg is placed in a lithotomy position and the injured leg is placed over a sterilized Mayo stand separately. For the posterior approach the table was tilt toward the injured side with the hip abducted and rotated externally. With a modified patient's positioning we were able to use combined anterior and posterior approaches simultaneously for the management of certain complex plateau fractures without changing the draping.

Stripping of the Hexagonal Recess in the Process of LCP (Locking Compression Plate) Removal

PURPOSE: To report the difficulties in the process of locking head screw removal due to the stripping of the hexagonal recess of the screw head. MATERIALS AND METHODS: We have removed 113 5.0-self tapping locking head screws and 202 3.5-self tapping locking head screws from 34 patients with fracture healing and 5 patients complicated with infection. All of the operations were done by one surgeon. All the screws were placed with the use of torque limiting attachment or driver. RESULTS: All of 113 5.0-self tapping locking head screws were removed without difficulties with an usual manner. 21 out of 202 3.5-self tapping locking head screws were removed with many difficulties due to the stripping of the hexagonal recess. 3 screws were removed successfully with the use of conical extraction screw. 12 screws were taken out by further stripping and destruction of the screw head. In 6 situations where the only one screw was left stripped, the plate was bent around the stripped screw and then it was removed by turning the plate as a handle. One screw was removed with the partial breakage of the near cortex upon lifting the plate after failed attempt of using conical extraction screw. CONCLUSION: Although we have followed the guidelines at the time of insertion we have experienced difficulties in the removal of 3.5 locking head screws due to the stripping of the hexagonal recess. Care should be taken at the time of removal of the locking plate especially for the 3.5 locking screws.

Conformity of the LCP-DF (Locking Compression Plate-Distal Femur) in Korean Adult Femur: A Cadaver Study

PURPOSE: To evaluate the conformity of the anatomically pre-shaped LCP-DF to the femurs of the Korean adult. MATERIALS AND METHODS: 67 adult femur obtained from the Korean adult cadaver were used. An eleven-hole LCP-DF was applied to the lateral surface of the distal femur according to the contour. Then the distance from the inner surface of the plate to the cortex was measured at the sites of mismatch. The angle between the distal most screw and the articular surface was measured. RESULTS: Mismatch was found at the level of proximal 4~5 holes of the plate with an average distance of 9.58 mm (0~18) at the tip of the plate. Otherwise, the overall conformity of the LCP-DF was excellent. The distal most screws are positioned such that the joint line is 3 degrees of valgus to this screw in average (range 0~18). CONCLUSION: It may be necessary to consider to bend the plate in case of mismatch at the tip especially for the plate longer than 9-hole plate. The angular relation between the distal most screw and the joint line can assist the judgement for the coronal plane alignment.

Treatment of Open Tibial Shaft Fractures using Unreamed Nailing

PURPOSE: To report the results of unreamed nailing using a nail with the largest possible diameter for the management of the open tibial shaft fractures. MATERIALS AND METHODS: Nineteen patients with open tibial shaft fractures underwent unreamed nailing with the largest possible diameter according to the isthmic diameter measured on preoperative radiography. There were 1 Grade I, 6 Grade II, 9 Grade IIIa, 3 Grade IIIb open fractures. There were 4 type A, 12 type B, 3 type C fractures according to the OTA classification. Fractures were classified as The nail was introduced after gentle passage of a 7 to 8 millimeter-hand reamer. RESULTS: Union was obtained in all cases. However 9 (47%) fractures required an additional procedures before union. In 6 cases, dynamization was done. Two of them were required exchange nailing for nonunion, 1 of two gained bony union through additional bone graft. Three of the others had gained union through exchange nailing, bone graft, bone transport respectively. There were one rotational malunion, one superfical and one deep infection. Interlocking screw breakage developed only in one patient. CONCLUSION: Our data indicate that unreamed nailing in the management of open tibial fractures is safe and reliable method. Using a tight fitting nail with the largest possible diameter is a safe and effective way to avoid the problems of screw breakage.

Anatomical Versus Mechanism of Injury Classification Systems in Children's Ankle Fracture / 대한정형외과학회잡지

We evaluated the two classification systems of children's ankle fractures, the anatomical (Salter-Harris) and the mechanism of injury (Dias-Tachdjian) classifications, in terms of their usefulness and inter-observer variations. An ideal or useful classification system should comprise any possible types of injury, be easily remembered, and have little inter-observer variations. Five observers were asked to classify 57 physeal fractures of the ankle according to each classification systems. Fifty-four (94%) fractures were classifiable with Salter-Harris anatomical classification system. If we adopt the recently developed Peterson's anatomical classification system, the other three fractures could also be classified. In contrast, the mechanism of injury classification system of Dias and Tachdjian could be applied to 44 (77%) fractures. Though the mechanism of injury classification system was more cumbersome to understand, each observer successfully memorized both classification systems. For observer variations, calculated by kappa statistics, there was an acceptable level of agreement for overall classification by both systems. The results indicate that both classification systems of children's ankle fracture have reproducibility within an acceptable range of inter-observer variation. The Dias-Tachdjian's system needed to be upgraded to a more comprehensive one to include some variant types of ankle injuries.

Preparation of the Femoral Tunnel through Anteromedial Portal during Arthroscopic Single Incision Anterior Cruciate Ligament Reconstruction

The original technique for endoscopic anterior cruciate ligament reconstruction has several potential complications because of constraints imposed by working through the tibial tunnel: improper femoral tunnel placement, violation of the femoral tunnel posterior wall, femoral interferenc screw divergence, graft laceration during screw insertion, and distal tibial bone block prr>trusion. We performed 25 endoscopic anterior cruciate ligament reconstructions with bone-tendon-bone graft using a mo3ified technique that minimizes each of these problems, through the use of a anteromedial portal more centrally and distally placed than the original that portal. Postoperative radiographic review showed femoral screw divergence in 20% of cases (2 in the anteroposterior plane, 2 in the lateral plane and 1 in both planes), but the average angles (AP: 0.52+- 1.85, Lateral: 1.48+-3.30) were insignificant. There was no graft damage during screw insertion or grafttunnel mismatch. We concluded that this modified technique allows simplified, reproducible tunnel and interference screw placement.

Synovial Plicae of the Knee on Arthroscopy and MRI / 대한정형외과학회잡지

The types of the synovial plicae were classified according to the classification of Kim and Choe(1997). The purpose of this study was to evaluate the diagnostic ability of MRI for synovial plicae. We retrospectively reviewed the MR findings of the knee in 95 cases of 91 patients. In all 95 cases, findings of arthroscopy and MR images were available. MRI was performed with a 1.5 Tesla Magnetom(Siemens) using a round surface coil. Pulse sequence were Tl weighted image(TR 650ms /TE 20ms) and T2 weighted image(TR 2000ms/TE 70ms). MR images could not show the infrapatella plicae and lateral plicae clearly, but some suprapatellar plicae were shown in T2 weighted MR images (37.5% of hole type, 80% of complete type, 26% of medial type). In 20(22%) of the 90 cases with medial patella plicae proved by arthroscopy, a low intensity band was shown above the medial condyle of the femur on T2 weighted MR images. These 20 cases included 3 of fenestra type, 9 of wide shelf type and 8 of medial shelf type. The low intensity band seen on T2-weighted MR images and its anatomical relation to the medial femoral condyle are helpful in diagnosing the presence of medial shelf type and wide shelf type of medial plicae.

Immediate Nailing of Open Tibial Shaft Fractures after Removal of External Fixation / 대한정형외과학회잡지

Many authors have recommended delayed conversion to nailing of open tibial shaft fractures which had been treated initially with external fixation. Most authors have agreed that it was safe to first remove the external fixator, temporarily immobilize the limb in a cast or traction to allow for pin tract healing(generally 1 to 3 weeks), and then proceed to nailing. But, as far as we know, there was few data that had proven the time interval for pin tract healing was necessary to decrease the risk of deep infection. The purpose of this study was to evaluate the results of secondary nailing that was done immediately after removal of external fixator in the patients of open tibial shaft fractures. There were 12 males and 1 female with an average age of the 37.2 years(range, 18-64 years). The mean follow up period was 16.7 months(range, 12-23 months). The external fixation had been mainteined for an average of 47.5 days(range, 21-90 days). Indication of conversion to nailing without time interval was abscence of any serous discharge, reddness or local heating around pin-sites and normal range of laboratory data. All 13 fractures had united without additional surgical procedures or major complications such as deep infection. There were three superficial infections controlled with curettage and short period of oral antibiotics. On the basis of the favorable results of this study, we concluded that the time interval for pin tract healing is not an absolute prerequisite for preventing deep infection as far as no pin tract infection is present.

Diagnostic Landmarks of Ankle Syndesmosis Separation Measured on Standard Ankle Anterior - posterior Radiographs of Normal Korean Adults / 대한정형외과학회잡지

We performed standardized anterior-posterior radiographs of the normal ankle on 50 males and 50 females to determine the validity of current radiographic landmarks of the ankle syndesmosis separation. The average tibiofibular overlap was 6.9+/-2.1mm. The tibiofibular clear space was measured 4.1+/-0.9mm overall. The ratio of the tibiofibular overlap to the fibular width averaged 48+/-14%. Our data show that for 95% confidence intervals, the values for the syndesmosis separation are : (1) tibiofibular overlap less than 2.7mm, (2) tibiofibular clear space greater than 5.9mm, (3) tibiofibular overlap: fibular width ratio less than 24%. According to current diagnositc criterion of tibiofibular overlap under 10mm, 87% of this cohort was defined as syndesmosis separation. Other current criteria of tibiofibular clear space over 5 mm and tibiofibular overlap: fibular width ratio less than 24%, the false positivity was only 7% and 2%, respectively. Therefore the tibiofibular clear space and the tibiofibular overlap: fibular width ratio are more reliable diagnositc criteria for syndesmosis separation than the tibiofibular overlap.

Surgical Management of Thoracolumbar Spine Fracture with Pedicle Screws and Inferior Laminar Hooks / 대한척추외과학회지

STUDY DESIGN: Clinical and radiographic results of spine fracutre treated with pedicle screws and hooks were reviewed. OBJECTIVES: Evaluate the efficacy of tile pedicle screw and hook for thoracolumar bursting fracture. SUMMARY OF LITERATURE REVIEW: Despite of the mechanical advantage of the pedicle screw, the metal failure in short segment fusion has been reported. A biomechanical study showed additional laminar hook increased rotational strength. MATERIALS AND METHODS: Between 1994 and 1996, seventeen patients who had a Denis type B bursting fracture of the thoracolumbar spine were treated by posterior instrumentation with pedicle screws and laminar hooks and auterior interbody fusion after partial corpectomy. They have been followed for an average of 13.4 months. RESULTS: At last follow-up, radiographs showed successful fusion of the injured spinal segment in all patient. The subsidence of grafts which were used In anterior interbody fusion was an average of 0.76mm. There was a loss of 2.6 degrees on average in the correction of the kyphosis. No patients had screw breakage or loosening. CONCLUSIONS: We concluded that posterior fixation with screws and hooks, anterior decompression by partial corpectomy, and strut-grafting in patient who had a Denis type B bursting frafture of the thoracolumbar spine yielded good radiographic and functional results.

Enlargement of Tibial Bone Tunnel After Single: Incision Arthroscopically Assisted Reconstruction of Anterior Cruciate Ligaments

After reconstruction of anterior cruciate ligament, increased idameter of femoral or tibia1 bone tunnel has been obsened on plain radiogram. The etiology of radiographic tunnel enlargement is not well understood and the significance of this tunnel enlargement is unknown. This retrospective study reviewed tibial tunnel diameter in 34 cases of anterior cruciate ligament reconstructions. And we evaluated the correlation between the tibial tunnel enlargement and the position of screw fixation, instability, choice of graft, and clinical results at 1 year postoperatively. AII operation was per formed using a single incision technique. After 3 or 4 months and one year after operation, the diameter of tibial tunnel was measured with digital caliper on the plain radiogram. Tibial tunnel sclerotic margins were measured in the level Of medial tibial plateau on the lateral view of knee. Average tunnel enlargement of 3 allografts was 1.62mm and that of 15 autografts was 2.03mm. No significant difference was seen in KT-10000 arthrometer measurements between enlarged group (amount of enlage-ent >+1 S.D) and not-enlarged group (less than +1 S.D). No coelation was present between the increased tunnel diameter and Lysholm score. Cases with 10mm or more vertical distance between the most proximal point of tihial interference screw and the level of m4eial tibial plateau had average 1.15mm tibial tunnel enlargement and cases with less than 10mm vertical distance ha & I average 2.52mm tibial tunne] enlargement;the difference was not significant (P>0.05). The tibial tunnel enlargement was not correlated with position of screw, clinical results, stability of knee. The tibial tunnel enlargement was not caused hy only mechanical factor such as motion of intra-tunnel portion of graft-tendon.

Solitary Plexiform Neurofibroma on the Median Nerve: A Case Report / 대한정형외과학회잡지

Neurofibroma, one of the peripheral nerve tumor, is a complex benign tumor arising from skin, deep soft tissue, nerve tissue and bone. The incidence of peripheral nerve tumor is relatively low and it may occur either solitarily or diffusely. Plexiform neurofibroma, a type of neurofibroma, develops characteristically in the patients with von Recklinghausen's disease and its exact incidence is unknown. The case reports of solitary plexiform neurofibroma not associated with von Recklinghausen's disease were extremely rare. We reported a case of solitary plexiform neurofibroma on the median nerve.

Comparative Study of the Simple Curettage and the Curettage with Bonegraft in Enchondroma of the Hand / 대한정형외과학회잡지

To determine whether simple curettage is recommendable for the solitary enchondroma of hand, the results of the simple curettage and the curettage with bonegraft were compared in the respects of operation time, the degree of new bone formation, healing time and complications. Thirty five patients have been evaluated to assess the results of treatments. The bone healing and the degree of new bone formation have been evaluated according to the criteria of Tordai (l990). The bone healing had been achieved at average 7.4 months after operation in the simple curettage group and at average 4.6 months in the curettage with bonegraft group (P<0.05). According to Tordai's criteria, among the simple curettage patients, 9 cases (64%) were group I, 5 cases (36%) were group II, no case was group III. Among the curettage with bonegraft patients, 16 cases (76%) were group I, 4 cases (19%) were group II, 1 case (5%) was group III. No significant difference was observed between the two groups in the degree of new bone formation (P=0.05). Although the healing time was longer in the simple curettage group, no significant difference was found in the degree of new bone formation. The pain of the bone donor site was absent in the simple curettage group, and the simple curettage can reduce the operation time. The curettage alone is a recommendable treatment for solitary enchondroma in hand.

Treatment of the Open Tibial Shaft Fractures: a comparison of the Ilizarov external fixator and unreamed interlocking intramedullary nail / 대한정형외과학회잡지

Open fractures of the tibial shaft have a high incidence of complication and often result in poor outcomes. The most common method of stabilization is the external fixation by way of the Ilizarov method but the small diameter interlocking intramedullary nailing has also been introduced. The purpose of this study is to analyze the result of Ilizarov method and to compare its results with those of delayed intramedullary nailing used in the treatment of open tibial shaft fractures. We analyzed 81 patients with open tibial shaft fractures, treated using Ilizarov external fixator, or by delayed locked intramedullary nailing between January 1987 and December 1994. The follow-up period was an average 14.5 months. Out of the 81 patients, 58 patients were treated by nails and 23 patients by Ilizarov external fixators. Both groups were given the same initial management but the operation of the nailing group was delayed until proper soft tissue coverage and healing of the wound were evident. In the Ilizarov method group, 58 fractures obtained union within 26 to 53 weeks (average of 32.8 weeks) and in the nailing group, 23 fractures showed union within 14 to 51 weeks (average of 21.2 weeks). There was a significant difference between the two groups (P<0.05). Complications in the Ilizarov group included 4 nonunions, 12 delayed unions, 3 malalignments, 14 wound infections and 13 stiff ankles. There were no nonunion, 10 delayed unions, 8 malalignments, 6 wound infections and 11 stiff ankles in the nailing group. In this study, the Ilizarov group had more delayed unions and nonunions took a longer period of time to obtain the union, and had a more limited range of motion in the ankle, than the nailing group. The nailing group was easier to manage, especially in the soft tis-sue procedure, and it did not require a high level of compliance while having a relatively low risk of malunion.

Significance of Arthroscopy in Patients with Popliteal Cysts of Knees / 대한정형외과학회잡지

To evaluate the intra-articular pathology of popliteal cysts of knee, we performed arthroscopy on patients with popliteal cysts between February 1992 and February 1995. Thirty-one patients (32 cases) have been treated by excision of cyst after arthroscopy. Mean duration of follow-up was 15 months (13-19 months). Location of cysts was in the right knee in 17 cases, in the left knee in 13 cases, and bilateral in one case. Pain or swelling was present in 12 (38%), giving-way was reported by 4 cases. Three cases revealed quadryceps atrophy. The McMurray test was postive in 6 cases. After arthroscopy, the cysts were excised. Ninteen cases (59%) had associated intra-articular lesions: seven medial meniscal tears, two lateral meniscal tears, seven had chondral damages, one had medial plica syndrome, and one had rheumatoid arthritis, Communication between the cyst and the knee was present in 7 cases (22%), all of whom were over 40 years of age. Thirteen cases was younger than 30 years of age, and 11 cases of these cases had no intra-articular pathology. Two other cases had lateral meniscal tears and medial plica syndrome, respectively. We recommend arthroscopy in middle and older aged patients with popliteal cysts for evaluating and treating intra-articular lesions.

Intramedullary Nailing with Knowles Pin for the Clavicle Shaft Fracture / 대한정형외과학회잡지

In the review of a series of 71 clavicle shaft fracture that were treated with open reduction and internal fixation, we tried a direct comparison between two fixation modes, that is, the fixation with plate and screws (54 cases) and the intramedullary nailing with Knowles pin (17 cases). The average time to healing was not significantly different between the two group; 10.8 weeks after the plating and 11.7 weeks with Knowles pinning. The rate of successful healing within four months after the surgery were also high in both groups: one delayed union and one nonunion in the plate group, and one delayed union in the Knowles pin group. There was one loosening in the Knowles pin group, which needed reoperation. Intramedullary fixation has several advantages compared with fixation with a plate and screws. It can be performed through a shorter incision: less dissection of soft tissue is needed: and, after healing, the pin is easily removed through a small incision under local anesthesia.

Intraarticular Arthroscopic Finding in Grade III MCL Rupture / 대한정형외과학회잡지

The medial collateral ligament is the most commonly injured ligamentous structure of the knee. The management of the medial collateral ligament injuries were divided into surgical and conservative treatment. More recently, many investigators reported that isolated medial collateral ligament injuries did well under non-operative treatment. So, arthroscopic examination of the knee to rule out other intraarticular pathologic conditions such as cruciate ligament injuries, meniscal tear and osteochondral lesion is essential. From October 1993 to April 1995, we treated 45 cases of Grade III medial collateral ligament injuries and arthroscopic finding for cruciate ligament, meniscus, bony structure were analized in these cases. The result were as follows; 1. Anterior cruciate ligament injury:37.5% in +1 degree, 42.8% in +2 degree, 86.7% in +3 degree 2. Posterior cruciate ligament injury:12.5% in +1 degree, 13.4% in +2 degree, 33.3% in +3 degree 3. Meniscal injury:12.5% in +1 degree, 21.3% in +2 degree, 33.4% in +3 degree 4. Medial capsular ligament injury was more frequent and severe in the meniscofemoral ligament than in the meniscotibial ligament, but that finding was not correlated with degree of medial instability.