Anomalous Course of Superficial Peroneal Nerve in Distal Fibular Fracture / 대한정형외과학회잡지

PURPOSE: The purpose of our study was to assess the anomalous location and course of the superficial peroneal nerve (SPN), which were come across during exposure of distal fibula fracture. MATERIALS AND METHODS: We operated on 238 cases of ankle fractures, and examined the anomalous location and course of SPN around the distal part of the fibula. The study was performed prospectively. RESULTS: The mean length of surgical exposure was 9.8 cm. In 10 (4%) of 238 cases, the nerve was anomalous in its course, which was in parallel with the distal fibula and rapidly curved anteriorly at 3.5 cm proximal to the tip of the fibula. We found 3 cases of injury to the SPN; one was completely transected, the second was partially transected, and the third was stretched over the fracture site, at 2.5 cm, 5 cm, and 6 cm proximal to the tip of distal fibula, respectively. CONCLUSION: We emphasize the importance of a detailed neurologic examination, including sensory test for patients with ankle fractures, because of the variation in course of the SPN around the distal fibula.

Cementless Total Hip Arthroplasty Using a Modular Femoral Component in Patients with Femoral Head Osteonecrosis: Comparison of Metal-on-Metal and Ceramic-on-Ceramic Articulation

PURPOSE: The purpose of this study was to evaluate the clinical and radiological outcomes after total hip arthroplasty using the S-ROM modular system for osteonecrosis of the femoral head, and to compare the results between the groups using metal-on-metal articulation and ceramic-on-ceramic articulation. MATERIALS AND METHODS: Sixty-six patients (78 hips) with osteonecrosis of the femoral head were evaluated after primary total hip arthroplasty between January 2001 and December 2004, using an S-ROM proximal modular femoral stem. The average follow-up was 77 months (range, 60 to 122 months) and all patients were followed for more than five years. RESULTS: The average Harris hip score improved from 53 points to 88.5 points at the final follow-up. At the latest radiologic evaluation, sixty-seven stems had bony ingrowth stability, and 10 stems had stable fibrous ingrowth. However, one stem had diffuse extensive osteolysis and loosening, which was revised at 9 years. Postoperative complications included 4 cases of heterotrophic ossificiation, 1 case of linear fracture after insertion of the femoral stem, 1 case of dislocation, 2 cases of infection, and 1 case of extensive osteolysis and loosening. There were 3 cases of revision and Kaplan-Meier survivorship analysis with revision estimated at a 95.7% chance of survival for the femoral component during 122 months. CONCLUSION: Our study showed that total hip arthroplasty using the S-ROM modular system with metal-on-metal articulation or ceramic-on-ceramic articulation had favorable clinical and radiological mid- to long-term results.

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.

Matrix Metalloproteinase-1 and Transforming Growth Factor-beta1 Expression during Distraction Osteogenesis and Fracture Healing of the Rat / 대한정형외과학회잡지

PURPOSE: To evaluate the temporal and spatial expression of Transforming Growth Factor-beta1 and Matrix Metalloproteinase-1 in distraction osteogenesis and fracture healing models. MATERIALS AND METHODS: Distraction osteogenesis was performed on the tibial diaphyses of Sprague- Dawley rats (latent period for 1 week, distraction for 2 weeks). The rats were euthanized at each week and the level of mRNA expression was assessed by real-time RT PCR and immunohistochemical staining. RESULTS: Although the level of TGF-beta1 mRNA and MMP-1 mRNA expression was increased during distraction osteogenesis and fracture healing, the level of mRNA expression was significantly higher in the distraction phase in the distraction group than in the fracture healing group at the same phase. After the distraction phase, the level of mRNA expression in both groups decreased to the base line. The peak expression of mRNA was followed by that of TGF-beta1 mRNA. Immunohistochemical staining revealed that TGF-beta1 was expressed mainly in the osteoblast and endothelial cells, and MMP-1 was expressed mainly in the endothelial cells of the vessel. CONCLUSION: There is specific time sequence in the expression of TGF-beta1 and MMP-1 during fracture healing and distraction osteogenesis. These results suggest that TGF-beta1 expression might be associated with the angiogenesis induced by MMP-1 expression during new bone formation.

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.

Usefullness of Routine MR-Myelography at MRI for Multiple Lumbar Stenosis / 대한정형외과학회잡지

PURPOSE: To determine if MR myelography (MRM) improves the interpretation of the severity of stenosis in patients with a multi-level lumbar stenosis. MATERIALS AND METHODS: Among the patients referred for MRI with MRM prospectively, 100 patients over 50 years old with multiple lumbar stenosis were enrolled in this study. The most severe stenotic level and the degree of stenosis at that level according to the extent of the remaining subarachnoidal space (1: normal to 50%, 2: over 50% but not a total block, 3: total block) were evaluated in a blinded manner by two observers. Conventional MRI (class A), MRM (class B) and MRI+MRM (class C) was evaluated independently and the interobserver and intraobserver reliability were assessed. RESULTS: In the selection of the most severe level and degree of stenosis, both observers showed a higher level of consensus with classes B and C than classes A and C. The interobserver k average values for the selection of the most severe level in classes A, B and C were 0.649, 0.782 and 0.832, respectively. In terms of the degree of stenosis, the average in classes A, B and C were 0.727, 0.771 and 0.784, respectively. The intraobserver k values for the above two items were the highest in class (B), followed by (C) and (A) in all observers and within the range of "almost perfect" (0.81< or =k< or =1) except for the selection of the level of one observer in clause A. CONCLUSION: MRM when used in routine practice can help improve the observer reliability in assessing the severity of stenosis in multiple lumbar stenosis.

Surgical Treatment of Spontaneous Cervicothoracic Spine Epidural Hematoma without Risk Factors: A Case Report / 대한척추외과학회지

Spinal epidural hematomas can often result from a spinal tap, trauma, pregnancy, bleeding diathesis, vascular malformations, hypertension, etc. However, a spontaneous spinal epidural hematomas (SSEH) without any risk factors are relatively rare clinical entities and the clinical suspicion is very difficult in an acute setting. The outcome for patients with SSEH usually is determined by the speed of the diagnosis and the initiation of the appropriate treatment. We present a good surgical outcome of a rare case of acute SSEH without any risk factors. The patient presented initially with paresis of both upper and lower extremities, upper thoracic and neck pain and mild headache. We report the diagnosis and treatment method of SSEH in this case with a review of the relevant literature.

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.

Effect of Carboxy Methyl Chitosan on Experimental Osteoarthritis in a Rabbit Knee: Carboxy methyl chitosan vs. Hyaluronan / 대한정형외과학회잡지

PURPOSE: This study evaluates the effect on carboxy methyl chitosan on the articular cartilage of an osteoarthritic knee. MATERIALS AND METHODS: The biological effect of chitosan on the osteoarthritic articular cartilage was compared with hyaluronan, which is one of the treatment modalities for an osteoarthritic knee. Chitosan or hyaluronan were injected into the intraarticular space of the experimental osteoarthritic knee of a rabbit with a transected anterior cruciate ligament at weekly intervals for 5 weeks, and the articular cartilage and synovium were obtained. Nine weeks later, the specimens were analyzed by their gross findings, histological examinations, and histo-morphometric studies. RESULTS: The hyaluronan and chitosan group showed less severe osteoarthritic changes than the control group. Although the hyaluronan group showed less severe osteoarthiricic changes than the chitosan group, there was no statistical significance. CONCLUSION: Carboxy methyl chitosan, which has an excellent affinity to the body, appeared to have an positive effect on delaying the progress of cartilage degeneration.

The Effect of Chitosan-TGF-beta1 Conjugate on Full Thickness Articular Cartilage Defect in the Rabbit Knee Model (Preliminary Report) / 대한정형외과연구학회지

PURPOSE: To evaluate the effect of the chitosan-TGF-beta1 conjugate on articular cartilage defects of rabbits' knees MATERIALS AND METHODS: Full thickness cartilage defect(6mm, round shape) was made at both knees of 20 rabbits and, after the lapse of 3 days, chitosan-TGF-beta1(15ng/ml, 1ml) was injected into one side(experimental group) of knees and PBS(1ml) was injected into the other side(control group). 5 rabbits were sacrificed 6 weeks after the injection and the rest of 15 rabbits 12 weeks later. Then, gross morphology and histological evaluation(Mendelson scoring) was conducted. RESULTS: No arthritic findings was observed and histological results in the experimental group at 6(Ave. 11.3+/-1.5) and 12(Ave. 4.5+/-1.9) weeks postoperatively were superior to those in the control group at 6(Ave. 14.6+/-1.7) and 12(Ave. 9.8+/-2.2) weeks. Especially at 12 weeks, the experimental group was superior to the control group statistically in results of 5 subgroups except for filling of defects. The difference of two groups at 12 weeks was more remarkable than those at 6 weeks. CONCLUSION: Regeneration of something very close to normal cartilage was observed in the experimental group. It shows that the biological activity of TGF-beta1 is sustained by the action of conjugate with chitosan, through prolonged half life of TGF-beta1.

Culture of Rabbit Chondrocytes Using Chitosan Bead / 대한정형외과연구학회지

PURPOSE: To confirm the adhesion and matrix formation of chondrocytes which were cultured on chitosan beads and to elucidate the difference between the porous chitosan beads and non-porous chitsan beads as scaffold for chondrocytes. MATERIALS AND METHODS: Chondrocytes isolated from rabbit articular cartilage were cultured in vitro on porous and non-porous chitosan bead for 2 weeks. Histochemical (H&E stain, Toluidin blue stain) and scanning electromicroscopic approaches were used to compare the differences between two groups. RESULTS: In both groups, adhesion and proliferation of chondrocytes were observed on scanning electron microscopy. which were more active in the porous chitosan bead group. On histochemical staining with toluidine blue, the porous chitosan bead group showed stronger metachromasia than that of the non-porous chitosan bead. CONCLUSION: It is concluded that both chitosan beads could work as an effective scaffold for culturing chondrocytes, and that porous chitosan bead may be a better scaffold than non-porous chitosan bead because of cavities in former bead.

Comparison of CRP in Spinal Compression Fractures: Simple vs Malignant metastatic disease / 대한정형외과학회잡지

PURPOSE: We undertook to evaluate the efficacy of C-reactive protein (CRP) determination as a screening test for the detection of malig-nancy in compression fracture patients by comparing simple compression fractures and malignant metastatic compression fractures of spine. MATERIALS AND METHODS: From January 1998 to March 2001, fifty-one patients who had compression fracture of spine with chronic back pain were analysed for CRP levels. The thirty-six patients had simple compression fractures of the spine and fifteen patients malignant metastatic compression fractures. The sensitivity, specificity and positive predictive value of CRP in the screening of benign simple compression fractures were calculated. RESULTS: CRP levels in malignant metastatic compression fracture were significantly higher than in simple compression fracture. The sensitivity of CRP in simple compression fractures was 97%, its specificity 80% and its positive predictive value 92%. CONCLUSION: We consider CRP titer to be a useful screening test for the detection of malignant metastatic compression fractures. In old age, a high titer of CRP needs more precise clinical definition for the detection of malignancy in compression fracture.

Diagnosis of Burst Fracture of the Spine on Plain Radiographs Using the Wintopo(R) Program / 대한정형외과학회잡지

PURPOSE: To evaluate the usefulness of plain lateral radiographs processed by the Wintopo(R) program (SoftSoft.netTM, version 1.11, USA)for a picture archiving communication system (PACS) for the diagnosis of bursting fracture. MATERIALS AND METHODS: From January 2001 to April 2002, 24 cases of thoracic and lumbar spine fractures with available computed tomographs were evaluated. Lateral plain radiographs were reviewed by five orthopedic residents, and then were saved as bmp files in a picture archiving communication system. The borderline posterior body in the lateral plain radiographs was defined using the vector image in the Wintopo(R) program. After processing, radiographs were re-evaluated. RESULTS: In all participants, the sensitivity of the diagnosis of bursting fracture was significantly improved after Wintopo(R) program processing. Although the specificity and positive predictive value were improved by processing, this was not statistically significant. CONCLUSION: Wintopo(R) program processing of plain lateral radiographs of the spine could improve the sensitivity of diagnosis for bursting fracture in acute spinal injury.

Discomfort in Winter Season after Fixing Lateral Malleolar Fracture with Plates: A comparison between stainless steel and titanium plate / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to find a method of proving cold discomfort in patients who complain during the winter seasons, after receiving an internal fixation with a metal plate, and to determine the different in the developments of cold discomfort according to the type of metal plate used. MATERIALS AND METHODS: Among 26 cases of lateral malleolar fracture, 16 stainless-steel plates and 10 titanium plates were compared. Discomfort was induced by placing ice over both lateral malleoli (ice provocation test), and the side on which discomfort was induced first was recorded. RESULTS: Ten patients who felt discomfort in the winter, among which 8 cases stainless-steel plate and 2 cases titanium plate. The degree of pain was rated as 3.6 on average (ranging 2-4) on the VAS (visual analogue scale). CONCLUSION: Cold discomfort during the winter season can be confirmed by using the ice provocation test (p=0.0004). The frequency of discomfort during the winter season was higher (p=0.126) in cases filted with stainless-steel plate (50%) than in those with a titanium plate (20%).

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.

A Biomechanical Study of Two Kinds of Tapered Pedicle Screws in Osteoporotic Lumber Spine / 대한정형외과학회잡지

PURPOSE: To compare the pullout strength and insertion torque of proximally tapered screw (PT) with fully tapered screw (FT) and to investigate the correlation between the pullout strength and bone mineral density, morphology of pedicle, and insertion torque of the screw in osteoporotic lumbar spine. MATERIALS AND METHODS: Fifteen osteoporotic lumbar vertebrae from four white human cadavers were used. Bone mineral density, pullout strength and insertion torque were measured by dual energy x-ray absorptiometry, MTS and torque screw driver individually. RESULTS: The FT screw provided greater pullout force and insertion torque than the PT screw in 12 of 15 vertebrae tested (p<0.01). Pullout strength was correlated with insertion torque in PT (r=0.666, P=0.0006) and FT (r=0.464, P=0.19) screws. CONCLUSIONS: Results of this study indicate that the FT screws provide higher pullout strength and insertion torque than PT screws in osteoporotic lumbar spine and suggest that the development of tapered minor diameter may lead to an improved pedicle screw with high pullout strength and insertion torque. Nevertheless, further study is needed to investigate the effect of tapering the minor diameter on the mechanical bending strength of the screw.

Pain after Use of the Central Third of the Patellar Tendon for Anterior Cruciate Ligament Reconstruction: Ipsilateral vs . Contralateral side Harvesting Group

graft as a successful procedure that provides functional stabiIity. Complications reported include arthro5brosis, patellofemoral joint pain, patellar tendinitis, patellar tendon rupture, recurrent laxity, posterolateral instabi5ty, medial subluxation of the patella, chronic knee pain and painful neuroma. Among them, anterior knee pain was the rnost frequent eomplication. Authors performed arthroscopy assisted one tunnel technique for reconsction of the ACL using autogenous Bone Patellar tendon-Rone (BPTB) in 87 patients. Patients were divid@d into two groups based on the harvested side (knee) of the BPTB. Group 1 consisted of 45 cases of ipsilateral side and group 2 consisted of 42 cases of contralsteral side in harvesting the BPTB. The patients were foll4wed up for at least 12 months to determine whether using the BPTB harvested from the contralateral knee wguld reduce the anterior knee pain at the ACL reconstructed knee. Althaugh there were no statistically signifiqant differences between group 1 and 2 with regard to anterior knee pain, the prevalence of the anterior knee pain was less frequent in group 2 than group 1. This study showed that using the contralateral side harvested autogenous patellar tendon would be a possible protector for anterior knee pain and assists for early rehabilitation.

Comparison of Patella Retention Versus Resurfacing in Total Knee Arthroplasty: Preliminary report / 대한정형외과학회잡지

There is a controversy in patella retention or resurfacing in total knee arthroplasty (TKA) till today. Authors studied 52 cases of 45 patients recieved total knee arthroplasty with patella retention (Group 1, twenty-five cases) or patella resurfacing (Group 2, twenty-seven cases) in patients with osteoarthritis. All operations were done by senior surgeon and the implants used were LCS type (33 cases), AMK type (12 cases), Genesis type (5 cases) and Tricon M type (2 cases). The indications of patella retention were small patella, nearly normal articular cartilage, minimal pre-operative patellofemoral pain, poor patellar bone quality and young patients. Patella retention were performed only with LCS prosthesis, which patella groove of the femoral component is deep and anatomical. The operative approaches used were medial parapatella approach in neutral or varus knee and lateral parapatella approch for severe valgus knee and tilting or lateral subluxation of the patella. The mean follow-up period was 24 months (range 12 months to 5 years). The method for clinical evaluation was Hospital for Special Surgery (HSS) knee scoring (consisted of pain, function, range of motion). The method for radiographical evaluation was Knee societys radiologic evaluation system for tibial and femoral alignment, and Keblishs method for patello-femoral congruence. The clinical HSS knee score was average 90.9 points in both groups, and 91.9 points in group 1, 90.0 points in group 2, and there was no statistically difference in HSS knee score between the two groups (P<0.05). The radiologic results had no significant difference in alignment and patello-femoral congruence between the two groups (P<0.05). But the complications were one case of patella fracture, one patella tendon rupture, one anterior instability and two cases of infection in group 2. In conclusion, the results of both groups were satisfactory. We think that it have relation to strict selection of the patients for patella retension and the use of prosthesis that the patella groove of femoral component is deep and anatomical.

Repair of Osteochondral Defect Using Grafts of Cultured Chondrocytes in Rabbits / 대한정형외과학회잡지

Chondrocytes isolated from the articular cartilage of rabbit knee joint were cultured in vitro within fibrin glue carrier for 2 weeks. Histochemical and electromicroscopical approaches were used to study chondrocytes behavior and phenotypic expression. In vitro study, chondrocyte assumed a rounded morphology, accumulated metachromatic matrix and took on the cytological characteristics of in vivo cartilage cells. Allogenic cultured chondrocyte in fibrin glue was transplanted into osteochondral defect in rabbit joint. The contralateral knee joint served as a control in which the defect was left empty. This in vivo study was performed for the investigation of the chondrogenic potential of cultured chondrocytes embedded in fibrin glue. Grafted defects was filled with cartilage in gross finding, repaired tissue consisted of differentiated chondrocytes and matrix resumed that of hyaline cartilage. At sixteen week after transplantation, subchondral region was partially transformed into bone without loss of overlying articular cartilage, but in control group, defect did not heal successfully. Repaired articular cartilage was thicker than host cartilage and tide mark was not shown up to 24 weeks. Some of repaired tissue was degraded partially. These results suggest that fibrin glue provides suitable environment for differentiation of chondrocyte and allograft of cultured chondrocyte in fibrin glue transplanted into large osteochondral defect improves cartilage repair.

Delayed subclavian - Vein thrombosis Following Nonunion of the Clavicular Fracture: A Case Report / 대한정형외과학회잡지

The possibility that immediate neurovascular injury will follow fracture of the clavicle has been generally known. A case of delayed involvement of the subclavian vein following a nonunion of clavicular fracture is reported emphasizing the proper reduction and union of the clavicle fracture is essential if delayed neurovascular complication are to be avoided or treated.