Open Reduction and Internal Fixation with AO Calcaneal Plate for Displaced Intra-articular Calcaneal Fracture

PURPOSE: To evaluate the surgical outcomes of open reduction and internal fixation of AO calcaneal plate in displaced intra-articular fractures of the calcaneus. MATERIALS AND METHODS: From January 2004 to July 2007, 25 patients with 27 displaced intra-articular calcaneal fractures were treated by open reduction and internal fixation using the AO calcaneal plate. Preoperative, postoperative evaluations and a follow-up after 1 year were done radiologically by the Bohler angle, Gissane angle, heel height and width among all patients. Their functional status was assessed by means of the Maryland foot score. RESULTS: The mean Bohler angle, Gissane angle, heel height and width were restored comparing with preoperative data. However, in Sanders type IV, some losses of reduction occurred at 1 year follow-up (p<0.05). The mean Maryland foot scores were 85 points in type II, 82 points in type III and 63 points in type IV. Sanders types significantly affected the clinical results (p<0.05). CONCLUSION: The AO calcaneal plate fixation using extensile L-shpaed lateral approach shows satisfactory radiologic and clinical results in the treatment of displaced intra-articular calcaneal fractures.

Effect of Hydroxyapatite on Bone Integration in a Rabbit Tibial Defect Model

BACKGROUND: The aim of the present study was to prepare hydroxyapatite (HA) and then characterize its effect on bone integration in a rabbit tibial defect model. The bone formation with different designs of HA was compared and the bony integration of several graft materials was investigated qualitatively by radiologic and histologic study. METHODS: Ten rabbits were included in this study; two holes were drilled bilaterally across the near cortex and the four holes in each rabbit were divided into four treatment groups (HAP, hydroxyapatite powder; HAC, hydroxyapatite cylinder; HA/TCP, hydroxyapatite/tri-calcium phosphate cylinder, and titanium cylinder). The volume of bone ingrowth and the change of bone mineral density were statistically calculated by computed tomography five times for each treatment group at 0, 2, 4, 6, and 8 weeks after grafting. Histologic analysis was performed at 8 weeks after grafting. RESULTS: The HAP group showed the most pronounced effect on the bone ingrowth surface area, which seen at 4, 6, and 8 weeks after graft (p 0.05). On histological examination, the HAP group revealed well-recovered cortical bone, but the bone was irregularly thickened and haphazardly admixed with powder. The HAC group showed similar histological features to those of the HA/TCP group; the cortical surface of the newly developed bone was smooth and the bone matrix on the surface of the cylinder was regularly arranged. CONCLUSIONS: We concluded that both the hydroxyapatite powder and cylinder models investigated in our study may be suitable as a bone substitute in the rabbit tibial defect model, but their characteristic properties are quite different. In contrast to hydroxyapatite powder, which showed better results for the bone ingrowth surface, the hydroxyapatite cylinder showed better results for the sustained morphology.

Risk Factors of Nonunion Demanding Surgical Treatment after Lumbar Posterolateral Fusion

STUDY DESIGN: This is a retrospective study for radiographically and clinically assessing nonunion after lumbar spine fusion. OBJECTIVES: We wanted to analyze the risk factors for nonunion that requires surgical treatment after lumbar spine fusion SUMMARY OF THE LITERATURE REVIEW: A diagnosis of the nonunion after lumbar spine fusion was made by using only the only radiologic images. The incidence of nonunion has been underreported because there are many asymptomatic patients. MATERIALS AND METHODS: The plain X-ray films were evaluated for 1317 patients who could be followed up more than 1 year after lumbar fusion. Nonunion was diagnosed at 1 year after fusion by instability seen on the flexion-extension radiograph and the clinical findings like as sustained pain and local tenderness at the surgical site. The risk factors we reviewed included age, the number of levels fused, associated diseases, smoking, alcohol drinking, the initial diagnosis, a previous history of spinal operation, infection, a clear zone and malposition of pedicle screws and metal failure. The relations between nonunion and the factors mentioned above were analyzed. RESULTS: Thirty-nine patients were diagnosed as having nonunion underwent reoperation and all had surgically confirmed nonunion. Smoking, infection and a previous history of spine operation had a significant influence on nonunion (p < 0.05). Clear zones persisting more than 1 year and metal failure also had a significant influence on nonunion (p < 0.05). Age, the number of fused levels, the initial diagnosis and alcohol drinking were not shown to influence the rate of nonunion (p < 0.05). CONCLUSION: A through clinical and radiologic evaluation is essential to diagnose nonunion, and this should not be done according to the radiologic images only. Risk factors such as a previous history of spine operation, infection, smoking, the development of a clear zone and metal failure all showed a statistically significant influence on nonunion. Additionally, preoperative and postoperative evaluation of these parameters is needed to achieve bone union.

Bipolar Hip Arthroplasty vs. Total Hip Arthroplasty for Osteonecrosis of the Femoral Head / 대한정형외과학회잡지

PURPOSE: To retrospectively compare surgical outcomes between bipolar hip arthroplasty and total hip arthroplasty in patients with osteonecrosis of the femoral head. MATERIALS AND METHODS: Between April 2000 and July 2004, we reviewed 51 cases with Ficat stage III osteonecrosis of the femoral head that underwent bipolar hip arthroplasty (BHA) and 52 cases that received total hip arthroplasty (THA). The minimum follow-up period was 5 years. All prostheses used in the current study had cementless stem and metal-on-polyethylene bearings. We analyzed clinical and radiological results, reoperation, operation time and blood loss the BHA group (mean follow-up of 81 months) and the THA group (82 months). RESULTS: There were no statistically differences between the two groups in preoperative and postoperative mean Harris hip scores. There were no significant differences between the two groups in clinical results, including persistent inguinal pain and radiologic changes around the acetabular cup and femoral stem (p>0.05). Three cases (5.9%) in the BHA group and 5 cases (7.7%) in the THA group underwent revisions. The mean operation time was 96 minutes in the BHA group and 118 minutes in the THA group. Mean blood loss was 625 cc in the BHA group, and 784 cc in the THA group. The differences between the two groups in mean operation time and blood loss were significant (p<0.05). CONCLUSION: The BHA group, which used cementless stem and metal-on-polyethylene bearings for Ficat stage III osteonecrosis of the femoral head, showed no significant differences from the THA group in postoperative radiologic change, clinical evaluation, and reoperation during 81 months of mean follow-up.

Clinical Outcome of Surgical Treatment for Intra-articular Distal Humerus Fracture

PURPOSE: To evaluate functions of the elbow joint according to surgical approach, time to exercise, and type of fracture after surgical treatment for the intra-articular comminuted fracture of the distal humerus. MATERIALS AND METHODS: 27 patients with the intra-articular comminuted fractures of the distal humerus underwent surgery from March, 2000 to January, 2007. We investigated the surgical approach, time for union, time to exercise and age. We also evaluated postoperative functions of the elbow joint according to the flexion contracture, the range of motion and the Mayo elbow performance score. RESULTS: The average follow-up period was 37 months and the average time for union was 14 weeks. The average range of flexion was 115 degrees, the average flexion contracture was 10 degrees, and the Mayo elbow performance score with average value of 85 point showed good clinical results. There were no statistically significant differences in functions of the elbow joint according to the operative method and age. However, patients with early postoperative exercise within 6 days showed statistically better outcomes than patients with postoperative exercise after 7 days. Type C1, 2 fractures showed statistically better results than the type C3 fracture. CONCLUSION: Stable fixation and early exercise are required to prevent postoperative complications and restore functions of the elbow joint with an intra-articular comminuted fracture of the distal humerus.

Anterior Knee Pain after Intramedullary Tibial Nailing / 대한정형외과학회잡지

PURPOSE: To document the incidence and analyze the causes of anterior knee pain following closed intramedullary nailing for tibial fractures. MATERIALS AND METHODS: Between January 2005 and February 2007, 50 tibial fractures (48 patients) were treated using locked intramedullary nails. We examined the relationship between postoperative anterior knee pain and age, gender distribution, mechanism of injury, cause and type of fracture, method of patellar tendon incision, and position of the nails on radiography. Anterior knee pain was assessed using a visual analogue scale (VAS). Pearson chi-square test was used to assess the incidence of knee pain. RESULTS: At a mean follow-up period of 16 months (range 13-30 months), 23 cases (46%) had developed anterior knee pain. Knee pain was more common in woman (p=0.000), but there was no statistically significant difference with regard to age, cause or type of fracture, reaming or incision technique. If the knee apex distance was below -30 mm on radiological analysis, there was no statistically significant increase in postoperative knee pain (p=0.000). Nail removal resolved or improved the symptoms in 77% of patients with anterior knee pain. CONCLUSION: Based on these data, nail prominence correlated with increased knee pain. We believe surgeons can decrease the severity of knee pain after tibial nailing by burying the tip of the nail as reflected on lateral radiographs.

The Analysis of Prognostic Factors on Unstable Burst Fracture on the Thoracolumbar Spine / 대한척추외과학회지

STUDY DESIGN: A retrospective clinical and radiological analysis OBJECTIVES: To determine the relationship between the classifications of unstable burst fractures on the thoracolumbar region, radiologic studies, signal change area on MRA and analysis of the prognostic factors. SUMMARY OF LITERATURE REVIEW: MRI is the first imaging modality that visualizes the extent of spinal cord derangement directly and it has the potential to provide an accurate diagnosis and prognosis. MATERIALS AND METHODS: From March 1998 to September 2006, 39 patients who were eligible for a follow up of more than 1 year with an unstable burst fracture on the thoracolumbar region were studied. With these cases, The size of the bone fragment at the initial injury, signal change area on MRI, time to surgery, reduction rate of the bone fragments, recovery of the posterior curvature of the vertebrae and height of the vertebral body were analyzed. RESULTS: The mean fracture size rate, average time to surgery, reduction rate of bone fragment and the recovery rate of the height of the vertebral body was 46.1+/-12.8%, 17+/-4.5 hours, 35.2+/-10.1%, and 57.9+/-17.4%, respectively. The data shows that the time elapsed until surgery had no relationship with the prognosis (P=0.317). Injuries with broad signal changes on MRI were not associated with the reduction rate of bone fragments, recovery of posterior curvature of the vertebrae and the height of the vertebral body. CONCLUSIONS: In unstable burst fractures of the thoracolumbar region, although a comparison of the prognostic factors on simple X-ray film had no significance, it still has significant meaning when correlated with the signals on MRI.

Risk Factors for Adjacent Segment Disease after Posterolateral Lumbar Fusion / 대한척추외과학회지

STUDY DESIGN: This is a retrospective study. OBJECTIVE: We wanted to analyze the treatment outcome and the risk factors for adjacent segment disease after lumbar fusion. SUMMARY OF LITERATURE REVIEW: Biomechanical alterations likely play a primary role in causing adjacent segment disease. Radiographically apparent, asymptomatic adjacent segment disease is common after lumbar fusion, but this does not correlate with the functional outcomes. MATERIALS AND METHODS: We reviewed 544 patients who underwent lumbar fusion at a minimum of 5-year follow-up between March 1993 and August 2006. Risk factors analysis was performed for 48 of 544 patients with adjacent segment disease and who were needed a second operation, and the treatment outcomes were assessed for 46 patients with a minimum 1-year follow-up after the second operation. The average interval to the second operation was 4.5 years, and the average follow-up after the second operation was 34.5 months. The treatment outcome was assessed by using the modified Brodsky criteria and the reoperation rate was assessed in relation to several risk factors. RESULTS: Excellent and good operative results were obtained in 29 cases (63%) and bony fusion was achieved in 41 cases (89%). Of the risk factors we examined, multi-level fusion, a high grade of initial radiographic degeneration, the loss of physiologic lumbar lordosis and the involvement of degenerative scoliosis were associated with a high reoperation rate, with statistical significance. Age, gender, the initial diagnosis, the upper placement of the proximal screws and the extent to the sacrum were not correlated with the reoperation rate. CONCLUSION: The treatment outcome was relatively satisfactory; however, the factors influencing the treatment outcome of the second operation still need to be considered. The fusion level, the initial radiographic degeneration, the preservation of lumbar lordosis and the involvement of degenerative scoliosis are considered to be risk factors for the failure of lumbar fusion.

Cause and Treatment of the Nonunion of Femoral Shaft Fracture after Interlocking Intramedullary Nailing

PURPOSE: To analyze the causes and the clinical results of treatment for the nonunion of femur shaft fractures that occurred after interlocking intramedullary nail fixation. MATERIALS AND METHODS: We reviewed 19 cases of aseptic nonunion of femur shaft fracture in 174 patients after interlocking IM nailing from March 1999 to February 2004 and followed up for more than one year. First we investigated the factors causing nonunion. For operative options, two methods about exchange nailing and exchange nailing with bone graft were performed. Finally clinical results were analyzed with bone union rate by treatment methods and compared with the nonunion factors statistically. RESULTS: According to the causes and types of nonunion, we performed larger IM nail change in 10 cases and IM nail change with bone graft in 9 cases. Bone union was achieved in all cases. Average bone union period were 18.5 weeks in exchange group and 16.1 weeks in exchange with bone graft group. There are significant difference between treatment methods statistically (p<0.05). Compared with the nonunion factors, initial open fracture and smoking groups showed late union rate statistically. CONCLUSION: Based on our analysis, IM nail change is a useful method for nonunion after initial IM nailing in femoral shaft fracture, and additional bone graft that according to the radiologic pattern and stability, especially the fracture gap is also a useful option for nonunion treatment.

Costoclavicular Syndrome: A Case Report

Costoclavicular syndrome is one of the four syndromes of thoracic outlet syndrome in which have similiar symptoms, and may result from cervical and thoracic scoliosis, formation of excessive callus or nonunion after fractures of clavicle or first rib. Conservative treatment may be offered. Surgical treatment includes scalenectomy with supraclavicular approach, transaxillary first rib resection with scalenectomy and correction of clavicular abnormality. The purpose of this paper is to evaluate the result of surgical intervention in costoclavicular syndrome of a 38-year old man with clavicular nonunion after an operation.

Treatment Outcome and Prognosis Regarding to MR Pattern and Signal Area in Spinal Cord Injury / 대한척추외과학회지

STUDY DESIGN: To determine the capability to predict the clinical manifestations and treatment outcomes of traumatic cervicothoracic cord injury patients based on MR images. OBJECTIVE: To determine the relationship between the differences in MR patterns and signal areas according to Maravilla and Cohen's classification and the PACS system compared with the Frankel classification, in patients that demonstrated neurologic improvement within 1 year. SUMMARY OF LITERATURE REVIEW: MR is the first imaging modality that directly visualizes the extent of spinal cord derangement, and thus, it has the potential to provide an accurate diagnosis of an injury and to determine the prognosis. MATERIALS AND METHODS: MR images were evaluated within 3 days of trauma in 36 spinal cord injury patients. The clinical follow-up period was more than 1 year. Quantitative analysis of spinal cord lesions was performed according to the PACS system. RESULTS: According to Maravilla and Cohen's classification, 36 cases were classified as follows: 8 cases of type I, 10 cases of type II, 9 cases of type III and 9 cases of type IV. There was 1 case of type I, 8 cases of type II, 5 cases of type III, and no cases of type IV, who demonstrated neurologic improvements of more than 1 grade in the Frankel classification. An analysis of the signal areas according to the PACS system demonstrated no cases of areas greater than 100 mm2, 5 cases of areas between 50 to 100 mm2, and 9 cases of areas less than 50 mm2 who demonstrated neurologic improvement. CONCLUSION: Classification according to the differences between MR imaging and MRI signal areas in patients with spinal cord injuries demonstrated the indicators of neurologic improvement; therefore, we MR imaging can be utilized as a prognostic factor in cases of spinal cord injuries.

Treatment of Hallux Valgus with Metatarsal Double Osteotomy and Longitudinal Pin Fixation / 대한족부족관절학회지

PURPOSE: The purpose of this study was to analyze the results of the treatment of hallux valgus with metatarsal double osteotomy and longitudinal pin fixation. MATERIALS AND METHODS: We reviewed 19 patients (21 feet) who had been treated by metatarsal double osteotomy and longitudinal pin fixation for the moderate or severe hallux valgus with increased distal metatarsal articular angle (DMAA), between 1999 and 2004. They were followed prospectively for a minimum of 20 months. Functional outcomes were measured via Hallux metatarsophalangeal-Interphalangeal (HMI) scale and Mayo clinic forefoot scoring system (FFSS). Radiographically, we assessed pre, postoperative and at the last follow-up, the hallux valgus angle (HVA), 1st and 2nd intermetararsal angle (IMA), DMAA. RESULTS: The average preoperative HVA, IMA, DMAA measured 36.76 degrees, 13.62 degrees, 26.00 degrees, respectively. At the last follow-up, HVA, IMA, DMAA measured 9.57 degrees, 7.14 degrees, 9.33 degrees. The correction of HVA, IMA, DMAA were 27.19 degrees, 6.48 degrees, 16.67 degrees. At the last follow-up, there were no recurrences and complications, except two patients complained of unsatisfactory stiffness in the 1st metatarsophalangeal joint and subjectively rated their results as fair. The others rated that as excellent or good. At the last follow-up, statistically, the mean HMI scale and FFSS improved significantly from pre-operative score. CONCLUSIONS: In the treatment of moderate or severe hallux valgus with increased DMAA by metatarsal double osteotomy and longitudinal pin fixation, we had good functional and radiological results without recurrences and significant complications. But the stiffness in the 1st metatarsophalangeal joint warrants further study.

Fine Classification and Treatment Outcome of Lateral Condyle Fracture of the Humerus in Children / 대한정형외과학회잡지

PURPOSE: This paper reports the outcome and complications of a lateral condyle fracture of the humerus in children treated by the fine classification of Jakob stage. MATERIALS AND METHODS: Forty-five cases of a lateral condyle fracture of the humerus in children were treated according to the fine classification of the Jakob stage. There were 4 cases of Jakob stage Ia fractures treated with the application of a simple cast; 16 cases of Jakob stage Ib & IIa fractures treated with a closed reduction and k-wire pinning; and 25 cases of Jakob stages IIb & III fractures treated with an open reduction and K-wire pinning. The average follow-up period was 25 months. RESULTS: Postoperative complications were seen in 18 cases. As minor complications, there were 2 cases of delayed union, 5 cases of hypertrophy of the lateral condyle and 10 cases of osteophyte formation. As major complications, 1 case of avascular necrosis and limitation of motion developed. There were no serious complications such as nonunion, malunion, ectopic ossification, early arrest of the growth plate, and nerve injury. The clinical outcomes were excellent in all but one case of a joint motion limitation. CONCLUSION: The fine classification of the Jakob stage is effective in determining the treatment method for lateral condyle fractures of the humerus in children.

The Factors Affecting Surgical Results in Cervical Spondylotic Myelopathy / 대한척추외과학회지

STUDY DESIGN: This is a retrospective study on the factors affecting the surgical results for cervical spondylotic myelopathy. OBJECTIVES: We wanted to analyze the clinical and radiologic factors affecting the results of treatment for cervical spondylotic myelopathy patients who underwent anterior decompression with fusion or open door laminoplasty. SUMMARY OF THE LITERATURE REVIEW: Many authors have reported on the prognostic factors affecting the results of surgical treatment for cervical spondylotic myelopathy; some of the reported factors do affect the results, but there is a wide range of opinion about them. MATERIALS AND METHODS: We reviewed 38 patients who underwent anterior decompression with fusion or open door laminoplasty for cervical spondylotic myelopathy between March 1999 and Dec. 2003. We analyzed the factors, including age, the duration of symptoms, the symptomatic classification, the preoperative and postoperative JOA scores, the compression ratio of the spinal cord and the surgical method. RESULT: The mean JOA score increased from 10.3+/-3.4 preoperatively to 14.9+/-4.6 postoperatively with a recovery rate of 69.0% +/- 21.24%. The preoperative JOA score and the compression ratio of the spinal cord on MRI correlated positively with the recovery rate. The patients' age showed negative correlation with the recovery rate. There is no difference between the two surgical methods for the recovery rate. CONCLUSION: The preoperative JOA score, the patients' age and the spinal cord compression ratio on MRI are the prognostic factors affecting the surgical results, but there are no difference between the two surgical method.

Results of Operative Treatment of Distal Femoral Fracture

PURPOSE: To evaluate the result of comparative study about the cases in the fracture of the distal femur treated with plate and screw, dynamic condylar screw, blade plate, retrograde intramedullary nail and external fixator. MATERIALS AND METHODS: The AO classification system was used. 84 cases who were preformed operation during the period from March 1996 to May 2002, were included in this study. The mean duration of follow-up was 25 months. According to Sachatzker criteria, we classified the following results to excellent, good, fair and poor. RESULTS: Type A were excellent or good result when treated with plate and screw, dynamic condylar screw and retrograde intramedullary nail. Type B were excellent or good result when treated with cannulated screw. Type C were excellent or good result when treated with plate and screw and blade plate. CONCLUSION: We conclude that the most important thing in operation is firmly internal fixation and to obtain this, accurately anatomical reduction and the choice of suitable instrument for the type of the fracture are needed. cannulated screw. Type C were excellent or good result when treated with plate and screw and blade plate.

The Influence of the Degree of Lumbar Disc Degeneration on MRI and the Amount of Removed Disc on Clinical Outcomes / 대한척추외과학회지

STUDY DESIGN: The influence of lumbar disc degeneration, the space-occupying ratio on MRI and the amount of removed disc on the clinical outcomes of an open discectomy were analyzed retrospectively. OBJECTIVES: This study analyzed the pre and post-operative factors associated with the clinical outcome of an open discectomy. SUMMARY OF LITERATURE REVIEW: Much controversy still exists regarding the factors that influence the clinical outcome following an open discectomy. MATERIALS AND METHODS: Out of 207 patients who had been treated with an open discectomy for a lumber disc herniation, between April 1997 and December 2003, 161 patients who underwent MRI with the same apparatus, with at least 6 months of follow-up, were analyzed. The study group was composed of 111 men and 50 women, with a mean age at the time of surgery of 33.1 years old. The mean follow-up period was 42 months. The degree of disc degeneration was classified according to the Thompson's classification, and the extent of the discectomy was measured by the volume. The postoperative outcomes were judged using Nayer's classification. RESULTS: The highest frequency of disc herniation occurred at the L4-5 level, with being of the subligamentous extrusion type. The disc degeneration observed on MRI had a high statistical correlation with age (p0.05). Clinically, 123 cases were more than fair, and 4 cases underwent reoperation due to recurrence. The clinical outcome, sex, age and space-occupying ratio were of little statistical value (p>0.05). Statistically, the greater the amount of disc removed, the better the clinical outcome (p<0.05). Those with disc degeneration classified as grade 3 from the MRI had unsatisfactory clinical outcomes (p<0.05). CONCLUSIONS: Those with disc degeneration classified as grade 3 from the MRI had unsatisfactory clinical outcomes. The greater the amount of disc removed the more satisfactory the clinical outcomes. No statistical relationships were found between the space-occupying ratio and the clinical outcome.

The Influence of the Degree of Lumbar Disc Degeneration on MRI and the Amount of Removed Disc on Clinical Outcomes / 대한척추외과학회지

STUDY DESIGN: The influence of lumbar disc degeneration, the space-occupying ratio on MRI and the amount of removed disc on the clinical outcomes of an open discectomy were analyzed retrospectively. OBJECTIVES: This study analyzed the pre and post-operative factors associated with the clinical outcome of an open discectomy. SUMMARY OF LITERATURE REVIEW: Much controversy still exists regarding the factors that influence the clinical outcome following an open discectomy. MATERIALS AND METHODS: Out of 207 patients who had been treated with an open discectomy for a lumber disc herniation, between April 1997 and December 2003, 161 patients who underwent MRI with the same apparatus, with at least 6 months of follow-up, were analyzed. The study group was composed of 111 men and 50 women, with a mean age at the time of surgery of 33.1 years old. The mean follow-up period was 42 months. The degree of disc degeneration was classified according to the Thompson's classification, and the extent of the discectomy was measured by the volume. The postoperative outcomes were judged using Nayer's classification. RESULTS: The highest frequency of disc herniation occurred at the L4-5 level, with being of the subligamentous extrusion type. The disc degeneration observed on MRI had a high statistical correlation with age (p0.05). Clinically, 123 cases were more than fair, and 4 cases underwent reoperation due to recurrence. The clinical outcome, sex, age and space-occupying ratio were of little statistical value (p>0.05). Statistically, the greater the amount of disc removed, the better the clinical outcome (p<0.05). Those with disc degeneration classified as grade 3 from the MRI had unsatisfactory clinical outcomes (p<0.05). CONCLUSIONS: Those with disc degeneration classified as grade 3 from the MRI had unsatisfactory clinical outcomes. The greater the amount of disc removed the more satisfactory the clinical outcomes. No statistical relationships were found between the space-occupying ratio and the clinical outcome.

Prognostic Factors Associated with Revision Operation of Spine (Second Review) / 대한척추외과학회지

STUDY DESIGN: Patients who had had a revision operation were classified according to their outcome OBJECTIVE: To review a consecutive series of patients who had had a revision operation on the lumbar spine and to determine which factors contributed to a successful outcome. SUMMARY OF LITERATURE REVIEW: The long-term failure rates after the primary surgery on the spine have been reported to be as high as 30 %. MATERALS AND METHODS: This study analyzed 57 patients who had had a revision operation on the lumbar spine between Sep-tember 1995 and December 2001, and had been followed for a minimum of two years and were available for analysis. All the patients had had a decompression and instrumented fusion except for two patients who had just undergone a bone graft. These patients were followed for an average of 39 months. There were 37 men and 20 women. The patients had undergone one or more surgical procedures and an average of 54 months had elapsed since the most recent operation. The average age at the time of the revision was 52 years. The outcome was considered to be successful if the patient had met the all three criteria (Ed note: What were the 3 criteria?). Several factors were evaluated using multiple regression (level of significance, P<0.05) to be determine which were related to a successful outcome. RESULTS: Statistical analysis revealed that the factors associated with a successful outcome were a younger age (p<0.02), fewer spinal levels of revision surgery (p<0.05), pain-free interval after a previous operation (p<0.01). No significant relationship was observed between the outcome and gender, the number of prior procedures, the spinal level operated on, the presence of preoperative neurological signs and the intervals between the previous surgery and the revision. CONCLUSION: These results suggest that the prognostic factors are useful for evaluating the successful outcome of revision surgery of the spine.

Factors Influencing to Clinical Outcomes of the Surgically Treated Degenerative Lumbar Spondylolisthesis / 대한척추외과학회지

STUDY DESIGN: To examine the factors considered in the selection of therapeutic methods, and the methods for accessing postoperative clinical outcomes, in degenerative lumbar spondylolisthesis. OBJECTIVES: In this retrospective study, patients who had taken only posterolateral fusion, and with a posterior lumbar interbody fusion, were evaluated. The analyses of the pre- and post-operative factors associated with the clinical outcomes of the surgery for degenerative lumbar spondylolisthesis were also performed. MATERIALS AND METHOD: Of the patients who had received the surgery for degenerative lumbar spondylolisthesis, between January 1995 and December 2000, there were 59 for whom follow-up observations were possible, and these were selected for the present study. The patients were comprised of 19 males and 40 females, with ages ranging from 42 to 74 years (58.4+/-8.4 years old). Of the 59 patients, 39, and 20, received a posterolateral fusion, or both a posterolateral fusion and a posterior lumbar interbody fusion, respectively. In the present study, the pre-operative factors considered were the surgical method, sex, age, L1 axis S1 distance (LASD), lordosis angle and the degree and duration of spondylolisthesis, with the degree of fusion, the lordosis angle of the fused body, the lordosis angle at the final follow-up and the lordosis angle of the fused body at the final follow-up, used as the post-operative factors. Each factor was statistically tested to see if it had a significant correlation with clinical outcomes (Recovery rate by Hirabayashi's method). A value of P < 0.05 was considered as being statistically significant. RESULT: The posterolateral fusion group showed a significantly lower recovery rate with an LSAD over 35 mm, a degree of spondylolisthesis over 10 mm and a pre-operative lordosis angle under 20 degrees, indicating that an additional posterior lumbar interbody fusion would provide a good clinical outcome. At the final follow-up, both groups showed significantly lower recovery rates with a lumbar lordosis angle under 20 degrees, and the posterolateral fusion group showed significantly lower recovery rates when the post-operative lordosis angle of the fused segment was under 18 degrees, and with a lordosis angle of the fused segment was under 18 degrees at the final follow-up. These post-operative factors showed significant correlations with the clinical outcomes. CONCLUSIONS: It is considered that an additional posterior lumbar interbody fusion is indicated in patients with a LSAD over 35 mm, an anterior slippage over 10 mm and a lumbar lordosis angle over 20 degrees. It is also considered that the lordosis angles of the fused segment, and the post-operative lumbar lordosis, are important factors that require peri-operative correction and maintenance.

Outcome of Different Grafted Bone in Lumbar Posterolateral Fusion / 대한척추외과학회지

OBJECTIVES: Using a retrospective analysis on the fusion rate and the postoperative improvement in symptoms, this study evaluated the clinical feasibility of a bone graft in lumbar fusion surgery in the following cases: (1) Group I: local autograft, (2) Group II: local autograft and iliac crest autograft, and (3) Group III: local autograft and customized heterograft. MATERIALS AND METHODS: Among the patients who had undergone a decompression and lumbar posterolateral fusion for various lumbar diseases, between January 1997 and December 1999, 178, in who 2 year follow-up observations had been possible, were selected for this study. The patients were allocated to 1 of 3 groups, Group I (47 patients), Group II (57 patients) and Group III (74 patients). For each group, the mean patient ages were 58.3, 49 and 62.4 years old, respectively, with male to female ratios of 24:23, 23:24 and 36:38. Postoperative radiographs were taken at 2 weeks, 3 months and 1 year, and further follow-up observations were conducted at 1-year intervals. The bone fusions was determined, along with the fusion rates, based on Lenke's criteria, and the post-operative clinical outcomes were evaluated as excellent, good, normal and poor, using Kim's method. A statistical analysis was performed with Chi-square tests. RESULTS: From the follow-up observations for over a year, the radiographic evaluations showed that the fusion rates of Groups I and II, over B: 86.6 and over B: 88.9%, were superior to the over B: 80.1% of Group III, but with no statistical significance. For the clinical outcomes, the 78.1 88% over good results were superior to the 69.4% of Group III, which also showed statistical significance. CONCLUSIONS: The selective use of customized heterograft was assumed to be effective in an insufficient autogenous bone or a difficult autogenous bone collection even though it causes significantly lower improvement in the symptoms.