Analysis of the Cement Distribution Pattern and Other Risk Factors that Affect the Incidence of Recompression Fractures of Vertebral Bodies after Vertebroplasty or Kyphoplasty / 대한정형외과학회잡지

Purpose@#With the increasing incidence of recompression fractures after vertebroplasty or kyphoplasty, this study analyzed the risk factors that affect the occurrence of recompression vertebral fractures, such as cement distribution, existence of avascular necrosis (Kummell’s disease), type of procedures, bone mineral density, sex, and age. @*Materials and Methods@#Two hundred and thirty-eight patients who underwent vertebroplasty or kyphoplasty at the author’s clinic from 2005 to 2015 were enrolled in this study. The patients were divided into four groups according to the distribution of injected cement. The patients were classified as type 1 and type 2 when injected cement was contacted only to the upper or lower endplate of the body respectively. They were classified as type 3 when both the upper and lower endplates were contacted by injected cement. When neither the upper nor the lower endplate was contacted, the patients were called type 4. This study statistically evaluated the effects of the risk factors, including the cement distribution on the incidence of recompression vertebral fracture after vertebroplasty or kyphoplasty. @*Results@#There were 59 cases (24.8%) of recompression fracture after vertebroplasty or kyphoplasty, among the 238 cases. According to the analysis, the recompression of the vertebral body after vertebroplasty or kyphoplasty occurred more often when the compression fracture was accompanied by osteonecrosis at the body (p<0.05). The patients who had injected cement distributed at both upper and lower plate simultaneously (type 3) had a lower incidence of recompression fracture of the vertebral body after vertebroplasty or kyphoplasty (p=0.008). In addition, the kyphoplasty group had a lower incidence of recompression after the procedure than vertebroplasty group (p=0.02). @*Conclusion@#Careful attention should be given to these patients with osteonecrosis at the compression fracture level through a preoperative evaluation. In addition, if the injected cement does not contact both the upper and lower endplates, careful observation is required during the follow-up period based on the high incidence of vertebral recompression fractures proven through this study. Further technical and biomechanical research and efforts will be needed to make the cement contact both endplates.

Relationship of Bone Mineral Density and Knee Osteoarthritis (Kellgren-Lawrence Grade):Fifth Korea National Health and Nutrition Examination Survey

Background@#Osteoarthritis (OA) and osteoporosis (OP) are the 2 most common bone disorders associated with aging. We can simply assume that older patients have a higher incidence of OA and OP with more severity. Although several papers have conducted studies on the relationship between OA and OP, none of them has demonstrated a conclusive link. In this study, we used radiological knee OA and bone mineral density (BMD; T-score of the total hip and lumbar spine) to analyze the incidence of OA and OP in a large population. We aimed to determine the relationship between OA and OP and investigate the associated risk factors. @*Methods@#This cross-sectional study used data extracted from the 2010–2012 Korea National Health and Nutrition Examination Survey. We evaluated a total of 4,250 participants aged ≥ 50 years who underwent knee radiography and dual-energy X-ray absorptiometry and their laboratory results. The relationship between radiological knee OA and BMD was assessed. The generalized linear model was used to evaluate the relationship between BMD and Kellgren-Lawrence (KL) grade. @*Results@#The higher KL grade was associated with older age, higher body mass index (BMI), female sex, and lower hemoglobin level (p 0.05). After adjusting for confounding factors (age, BMI, diabetes, hypertension, smoking, and alcohol consumption), the average T-scores of total hip and lumbar spine were the highest in the mild OA group with KL grade 2 (–0.22 ± 1.08 and –0.89 ± 1.46, respectively,p < 0.001). The average T-scores of the total hip and lumbar spine significantly decreased as OA progressed from moderate (KL grade 3; –0.49 ± 1.05 and –1.33 ± 1.38, respectively, p < 0.001) to severe (KL grade 4; –0.73 ± 1.13 and –1.74 ± 1.75, respectively, p < 0.001). T-scores of the moderate-to-severe OA group were significantly lower than those of the non-OA group (KL grades 0 and 1, p < 0.001). @*Conclusions@#Compared with the non-OA group, BMD (T-scores of the total hip and lumbar spine) was higher in the mild OA group and lower in the moderate-to-severe OA group.

Correlation of the Deformation of the Kyphotic Angle with the Fat Infiltration Rate of Multifidus and Erector Spinae in Patients with Acute Osteoporotic Fractures of the Lumbar Spine / 대한정형외과학회잡지

Purpose@#Verifying a reliable predictor of the progression of vertebral deformity in patients with acute osteoporotic fractures of the lumbar spine may be useful. A qualitative analysis of the muscle near the spine was performed using magnetic resonance imaging (MRI), and its correlation with a spinal deformity was determined under the hypothesis that the causes of the kyphotic deformity are associated with muscle reduction in the multifidus and erector spinae. @*Materials and Methods@#The study was performed in a retrospective manner using the electronic medical records of patients who presented to the author’s institution between January 2007 and March 2018, and were diagnosed with an acute lumbar fracture. The fat infiltration rates of the multifidus and erector spinae were measured using MRI taken at the time of injury, and the mean value was defined as the total fat infiltration rate (TFI). Based on lateral radiographs of the lumbar spine at the one-year follow-up, the loss of height of the vertebral body, the kyphotic angle and the wedge angle were measured. The statistical significance was confirmed by calculating the Pearson correlation coefficient. @*Results@#One hundred twenty-nine patients, of which 30 were male and 99 were female, were examined. The mean age was 71.28 years. The mean T-score was - 3.53±0.79 g/cm2 , and the mean fat infiltration was 15.20%±11.99%. TFI was positively correlated with age (R=0.373, p<0.001), compression rate (R=0.369, p<0.001), and Cobb’s angle (R=0.386, p<0.001) after a one year follow-up, but negatively correlated with the BMD score (R= - 0.252, p=0.004). As the fracture progressed to the lower lumbar level, the compression rate (R= - 0191, p=0.030) and wedge angle (R= - 0.428, p<0.001) at the time of injury tended to decrease. @*Conclusion@#In patients with osteoporotic vertebral fractures, the fat infiltration rate may be an important predictor of conservative treatment. The prognosis of patients with a high-fat infiltration rate should be explained during patient education, and the patients must be monitored closely through short-term outpatient follow-up.

Epidemiology of Achilles Tendon Rupture in South Korea: Claims Data of the National Health Insurance Service from 2009 to 2017

Background@#The incidence of Achilles tendon rupture and its trend has not been studied in Asia. The purpose of this nationwide study was to analyze the trend of incidence and surgical treatment of tendon ruptures in South Korea based on sex, age, and income level of patients, as well as seasonal variation. @*Methods@#A descriptive epidemiologic study was performed based on the data collected retrospectively from the Korea National Health Insurance Service. Data of all outpatients and inpatients were collected from approximately 52 million residents of South Korea, primarily diagnosed with Achilles tendon rupture from 2009 to 2017. @*Results@#A total of 112,350 patients had Achilles tendon rupture, of which 44,248 patients underwent surgical treatment during the study period. The overall, age-specific, and sex-specific incidence of Achilles tendon rupture and surgical treatment showed an increasing trend. Patients in the age group of 41 to 50 years showed the highest increase in incidence. Regarding season, higher incidence was reported during spring and summer, whereas the lowest incidence was found in winter. Higher income level was associated with increased incidence of the condition. @*Conclusions@#The incidence of Achilles tendon rupture and surgical treatments increased rapidly in patients between 41 and 50 years of age. Patients in the higher income quintile groups experienced more Achilles tendon injury than those in lower income groups, and fewer ruptures were observed during winter.

Correlation Analysis between the Factors Associated withOsteoporosis and the Fat Infiltration Rate of the Multifidus andErector Spinae Muscles in Osteoporotic Vertebral CompressionFracture Patients / 대한정형외과학회잡지

Purpose@#To examine the relationship between total fat infiltration (TFI) rate, which quantifies the reduction of muscles around the spineand is an important factor for sarcopenia, and the factors affecting osteoporotic vertebral compression fracture. @*Materials and Methods@#Patients treated for osteoporotic compression fractures of the lumber spine from January 2012 to December2016 were analyzed retrospectively. Among them, this study included ninety-eight patients who were 1) diagnosed with osteoporosis witha bone mineral density (BMD) T score of less than 2.5 g/cm2, 2) received vertebroplasty or kyphoplasty for lumbar fractures, 3) involved onesegment of the lumbar spine, and 4) were followed-up for more than one year. The TFI rate confirmed by analyzing magnetic resonanceimagings with the Image J program was studied. Based on this, the relationship between the TFI of the multifidus and erector spinaemuscles and the factors of osteoporosis were analyzed. @*Results@#The mean TFI of the multifidus and erector spinae was 14.66±10.16. The spine BMD showed a positive correlation with the hipBMD, but a negative correlation with the TFI. A positive correlation was observed between the hip BMD and body mass index. In addition,vitamin D was positively correlated with both the hip and spine BMD but negatively correlated with the TFI rate. @*Conclusion@#Muscle growth helps treat osteoporosis, and can prevent fractures that occur frequently in osteoporosis patients. Increasingthe vitamin intake can also slow the progression of muscle atrophy.

Posterior Correction of Adolescent Idiopathic Scoliosis with High-Density Pedicle Screw-Only Constructs: 5 Years of Follow-Up

PURPOSE: This study aimed to analyze radiological outcomes in patients with adolescent idiopathic scoliosis (AIS) who underwent posterior correction with high-density pedicle screw-only constructs. We hypothesized that high-density pedicle screw-only constructs in AIS would provide a high correction rate and would facilitate the maintenance of the correction or obviate the loss thereof.MATERIALS AND METHODS: We retrospectively analyzed radiological outcomes over a minimum follow-up period of 5 years in patients with AIS who underwent posterior correction with high-density pedicle screw-only constructs. A total of 124 consecutive patients were included. Demographic data, including age, sex, operated fusion level, numbers of screw, Lenke curve type, Risser stage, and follow-up period were retrospectively collected from electronic medical records and radiological measurements including serial follow-up.RESULTS: The average number of pedicle screws was 1.96/vertebra. The average curve correction was 48.3% for the proximal thoracic (PT) curve, 83.1% for the main thoracic (MT) curve, and 80.2% for the thoracolumbar/lumbar (TL/L) curve at final follow-up. Use of high-density pedicle screw-only constructs helped achieve excellent correction rates, with no significant loss of correction at final follow-up.CONCLUSION: We obtained excellent correction rates of 48.3% for PT, 83.1% for MT, and 80.2% for TL/L curves using high-density pedicle screw-only constructs in AIS, with no significant loss of correction at final follow-up.

Surgical Treatment for Displaced Intra-Articular Calcaneal Fractures in Elderly Patients: Comparison of the Minimally Invasive Approach and Extensile Lateral Approach

PURPOSE: As the functional demands for activities in elderly patients are increasing according to their life extension, the need for surgical treatment is also increasing in elderly patients with displaced intra-articular calcaneal fractures. In addition to the extensile lateral approach (ELA), which is a surgical procedure that showed good results on intra-articular calcaneal fractures, the minimally invasive approach (MIA) also showed an outstanding result. This study compared the radiological and clinical results of intraarticular calcaneus fractures in elderly patients in two groups: ELA and MIA. MATERIALS AND METHODS: Thirty patients aged over 65 years with intra-articular calcaneus fractures, who could be followed-up more than 14 months, were included in this study. Thirteen patients of the MIA group and 17 patients of the ELA group were analyzed retrospectively using radiological and clinical assessments. RESULTS: No significant difference in union time, posterior facet reduction accuracy, subtalar osteoarthritis frequency, Bohler angle, calcaneal width, American Orthopaedic Foot and Ankle Society score, visual analogue scale score, 36-item short form survey, and foot function index was observed between the two groups. The p-value of the average height of the calcaneus correction, average length of calcaneal correction, and average loss of correction length were <0.001, 0.005, and 0.015, respectively. The incidence of complications, including soft tissue necrosis and bone infection, were 23.1% in the ELA group and none in the MIA group. CONCLUSION: The clinical outcomes were similar in the two groups. The degree of reduction of fracture showed a better result in the MIA group than the ELA group. Furthermore, there were no complications in the MIA group, whereas the ELA group showed some complications.

Surgical Treatment of Osteoporotic Vertebral Compression Fractures at Thoraco-Lumbar Levels: Only Pedicle Screw Constructs with Polymethylmethacrylate Augmentation / 대한정형외과학회잡지

PURPOSE: To investigate the radiological efficacy of polymethylmethacrylate (PMMA) augmentation of pedicle screw operation in osteoporotic vertebral compression fractures (OVCF) patients. MATERIALS AND METHODS: Twenty OVCF patients, who underwent only posterior fusion using pedicle screws with PMMA augmentation, were included in the study. The mean follow-up period was 15.6 months. The demographic data, bone mineral density (BMD), fusion segments, number of pedicle screws, and amount of PMMA were reviewed as medical records. To analyze the radiological outcomes, the radiologic parameters were measured as the time serial follow-up (preoperation, immediately postoperation, postoperation 6 weeks, 3, 6 months, and 1 year follow-up). RESULTS: A total of 20 patients were examined (16 females [80.0%]; mean age, 69.1±8.9 years). The average BMD was −2.5±0.9 g/cm2. The average cement volume per vertebral body was 6.3 ml. The mean preoperative Cobb angle of focal kyphosis was 32.7°±7.0° and was improved significantly to 8.7°±6.9° postoperatively (p<0.001), with maintenance of the correction at the serial follow-up, postoperatively. The Cobb angle of instrumented kyphosis, wedge angle, and sagittal index showed similar patterns. In addition, the anterior part of fractured vertebral body height averaged 11.0±5.0 mm and was improved to 18.5±5.7 mm postoperatively (p=0.006), with maintenance of the improvement at the 3-month, 6-month, and 1-year follow-up. CONCLUSION: The reinforcement of pedicle screws using PMMA augmentation may be a feasible surgical technique for OVCF. Moreover, it appears to be appropriate for improving the focal thoracolumbar/lumbar kyphosis and is maintained well after surgery.

Relationship between the Progression of Kyphosis in Thoracolumbar Osteoporotic Vertebral Compression Fractures and Magnetic Resonance Imaging Findings / 대한정형외과학회잡지

PURPOSE: To examine the relationship between the progression of a kyphotic deformity and the magnetic resonance imaging (MRI) findings in conservatively treated osteoporotic thoracolumbar compression fracture patients. MATERIALS AND METHODS: This study categorized the patients who underwent conservative treatment among those patients who underwent treatment under the suspicion of a thoracolumbar compression fracture from January 2007 to March 2016. Among them, this retrospective study included eighty-nine patients with osteoporosis and osteopenia with a bone density of less than −2.0 and single vertebral body fracture. This study examined the MRI of anterior longitudinal ligament or posterior longitudinal ligament injury, superior or inferior endplate disruption, superior of inferior intravertebral disc injury, the presence of low signal intensity on T2-weighted images, and bone edema of intravertebral bodies in fractured intravertebral bodies. RESULTS: In cases where the superior endplate was disrupted or the level of bone edema of the intravertebral bodies was high, the kyphotic angle, wedge angle, and anterior vertebral compression showed remarkably progression. In the case of damage to the anterior longitudinal ligament or the superior disc, only the kyphotic angle was markedly prominent. On the T2-weighted images, low signal intensity lesions showed a high wedge angle and high anterior vertebral compression. On the other hand, there were no significant correlations among the posterior longitudinal ligament injury, inferior endplate disruption, inferior disc injury, and the progression of kyphotic deformity and vertebral compression. The risk factors that increase the kyphotic angle by more than 5° include the presence of injuries to the anterior longitudinal ligament, superior endplate disruption, and superior disc injury, and the risk factors were 21.3, 5.1, and 8.5 times higher than those of the uninjured case, and the risk differed according to the level of bone edema. CONCLUSION: An osteoporotic thoracolumbar compression fracture in osteoporotic or osteopenic patients, anterior longitudinal ligament injury, superior endplate and intravertebral disc injury, and high level of edema in the MRI were critical factors that increases the risk of kyphotic deformity.

Response to: Comparison of Posterior Lumbar Interbody Fusion and Posterolateral Lumbar Fusion in Monosegmental Vacuum Phenomenon within an Intervertebral Disc

No abstract available.

Comparison of Posterior Lumbar Interbody Fusion and Posterolateral Lumbar Fusion in Monosegmental Vacuum Phenomenon within an Intervertebral Disc

STUDY DESIGN: Retrospective. PURPOSE: To compare the clinical and radiological outcomes of posterolateral lumbar interbody fusion (PLIF) and posterolateral lumbar fusion (PLF) in monosegmental vacuum phenomenon within an intervertebral disc. OVERVIEW OF LITERATURE: The vacuum phenomenon within an intervertebral disc is a serious form of degenerative disease that destabilizes the intervertebral body. Outcomes of PLIF and PLF in monosegmental vacuum phenomenon are unclear. METHODS: Monosegmental instrumented PLIF and PLF was performed on 84 degenerative lumbar disease patients with monosegmental vacuum phenomenon (PLIF, n=38; PLF, n=46). Minimum follow-up was 24 months. Clinical outcomes of leg and back pain were assessed using visual analogue scales for leg pain (LVAS) and back pain (BVAS), and the Oswestry disability index (ODI). The radiographic outcome was the estimated bony union rate. RESULTS: LVAS, BVAS, and ODI improved in both groups. There was no significant difference in the degree of these improvements between PLIF and PLF patients (p>0.05). Radiological union rate was 91.1% in PLIF group and 89.4% in PLF group at postoperative 24 months (p>0.05). CONCLUSIONS: No significant differences in clinical results and union rates were found between PLIF and PLF patients. Selection of the operation technique will reflect the surgeon's preferences and patient condition.

Rupture of Achilles Tendon after Steroid Injection in Achilles Tendinitis (A Report of Five Cases) / 대한족부족관절학회지

PURPOSE: The purpose of the study was to investigate five cases with chronic Achilles tendon rupture that occurred after steroid injections. MATERIALS AND METHODS: In our hospital, we experienced five cases of chronic Achilles tendon rupture from September 2010 to March 2012. All patients had got steroid injection for Achilles tendinitis at the other hospitals, and their heel pain was aggravated when they visited our outpatient department. After treatment, signs and symptoms of Achilles tendon rupture were developed and the diagnosis was confirmed by ultrasonography or magnetic resonance imaging (MRI). Surgical treatment was done for Achilles tendon rupture. RESULTS: There was difference between intra-operative findings of Achilles tendon rupture and usual chronic Achilles tendon rupture. Unlike usual findings of chronic Achilles tendon rupture whose scar tissue or tissue attenuation are found around the defect area of Achilles tendon, there were partial necrosis of tendon severe adhesion with surrounding tissue, extensive defect and longitudinal rupture on ruptured area. Also, severe inflammation of paratenon, granulation and fibrinoid deposit were found on biopsy findings in four cases. CONCLUSION: Based on review of data about relative risk and benefit of local corticosteroid injection to inflammatory lesion in Achilles tendon, it requires more attention to Achilles tendon rupture following local corticosteroid injection.

Morphometric Analysis of Corneal Endothelium in the Intercapsular Cataract Extraction with Posterior Chamber Lens Implantation

To compare corneal endothelial damage in intercapsular cataract extraction with post erior chamber lens implantation (Intercapsular P-ECCE+PCL) to that in conventional extracapsular cataract extraction with posterior chamber lens implantation (P-ECCE+PCL), and to detect the most appropriate index for comparision of the endothelial damage, the author has measured morphologic characteristics of corneal endothelium in 20 cases of intercapsu1ar P-ECCE+PCL (Group 1), and 21 cases of P-ECCE+PCL (Group 2) preoperatively and one week after surgery. Morphometric data (density, area, coefficient of variation, perimeter, shape factor, hexagonality, lengths) were obtained by contact type specular microscope, computer assisted digitizer and image analysis program. The mean endothelial cell loss one week after surgery was 10.82% in group 1, and 20.22% in group 2 respectively. The mean hexagonality loss one week after surgery was 28.05% in group 1, and 38.84% in group 2 (p<0.05). The mean coefficient of variation (CV) loss at postoperative one week was 30.68% in group 1, and 38.84% in group 2. As a whole, group 1 showed less reduction of endothelial damage compared to group 2 but no statiscally significant changes were noted except hexagonality. Therefore, the corneal endothelium was less damaged after intercapsular P-ECCE+PCL than after P-ECCE+PCL, and the adequate index for comparision of endothelial damage are CV and hexagonality as well as cell density, among which hexagonalty is the most important parameter.

A Case of Primary Malignant Lymphoma of the Conjunctiva

Involvement of the conjunctiva with malignant lympoma is very rare. Primary malignant lymphoma of the conjunctiva equally affects men and women over age of 40 years and has a predilection for inferior conjunctival fornices. Most lesions occur unilaterUy, involving right and left sides equally frequently. Periorbital swelling is the most common presenting symptom followed by proptosis, ptosis, pain and poor or blurred vision. Radiation therapy appears to be treatment of choice for malignant lymphoma involving the conjunctiva Surgical treatment alone is less likely to remove all the tumor and should be conjoined with a wide field of radiotherapy. The prognosis of the case depends upon whether or not the disease is generalized. Although in Korea a few cases of secondary involvement of the conjunctiva with generalized malignant lymphoma have been reported, no primary case has yet been reported. The authors reported here a case of primary malignant lymphoma of the conjunctiva in a 48 year-old female patient with a review of the literatures.

Morphometric Analysis of the Rabbit Corneal Endothelium Specular Microscopy Versus Alizarin Red S Staining

Analysis of endothelial morphology by computer assisted digitizer and image analysis program provides very useful indices of cell shape and size which appear to correlate to the monolayer's functional status. To study the influences of the Alizarin red S staining, which is commonly used in animal experiments of corneal endothelium and vital staining, on the morphologic characteristics of corneal endothelium, morphometric data(density, area, coefficient of variation, perimeter, shape factor, hexagonality, lengths) obtained by specular microscopy of the endothelium are compared to data obtained by Alizarin red S staining of the endothelium of the excised cornea. Mean endothelial cell area was measured as 389.58 +/- 37.14 micrometer2, density was 2588 +/- 251 cells/mm2. The corresponding values measured after Alizarin red S staining, cell area was 407.42 +/- 45.3 micrometer2 and density was 2484 +/- 294 cells/mm2. But no significant differences were noted in comparing all morphometric data obtained by staining to that obtained from specular microscopy. Therefore, Alizarin red S staining combined with cell morphometric analysis could provide valuable data in a cornea which lacks clarity limits or precludes specular microscopy.

The Effect of a Collagen Shield on Concentrations of Tobramycin in Corneas

Collagen shields made of porcine scleral collagen were immersed in a solution containing tobramycin sulfate(40 mg/ml) for five minutes, then applied to rabbit corneas. One, four and eight hours after application, the corneas were assayed for antibiotics by agar diffusion bioassay. We divided study groups as 4 groups, that is, collagen shield, subconjunctival, therapeutic soft contact lens and topical group, and compared the corneal concentradon of tobramycin in each group. Shields immersed in 40 mg/ml tobramycin produced significantly higher concentrations of tobramycin in the cornea at one and four hours than those of the other groups. Tobramycin concentrations in cornea eight hours after application became lower than those of one and four hours after application but, higher than minimal inhibitory concentration of Pseudomonas aeruginosa. Collagen shield containing antibiotics can serve as a vehicle for drug delivery and may prove superior to current methods for the initial treatment of bacterial keratitis, and preoperative and postoperative antibiotic prophylaxis.