CT-Free Registration Method for Finding Accurate Orientation of Acetabular-Cup in Total Hip Replacement Surgery / 대한정형외과연구학회지

PURPOSE: This paper is proposing an improved CT-free registration method which may provide us an accurate and reliable placement of acetabular cup without CT/MRI images. DESIGN AND METHODS: The proposed method employs a T-bar shaped gauge placed on the anatomical landmarks of the pelvis for the registration. The T-bar shaped gauge has its own LED markers and the position of the gauge is obtained through OPTOTRAK3020 system. These landmark points are the anterior superior iliac spines and the symphysis pubis defining anterior pelvic plane. Two subjects were tested to compare the landmark based registration and the proposed T-bar based registration. RESULTS: The measurement deviations of the pelvic obliquity in the frontal plane, tilt in the sagittal plane, and rotation in the transverse plane were 2.08, 1.41, and 2.51 degrees respectively in the point based registration. The T-bar based registration produced 40% smaller deviations(p<0.05): the pelvic obliquity in the frontal plane, tilt in the sagittal plane, and rotation in the transverse plane were 0.84, 0.81, and 1.17 degrees respectively in the T-bar based registration. There was no outlier exceeding 5 degrees in measurement deviation by the T-bar based registration while the outliers were found by the landmark based registration. CONCLUSIONS: We found that T-bar based CT free registration method is more reliable and accurate than the landmark based registration for the acetabular cup navigation. Also, the new method produced more precise registration(p<0.05). We are expecting some offset error of the new registration method due to the skin thickness existing between the T-bar frame and the bony pelvic frame, which may be compensated if we may accumulate sufficient database of the offset.

Neglected Compartment Syndrome caused by Folk Remedy: Two Case Reports / 대한정형외과학회잡지

Compartment syndrome usually develops as a result of traumatic musculoskeletal injury or vascular injury. Early diagnosis and emergency fasciotomy are mandatory for the decompression of compartment pressure in the acute stage. Minor trauma or a non traumatic event can cause compartment syndrome. No report was available of the folk remedy. We report upon two cases of neglected compartment syndrome caused by a folk remedy.

Cadaveric Study of Robotic Femoral Canal Preparation by Gauge Based Registration in Total Hip Arthroplasty / 대한정형외과연구학회지

PURPOSE: To propose a method providing an accurate femoral shaping for cementless total hip arthroplasty to maximize bone contact without femoral bone breakage and make secure correct position of the implant by eliminating the manual broach process MATERIALS AND METHODS: 5-cadaver specimens were tested with this system. A reamer-shaped registration gauge is inserted into the femoral canal. This gauge defines the position of the implant to be inserted. Then, the base frame is attached to the femur and the position of the gauge with respect to the base frame is measured. After removing the gauge, a mini robot is mounted on the frame and shapes the femoral canal. After the milling operation, model implant is inserted and its position and gap are measured. RESULTS: Anteversion angle error was 0.9degrees(S.D.1.7) and Varus/Valgus alignment error was 1.1degrees(S.D.1.5). 95%(S.D. 3.2) of contact surface had less than 0.3mm gap error. CONCLUSIONS: Proposed THA surgery system increased the accuracy of stem position and fitness compared with manual operation. Our mini robot THA surgery provides most of the benefits RobodocR does while operating procedure is much more simplified and economic.

Early Decompressive Surgery for Compressive Neuropathy by Hematoma after Posterior Spinal Decompressive Surgery / 대한척추외과학회지

STUDY DESIGN: A retrospective analysis was performed to identify the diagnostic and therapeutic factors related to postoperative compressive neuropathy by hematoma after posterior spinal decompressive surgery. OBJECTIVES: To document by analysis the clinical course of postoperative compressive neuropathy by hematoma, the efficacy of early surgical decompression, and to recommend methods of prevention. SUMMARY OF LITERATURE REVIEW: Various diagnostic and treatment modalities have been applied to postoperative compressive neuropathy after spinal surgery. However, the timing of surgical decompression remains controversial. MATERIALS AND METHODS: Five cases of postoperative compressive neuropathy after posterior spinal decompressive surgery, which occurred from May 1996 to May 2000, were investigated in terms of causes, clinical courses, and management profiles after early surgical decompression, and final outcome. RESULTS: Five cases (2.14%) among 234 patients were managed by re-decompression including the evacuation of hematoma. Four cases, which had been managed by earlier surgical decompression showed neurologic improvement after 2 postoperative weeks, and achieved favorable clinical results without grave neurologic sequelae. However, in one case, in which surgical decompression had been delayed, weakness of the peroneii remained. CONCLUSION: Early evacuation of hematoma achieved a more favorable result than a delayed operation. Early diagnosis and prompt surgical decompression is recommended to reduce neurologic sequelae.

Management of Deep Infection after Posterior Spinal Instrumentation with Prolonged Suction Drainage / 대한척추외과학회지

STUDY DESIGN: A retrospective analysis about related diagnostic and therapeutic factors in postoperative deep infection cases after posterior spinal instrumentation. OBJECTIVES: Analysis of the inherent risk factors associated with deep infection and the efficacy of management with prolonged suction drainage without removal of implants. SUMMARY OF LITERATURE REVIEW: Various treatment modalities have been applied to control deep infection after spinal instrumentation. Validity of removing implants to control the infection is still controversial because it may cause loss of spinal stability. MATERIALS AND METHODS: Five cases of postoperative deep infection after posterior spinal fixation from May 1996 to May 2000 were investigated about combined general illness, features of infection, various profiles on management of the infection with surgical irrigation and debridement followed by prolonged suction drainage, and final outcomes. RESULTS: Remarkable risk factors were diabetes and obesity. Evidences of infection such as discharge from the wound, dehiscence, fever were observed since average 18.8th day postoperatively. By only one surgical procedure for each patient followed by prolonged suction drainage for mean 19.2 days and administration of IV antibiotics for average 43.6 days followed by oral antibiotics for 33.8 days, deep infections were controlled successfully without removal of implants and without any grave complications. All achieved favorable clinical results and posterolateral fusion. CONCLUSION: Irrigation and debridement accompanied by prolonged suction drainage using Hemo-vac and administration of susceptible antibiotics seemed to be one of the effective methods in controlling deep infection after posterior instrumentation and in maintaining the postoperative stability of spine.

Pyogenic L4-5 Spondylitis Managed with Percutaneous Drainage Followed by Posterior Lumbar Interbody Fusion: A Case Report / 대한척추외과학회지

STUDY DESIGN: A case report and review of literature OBJECTIVE: Mostly operative treatment for pyogenic spondylits has been performed via anterior approach, which is often followed by greater morbidity and late sequelae. Efficacy of percutaneous drainage and posterior lumbar interbody fusion (PLIF), which are increasingly applied with favorable results, as an alternative of anterior surgery was investigated. MATERIAL AND METHOD: A case of pyogenic L4-5 spondylitis with psoas abscess but without neurologic deficit in a 66-year old lady was reviewed. Percutaneous drainage under fluoroscopic guide was performed. 7 weeks later, curettage of disc space and posterior lumbar interbody fusion using autogeous graft was performed to get rid of dead space and achieve stability. Administration of antimicrobial agents followed. RESULTS: Infection was controlled successfully. Clinical features including ambulatory function improved. Solid fusion was achieved. SUMMARY: In treating pyogenic spondylitis with moderate abscess, percutaneous drainage and posterior lumbar interbody fusion seemed to be one of alternatives of anterior surgery.

"Jammed Leg" Injury of Short-Fronted Vehicle Drivers in Frontal Collision Accidents / 대한정형외과학회잡지

PURPOSE: To Investigate the patterns and to document the clinical and technical significances of the leg injuries of drivers of short-fronted vehicles in frontal collision accidents. MATERIALS AND METHODS: Twelve cases of jammed leg injury were chosen from hospitals in the Chungcheong Province area and investigated in terms of nature of the accident, distribution of injuries, methods and duration of treatment and final sequelae. RESULTS: The patients had multiple injuries on the lower extremities, such as, fractures of the femoral shaft, tibial shaft, foot and ankle and soft tissue injuries, requiring an average 8.3 surgical procedures and 7 months admission, and from which permanent sequlae resulted, though associated injuries of the head, chest, abdomen were not significant. CONCLUSION: "Jammed leg injury" seemed to be related with the design of short-fronted vehicles. As these injuries can cause considerable functional and socioeconomic loss with long treatment periods and permanent residual sequelae. Preventive measures appear to be necessary, possibly involving vehicle design modification.

Differential Diagnosis of Heel Pain in Seronegative Spondyloarthropathy from the Heel Pain Syndrome / 대한정형외과학회잡지

PURPOSE: We attempted to differentiate the heel pain in seronegative spondyloarthropathy from that in the posterior heel pain syndrome. MATERIALS AND METHODS: Forty one patients who complained of heel pain were included in this study. The evaluation consisted of history taking, physical examination, roentgenogram, bone scan, and serological tests including ESR, CRP, rheumatoid factor, and HLA-B27. The patients were classified into two groups. Group A consisted of seronegative spondyloarthropathy patients and group B consisted of plantar fasciitis, Achilles tendinitis, and retrocalcaneal bursitis patients. RESULTS: There were 14 patients in group A, and 27 patients in group B. The characteristic clinical features were the following in group A compared with those in group B. The age of patients was younger and males predominated. Also patients complained of a combined metatarsalgia or other joint pain. On the physical examination, tenderness existed on the calcaneal body rather than the bony attachment site of Achilles tendon or plantar fascia. Serologic tests revealed an elevated ESR, and a positive HLA-B27. A bone scan showed diffuse uptake in the calcaneal body and the metatarsophalangeal joint area, and an increased SIS ratio. CONCLUSION: Seronegative spondyloarthropathy should be differentiated in a patient who complains of heel pain.

Bridge Reconstruction of Donor Iliac Crest with Resected Rib in Anterior Fusion of Thoracolumbar Spine / 대한척추외과학회지

STUDY DESIGN: A retrospective study about the efficacy of bridge reconstruction of donor iliac defect utilizing resected rib dur-ing surgical approach of thracolumbar vertebrae. OBJECTIVES: To evaluate the outcome in clinical aspect for cosmesis and pain, and radiological aspect for incorporation of rib with crest. SUMMARY OF LITERATURE REVIEW: Many iliac donor site problems were reported such as pain, deformity, fracture etc. Filling the bone defect with bone, cement, or artificial bone seems to reduce the donor site problems. MATERIALS AND METHODS: In fourteen patients who underwent anterior fusion of vertebrae, bridge reconstructions of iliac crest using resected rib for thoracoabdominal approach to vertebral body were performed. Postoperatively, donor site pain, residual deformity, and radiologic finding of the union between rib and iliac crest were evaluated. RESULTS: No patients had significant pain on donor iliac crest. Acceptable pain was complained by five patients after 1 month postoperatively and by three patients after 2 months postoperatively. After 3 months, no patients had pain problem at iliac donor site. Two patients presented palpable step-off on iliac crest, but external contours of iliac crest were satisfactory in all patients. Radi-ologic union of the rib-crest junction was confirmed within 6 months postoperatively in all cases. CONCLUSIONS: Bridge reconstruction of iliac crest defect using resected rib is a simple and effective method that can minimize residual donor site problems in anterior spinal surgeries of thoracic and upper lumbar vertebrae.

MMPI Profile in Patients with Chronic Low Back Pain / 대한정형외과학회잡지

PURPOSE: The causative pathology of chronic low back pain cannot be defined in many patients. To evaluate the relations between psychoneurotic status and chronic low back pain, the authors surveyed Minnesota Multiphasic Personal Inventory (MMPI) in the patients with chronic low back pain. MATERIALS AND METHODS: From July 1997 to December 1998, questionaire including MMPI were given to the patients who visited our Department for chronic (>6 weeks) low back pain. 50 patients (33 male, 17 female) completed MMPI. The mean age was 33.4 years (range 17-55) . MMPI scores were evaluated in two ways for each individual, mean scores of each clinical scale and two code method. Then mean scores were compared according to sex, radiating pain, radiologic abnormalities. RESULTS: In total 50 patients, three scales showed mean score over 55. Those were Hs:59.1 +/- 10.3, D:55.4 +/- 11.2 and Hy: 59.0 +/- 10.8. No significant differences were observed between the groups divided according to the sex, radiating pain, radiologic abnormalities. The two code method revealed that at least one of the neurotic triad (Hy, Hs, D) ranked within the highest two in 46 (92%) patients. CONCLUSION: It seemed that large proportion of patients with chronic low back pain had psychological tendency to hypochondriasis and/or depression and/or hysteria. MMPI seemed to be one of the useful methods in evaluation of psychogenic factors in chronic low back pain patients without definite organic pathology.

Efficacy of Bee Venom Injection for Osteoarthritis Patients / 대한류마티스학회지

OBJECTIVES: Bee venom contains a potent antiinflammatory peptide 401 as well as mellitin. The purpose of this study was to see the efficacy and safety of purified bee venom injection therapy for knee or spinal osteoarthritis patients. METHODS: One hundred and one osteoarthritis patients were randomly assigned to bee venom injection therapy or oral nabumetone medication group. Bee venom injection group was subdivided into 3 groups according to different dosing schedule(group A: gradual increase up to 0.7mg, group B: up to 1.5mg and group C: up to 2.0mg). Control group patients(group D) were given 1000mg nabumetone daily for 6 weeks. There were 25, 26, 25, and 26 patients assigned to A, B, C, or D group. The efficacy of treatment was evaluated by measuring instruments developed by authors, and the safety of bee venom injection was evaluated by hematology and chemistry laboratory examination. RESULTS: Among 101 patients, eighty-one patients completed the study, but twenty patients were dropped out and two of these patients were dropped out due to adverse drug reaction. The efficacy in bee venom group showed better improvement than nabumetone group(p<0.01). Within bee venom group, group B and C showed better improvement than group A(p<0.01). Itching around injection site occurred in most patients, and bodyache occurred in 49 patients (81.7%). Hemoglobin was decreased(0.3g/dl) in group C, but no significant changes were observed in other laboratory values. CONCLUSION: The efficacy of bee venom injection in the control of knee or back pain in osteoarthritis patients was better than nabumetone medication. No severe allergic or adverse reaction was observed in bee venom treatment patients, but problems related with bee venom injection, such as pruritis, bodyache, and the possibility of anaphylaxis, should be considered for the use of bee venom injection.

Lumbar Disc Herniation with Cauda Equina Syndrome after Self Traction Therapy: A Case Report / 대한척추외과학회지

STUDY DESIGN: A retrospective case report of lumbar disc herniation with cauda equina syndrome after self traction therapy. OBJECTIVES: Documentation of clinical significance and manifestations of disc herniation with cauda equina syndrome as one of the complications after self traction therapy. SUMMARY OF BACKGROUND DATA: Various conservative managements of acute low back pain in adults such as traction, spine manipulation therapy(SMT), and exercise therapy may produce harmful complications, especially when performed by non-professional therapists. Recently, reports of complication from SMT are increasing, however, understanding of biomechanism and natural history of traction, SMT, and exercise therapy are still poor. Therefore background information on the possible complications from their management is essential for physicians. METHOD: A case of acute cauda equina syndrome after self traction therapy in a 41 year-old man. Magnetic resonance imaging revealed severe compression of cauda equina by a huge mass. Emergency lumbar laminectomy was performed and all the compressing mass was removed. The mass was proven to be prolapsed disc of nearly whole nucleus amount and scanty nucleus was found within the disc space. RESULT: Acute low back pain and radiating pain disappeared immediately after operation. And neurologic deficits began to improve after postoperative 1 week. At the 15 month follow-up, the patient had recovered fully except minimal paresthesia on the right foot. CONCLUSION: More attentions to the possibility and clinical features of this complication seemed to be needed to the clinicians and therapists who do conservative management for the low back problems, especially SMT, traction, exercise therapy etc.

A Case-Control Study on Effects of Genetic Polymorphisms of GSTM1, GSTT1, CYP1A1 and CYP2E1 on Risk of Lung Cancer / 예방의학회지

OBJECTIVES: This study was performed to investigate effects of genetic polymorphisms of glutathione S-transferase M1 (GSTM1), glutathione S-transferase M1 (GSTT1), cytochrome P450 1A1 (CYP1A1) and cytochrome P450 2E1 (CYP2E1) on lung cancer development. METHODS: Ninety-eight lung cancer patients and 98 age-sex matched non-cancer patients hospitalized in Chungbuk National University Hospital from March 1997 to August 1998, were the subjects of this case-control study. Direct interview was done and genotypes of GSTM1, GSTT1, CYP1A1 and CYP2E1 were investigated using multiplex PCR or PCR-RFLP methods with DNA extracted from venous blood. Effects of the polymorphisms of GSTM1, GSTT1, CYP1A1 and CYP2E1, lifestyle factors including smoking, and their interactions on lung cancer were statistically analyzed. RESULTS: GSTM1 was deleted in 67.01% of the cases and 58.16% of the controls, and the odds ratio(95% CI) was 1.46(0.82-2.62). GSTT1 deletion was 58.76% for the lung cancer patients and 50.00% for the controls OR:1.43(0.81-2.51). The frequencies of Ile/Ile, Ile/Val and Val/Val of the CYP1A1 polymorphisms were 59.18%, 35.71%, and 5.10% for the cases, and 52.04%, 45.92%, 2.04% for the controls, respectively. Risk of lung cancer was not associated with polymorphism of CYP1A1 (x2trend=0.253, p-value>0.05). The respective frequency of c1/c1, c1/c2, c2/c2 genotypes for CYP2E1 were 50.00%, 42.86%, 7.14% for the lung cancer patients, and 66.33%, 30.61%, 3.06% for the controls (x2trend=5.783, p<0.05). c2 allele was a significant risk factor for lung cancer. We also observed a significant association of cigarette smoking history with lung cancer risk. The odds ratio(95% CI) of cigarette smoking was 3.03(1.58-5.81). In multiple logistic analysis including genotypes of GSTM1, GSTT1, CYP1A1 and CYP2E1, and smoking habit, only smoking habit came out to be a significant risk factor for lung cancer. CONCLUSION: Genetic polymorphisms of GSTM1, GSTT1, CYP1A1 and CYP2E1 are not so strongly associated with lung cancer as lifestyle factors including cigarette smoking.

Difference of Wear Damage of the Miller-Galante 1 and 2 Polyethylene Tibial Components / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to examine the effects of change of polyethylene resin type and manufacturing method on the wear of polyethylene tibial component. MATERIALS AND METHODS: Thirteen MG I and 10 MG II components were retrieved at revision surgery. Each polyethylene tibial component was graded for surface wear damage. Density profiles of the polyethylene were measured to examine the extent of oxidative degradation of the polyethylene. RESULTS: The primary damage mode of the MG I retrievals was scratching and metallic debris, but the primary damage mode of the MG II was delamination (P<0.05). For the implants with implantation time of 5 years or more, the MG II polyethylene had a higher density value (0.959+/-0.002 g/cc, n=7) compared with the MG I (0.948+/-0.004 g/cc, n=11). Both delamination and polyethylene degradation increased with length of implantation time for the MG II components (P<0.01). Even after gamma sterilization, the directly molded 1900 MG I components experienced significantly less delamination and degradation than the machined GUR 415 MG II tibial components. CONCLUSIONS: This study suggests that delamination of polyethylene tibial components is influenced by resin type and/or manufacturing method

Multifocal Acute Osteomyelitis in a Mole Adolescent: A Case Report / 대한정형외과학회잡지

A 13-year-old boy developed fever and right leg pain, and multiple acupunctures were done on legs, then visited our ER for high fever, chill and painful swellings in both legs. Bone scan showed multiple hot spots on both distal femur, both proximal tibia, and left distal tibia. MRI revealed subperiosteal abscess in right proximal and left distal tibia and signal changes without abscess in other hot spot sites on bone scan. Surgical drainage of subperiosteal abscess and curettage were performed in the right proximal and the left distal tibia. Percutaneous drillings were done to other hot spot sites. All the lesions were cured after combined antibiotic chemotherapy. Multifocal osteomyelitis in a rapidly growing adolescent has been reported not rarely. It seemed that more attentions should be paid to the possibility of multifocal acute osteomyelitis in an adolescent

Analysis of Tensile Strength of Double Helix Wires / 대한정형외과학회잡지

PURPOSE: To compare the tensile properties of double helical twisting. MATERIALS AND METHODS: 21G and 18G stainless steel wires were used. Monostrand, untwisted double strand and manually twisted double helix wires were tested under gradually increasing tension force until the wires break. Data were analyzed by using a computer system to get force-strain curves. RESULTS: Forces at the break point showed no significant differences between untwisted double strand wires and helically twisted double strand wires. Forces at the yield point deformation were proportionally increased to the degree of helical twisting until the wires were twisted 20 times (piptch number: 24/10 cm) with no more increase after then. Final strain at break point decreased by helical twisting, which means the range of plastic deformation decreased. CONCLUSION: By helical twisting, the wires increase in elastic range and decrease in plastic deformation. Therefore, double helix wiring seemed to be a more effective method of fixation compared to the untwisted double strand wires.

Morphological Difference of Polyethylene Section in Knee Arthroplasty

The purpose of this study is to see the value of transsectional morphology of polyethylene for evaluation of wear and characteristics of ultra-high molecular weight polyethylene. Retrieved nineteen polyeth- ylene tibial components were examined for this study. Ten components were the directly molded 1900 Himont polyethylene, and 9 components were the machined GUR 415 polyethylene. Transsection of polyethylene(thickness: 60 - 150 micron) was obtained by microtome and was examined microscopical- ly for the fusion defects, subsurface white bands, and delamination as a mode of wear. Significant differ- ences between two groups of polyethylene were found. Fusion defects greater than 100 micron were observed in 5 among 9 GUR 415 polyethylene. Subsurface white band were observed in 7 among 9 GUR 415 polyethylene. Delamination was found in 6 arnong 9 GUR 415 polyethylene. Neither fusion defects greater than 100 micron, nor delamination were observed in 1900 Himont polyethylene. Morphological examination of polyethylene section is an efficient way to differentiate the polyethylene and to evaluate the wear behavior of retrieved polyethylene. This study suggests that delamination of polyethylene tibial components is influenced by resin type and / or manufacturing method.

The Significances of Bony Lesions Observed on MRI of Traumatic Knees / 대한정형외과학회잡지

Diagnosis of trauma to the soft tissue structures of the knee such as menisci, cruciate ligaments, and collateral ligaments has been greatly advanced by MRI. Some bony lesions which couldnt be seen by simple X-rays, also became to be visualized by MRI. The authors reviewed 131 MRI s of traumatized knees from March, 1992 to August, 1995. Among them, various traumatic lesions of bone were found in 62 cases. Those cases were thoroughly reviewed to define the significances of the lesions, by reviewing the medical records and careful examination of simple X-rays and MRI. The bony lesions could be classified into four groups, such as coronal plane injuries (valgus, varus), sagittal plane injuries(contusion of proximal tibia-posterior cruciate ligament injury, patello-femoral contusions), nonspecific direct contusion, and tibial condylar fractures. In the valgus group, 3 components of MRI lesions as the evidences of valgus injury could be observed. They were direct contusions on lateral aspect of the knee, tension failure of medial aspect(medial collateral ligament injury), compression failure of lateral aspect of knee(focal compression lesions of femoral and/or tibial condyle adjacent to lateral meniscus). In other types of injuries, similar findings were observed as evidences of the events at the trauma. Most of the bony lesions were located at the sites where external forces were exerted and/or internal responses took place. It seems that bony lesions seen at MRI of traumatized knee are not simply meaningless, incidental findings but document the events at the time of the trauma.

Occlusion of Vertebral Artery and Cerebral Infarction after Cervical Spine Fracture: A Case Report / 대한척추외과학회지

STUDY DESIGN: A case of brain infarction due to occlusion of vertebral artery after cervical spine fracture is reported. OBJECTIVES: Documentation of possibility and clinical significances of brain infarction as one of grave complications after cervical spine injury. SUMMARY OF LITERATURE REVIEW: Occlusion of vertebral artery and consequent brain infarction can be associated with cervical spine injuries because vertebral arteries course through the transverse foramina from sixth to second corvical vertebrae. Infarction of vertebrobasilar system may cause impairment of cerebral, cerebellar, or brain stem function and can occasionally bring grave functional loss, even death. MATERIALS AND METHODS: A case of occlusion of vertebral artery and consequent cerebral infarction after cervical spine fracture in a 66 year-old man. Brain CT and angiogram were performed. He was managed with anticoagulants. RESULTS: Neurologic deficits from brain infarction disappeared after 2 weeks. CONCLUSIONS: Attention to the possibility of these complications and awareness of their clinical features seem to be mandatory in managing cervical spine injury patients.

Strength of Surgical Wire by Different Wiring Technique / 대한정형외과학회잡지

The role of surgical wire in the bone and joint surgery is very important. To get a maximum effect of the surgical wiring, the orthopaedic surgeon should not only select appropriate wire diameter but also apply adequate wiring technique. When strong fixation is required, wire loops are frequently untrustworthy. These are due to insufficient caliber or inadequate technique of wire thightening and/or twisting. The theoretical background for effective wiring technique and useful diameter in cerclage wiring is poor. Ultimate stress and stress at breaking point of different diameter of the wire was higher in 16G than 18G or 21G. Twist knot was stronger than knot twist. Wire holder was more effect than tensioner(york). Tension tightening with twist knot by wire holder have been found most suitable for internal fixation by surgical wire.