Computed Tomography Evaluation of Percutaneous Pedicle Screws Inserted during Minimally Invasive Transforaminal Lumbar Interbody Fusion: Long-term Follow-up Results of Screw Violation

Background@#To evaluate the accuracy of percutaneous pedicle screw (PPS) insertion in degenerative lumbar disease treated with minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) and to analyze risk factors and long-term clinical outcomes of screw violation. @*Methods@#Sixty-two consecutive patients (262 screws) were included. Based on postoperative computed tomography (CT) axial images, a PPS that perforated out of the pedicle was classified into a violation group, while screws surrounded by pedicular cortical bone were classified into a correct group. A logistic regression model was used for risk factor analysis of violation. We also observed the long-term clinical outcomes using the Oswestry disability index and visual analog scale. @*Results@#Of the 262 screws, 14 (5.3%) were considered to be violated (10 medial violations and 4 lateral violations). All violations of S1 and L5 were in the medial direction. In contrast, entire violations of L4 were always lateral and of the 2 violations of L3, one was lateral and the other was medial. There were no cases of superior or inferior violation. The mean pedicle convergence angle (CA) was significantly higher in the violation group (mean ± standard deviation, 27.0° ± 6.2°) than in the correct group (21.7° ± 5.4°).There were no significant differences according to vertebral rotational angle, body mass index, bone mineral density, and surgical timing (learning curve) between the two groups. Logistic regression analyses demonstrated that a high CA was a significant risk factor for pedicle wall violation (p = 0.002). There were no significant differences in clinical or radiographic results between the two groups in 60 patients who were followed up for more than 1 year and in 40 patients who were followed up for more than 5 years. There were 2 patients who required reoperation to replace a screw due to leg pain. @*Conclusions@#With PPS insertion during MI-TLIF, the rate of pedicle violation was 5.3% (14/262). An understanding of the anatomical characteristics of each vertebra and the unique structures of the patient is essential to prevent pedicle violations. Even in the violation group, PPS fixation was found to be a safe and useful procedure with successful long-term radiographic and clinical outcomes.

Management of Osteoporotic Vertebral Fracture: Review Update 2022

A vertebral fracture is the most common type of osteoporotic fracture. Osteoporotic vertebral fractures (OVFs) cause a variety of morbidities and deaths. There are currently few “gold standard treatments” outlined for the management of OVFs in terms of quantity and quality. Conservative treatment is the primary treatment option for OVFs. The treatment of pain includes short-term bed rest, analgesic medication, anti-osteoporotic medications, exercise, and a brace. Numerous reports have been made on studies for vertebral augmentation (VA), including vertebroplasty and kyphoplasty. There is still debate and controversy about the effectiveness of VA in comparison with conservative treatment. Until more robust data are available, current evidence does not support the routine use of VA for OVF. Despite the fact that the majority of OVFs heal without surgery, 15%–35% of patients with an unstable fracture, persistent intractable back pain, or severely collapsed vertebra that causes a neurologic deficit, kyphosis, or chronic pseudarthrosis frequently require surgery. Because no single approach can guarantee the best surgical outcomes, customized surgical techniques are required. Surgeons must stay current on developments in the osteoporotic spine field and be open to new treatment options. Osteoporosis management and prevention are critical to lowering the risk of future OVFs. Clinical studies on bisphosphonate’s effects on fracture healing are lacking. Teriparatide was intermittently administered, which dramatically improved spinal fusion and fracture healing while lowering mortality risk. According to the available literature, there are no standard management methods for OVFs. More multimodal approaches, including conservative and surgical treatment, VA, and medications that treat osteoporosis and promote fracture healing, are required to improve the quality of the majority of guidelines.

Long-Term Clinical and Radiological Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion: 10-Year Follow-up Results

Background@#Many studies have reported that minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) provides satisfactory treatment comparable to other fusion methods. However, in the case of MI-TLIF, there are concerns about the long-term outcome compared to conventional bilateral PLIF due to the small amount of disc removal and the lack of autogenous bone graft. Long-term follow-up studies are still lacking as most of the previous reports have follow-up periods of up to 5 years. @*Methods@#Thirty patients who underwent MI-TLIF were followed up for > 10 years (mean, 11.1 years). Interbody fusion rates were determined using a modified Bridwell grading system.Adjacent segment disease (ASD) was defined as radiological adjacent segment degeneration (R-ASDeg) as seen on plain X-rays; reoperated adjacent segment disease referred to the subsequent need for revision surgery. Clinical outcomes after surgery were assessed based on back and leg pain as well as the Oswestry disability index (ODI). @*Results@#The overall radiological fusion rate, at the 1-, 5-, and 10-year follow-up was 77.1%, 91.4%, and 94.3%, respectively. The incidence of R-ASDeg 1, 5, and 10 years after surgery was 6.7%, 16.7%, and 43.3% at the proximal adjacent segment and 4.8%, 14.3%, and 28.6% at the distal adjacent segment, respectively. R-ASDeg at either the proximal or distal segment was determined in 50.0% of the patients 10 years postoperatively. All clinical parameters improved significantly during follow-up, although the ODI and the visual analog scale (VAS) for leg pain at the 10-year follow-up were significantly worse in the R-ASDeg group than in the other patients (P = 0.009, P = 0.040). @*Conclusion@#MI-TLIF improved both clinical and radiological outcomes, and the improvements were maintained for up to 10 years after surgery. However, R-ASDeg developed in up to 50% of the patients within 10 years, and both leg pain on the VAS and the ODI were worse in patients with R-ASDeg.

Current Concepts in the Management of Osteoporotic Vertebral Fractures: A Narrative Review

Vertebral fractures are the most common type of osteoporotic fracture and can increase morbidity and mortality. To date, the guidelines for managing osteoporotic vertebral fractures (OVFs) are limited in quantity and quality, and there is no gold standard treatment for these fractures. Conservative treatment is considered the primary treatment option for OVFs and includes pain relief through shortterm bed rest, analgesics, antiosteoporotic drugs, exercise, and braces. Studies on vertebral augmentation (VA) including vertebroplasty and kyphoplasty have been widely reported, but there is still debate and controversy regarding the effectiveness of VA when compared with conservative treatment, and the routine use of VA for OVF is not supported by current evidence. Although most OVFs heal well, approximately 15%–35% of patients with unstable fractures, chronic intractable back pain, severely collapsed vertebra (leading to neurological deficits and kyphosis), or chronic pseudarthrosis frequently require surgery. Given that there is no single technique for optimizing surgical outcomes in OVFs, tailored surgical techniques are needed. Surgeons need to pay attention to advances in osteoporotic spinal surgery and should be open to novel thoughts and techniques. Prevention and management of osteoporosis is the key element in reducing the risk of subsequent OVFs. Bisphosphonates and teriparatide are mainstay drugs for improving fracture healing in OVF. The effects of bisphosphonates on fracture healing have not been clinically evaluated. The intermittent administration of teriparatide significantly enhanced spinal fusion and fracture healing and reduced mortality risk. Based on the current literature, there is still a lack of standard management strategies for OVF. There is a need for greater efforts through multimodal approaches including conservative treatment, surgery, osteoporosis treatment, and drugs that promote fracture healing to improve the quality of the guidelines.

Current Concepts in the Management of Osteoporotic Vertebral Fractures: A Narrative Review

Vertebral fractures are the most common type of osteoporotic fracture and can increase morbidity and mortality. To date, the guidelines for managing osteoporotic vertebral fractures (OVFs) are limited in quantity and quality, and there is no gold standard treatment for these fractures. Conservative treatment is considered the primary treatment option for OVFs and includes pain relief through shortterm bed rest, analgesics, antiosteoporotic drugs, exercise, and braces. Studies on vertebral augmentation (VA) including vertebroplasty and kyphoplasty have been widely reported, but there is still debate and controversy regarding the effectiveness of VA when compared with conservative treatment, and the routine use of VA for OVF is not supported by current evidence. Although most OVFs heal well, approximately 15%–35% of patients with unstable fractures, chronic intractable back pain, severely collapsed vertebra (leading to neurological deficits and kyphosis), or chronic pseudarthrosis frequently require surgery. Given that there is no single technique for optimizing surgical outcomes in OVFs, tailored surgical techniques are needed. Surgeons need to pay attention to advances in osteoporotic spinal surgery and should be open to novel thoughts and techniques. Prevention and management of osteoporosis is the key element in reducing the risk of subsequent OVFs. Bisphosphonates and teriparatide are mainstay drugs for improving fracture healing in OVF. The effects of bisphosphonates on fracture healing have not been clinically evaluated. The intermittent administration of teriparatide significantly enhanced spinal fusion and fracture healing and reduced mortality risk. Based on the current literature, there is still a lack of standard management strategies for OVF. There is a need for greater efforts through multimodal approaches including conservative treatment, surgery, osteoporosis treatment, and drugs that promote fracture healing to improve the quality of the guidelines.

Comparison of Cortical Ring Allograft and Plate Fixation with Autologous Iliac Bone Graft for Anterior Cervical Discectomy and Fusion

STUDY DESIGN: A retrospective cohort study. PURPOSE: To compare the clinical and radiological outcomes of patients who underwent anterior cervical discectomy and fusion (ACDF) supplemented with plate fixation using allograft with those who underwent ACDF using tricortical iliac autograft. OVERVIEW OF LITERATURE: As plate fixation is becoming popular, it is reported that ACDF using allograft may have similar outcomes compared with ACDF using autograft. METHODS: Forty-one patients who underwent ACDF supplemented with plate fixation were included in this study. We evaluated 24 patients who used cortical ring allograft filled with demineralized bone matrix (DBM) (group A) and 17 patients who used tricortical iliac autograft (group B). In radiological evaluations, fusion rate, subsidence of grafted material, cervical lordosis, fused segmental lordosis, and radiological adjacent segment degeneration (ASD) were observed and analyzed with preoperative and postoperative plain radiographs. Clinical outcomes were evaluated using the Neck Disability Index score, Odom criteria, and Visual Analog Scale score of neck and upper extremity pain. Radiological union was determined by dynamic radiographs using cutoff values of 1 mm of interspinous motion as the indication of pseudarthrosis. RESULTS: There was no significant difference in the fusion rate, graft subsidence, cervical lordosis, fused segmental lordosis, and ASD incidence between the groups. Operative time was shorter in group A (136 min) than in group B (141 min), but it was not significant (p>0.05). Blood loss was greater in group B (325 mL) than in group A (210 mL, p=0.013). There was no difference in the clinical outcomes before and after surgery. CONCLUSIONS: In ACDF with plate fixation, cortical ring allograft filled with DBM group showed similar radiological and clinical outcomes compared with those of the autograft group. If the metal plate is reinforced, using cortical ring allograft could be a viable alternative to autograft.

Blood Management Protocol without Transfusion in Orthopedic Surgery / 대한수혈학회지

We developed a new blood management protocol that allows patients to not undergo transfusion during major orthopaedic surgery. Here, we report the safety of or our protocol. The preoperative pharmacological protocol consisted of the administration of 40 µg of recombinant erythropoietin subcutaneously and 100 mg of iron supplements intravenously. During the operation, reinfusion of drainage blood using a cell saver and plasma expander was used. The cell saver device passed the collected blood through a filter, which washed the blood, removing the hemolyzed cells and other impurities. Intravenous tranexamic acid 1 g is given just before the operation, except high-risk patients for venous thromboembolism. Postoperatively, recombinant erythropoietin and iron supplements were administered in the same manner with the preoperative protocol and continued until a hemoglobin level reached 10 g/dL.

Comparison of the Efficacy and Safety Profiles of a Mixed ‘PF-72’ and ‘0.75% Ropivacaine HCl’ Versus a ‘0.75% Ropivacaine HCl’ and No Treatment Group: A Randomized, Single-Blind, Single-Institution Pilot Study

OBJECTIVES@#The efficacy and safety of ‘PF-72’ for management of postoperative acute pain through a mixed ‘PF-72’ and 0.75% ropivacaine hydrochloride solution in patients with posterior spine surgery was evaluated as ‘0.75% ropivacaine’ and ‘untreated’ controls.SUMMARY OF LITERATURE REVIEW: Postoperative acute pain is major surgical side effect that lead to the deterioration of the quality of life. Traditional pain control results in variable side effects, and multimodal pain management has been recommended as an alternative. Local anesthetics is a short-acting time lower than 12 hours. There is controversy about the efficiency and stability of thermoreactive hydrogel products as a drug delivery system.@*MATERIALS AND METHODS@#Patients scheduled for posterior spine surgery were enrolled by the inclusion criteria. In the treated group, PF-72 and ropivacaine mixture was injected to the surgical wound before closure. In control group 1, only 0.75% ropivacaine hydrochloride was injected. In the control group 2, the surgical site was without injection. Ten patients were randomly assigned to each group and standardized drugs for pain control were applied postoperatively and rescue regimens were applied when necessary. Postoperative pain score and the cumulative area under the curve (AUC) of pain score were compared. The percentage of subjects who were painless (pain score ≤ 3) was examined at each observation point. The first time of injection and the total dose of the rescue regimen were examined. Postoperative nausea and vomiting (PONV) were also evaluated.@*RESULTS@#There was no significant difference in demographic data. The sum AUC of pain scores in the treated group was significantly lower than that in the control group 1 and 2 at all observation times. The proportion of painless patients was significantly higher in the treated group than in the control group 2. There was no significant difference between the first administration time and the total usage of the rescue regimen, and the percentage of patients with PONV at all time points. There was no statistically significant difference in the incidence of adverse events.@*CONCLUSIONS@#PF-72 and ropivacaine mixture showed significant effects for pain management up to 72 hours postoperatively for the patients who underwent posterior spinal surgery without fatal complications.

Comparison of the Efficacy and Safety Profiles of a Mixed ‘PF-72’ and ‘0.75% Ropivacaine HCl’ Versus a ‘0.75% Ropivacaine HCl’ and No Treatment Group: A Randomized, Single-Blind, Single-Institution Pilot Study

STUDY DESIGN: Prospective pilot study OBJECTIVES: The efficacy and safety of ‘PF-72’ for management of postoperative acute pain through a mixed ‘PF-72’ and 0.75% ropivacaine hydrochloride solution in patients with posterior spine surgery was evaluated as ‘0.75% ropivacaine’ and ‘untreated’ controls. SUMMARY OF LITERATURE REVIEW: Postoperative acute pain is major surgical side effect that lead to the deterioration of the quality of life. Traditional pain control results in variable side effects, and multimodal pain management has been recommended as an alternative. Local anesthetics is a short-acting time lower than 12 hours. There is controversy about the efficiency and stability of thermoreactive hydrogel products as a drug delivery system. MATERIALS AND METHODS: Patients scheduled for posterior spine surgery were enrolled by the inclusion criteria. In the treated group, PF-72 and ropivacaine mixture was injected to the surgical wound before closure. In control group 1, only 0.75% ropivacaine hydrochloride was injected. In the control group 2, the surgical site was without injection. Ten patients were randomly assigned to each group and standardized drugs for pain control were applied postoperatively and rescue regimens were applied when necessary. Postoperative pain score and the cumulative area under the curve (AUC) of pain score were compared. The percentage of subjects who were painless (pain score ≤ 3) was examined at each observation point. The first time of injection and the total dose of the rescue regimen were examined. Postoperative nausea and vomiting (PONV) were also evaluated. RESULTS: There was no significant difference in demographic data. The sum AUC of pain scores in the treated group was significantly lower than that in the control group 1 and 2 at all observation times. The proportion of painless patients was significantly higher in the treated group than in the control group 2. There was no significant difference between the first administration time and the total usage of the rescue regimen, and the percentage of patients with PONV at all time points. There was no statistically significant difference in the incidence of adverse events. CONCLUSIONS: PF-72 and ropivacaine mixture showed significant effects for pain management up to 72 hours postoperatively for the patients who underwent posterior spinal surgery without fatal complications.

Association between Smoking and Delayed Neuropsychological Sequelae in Acute Carbon Monoxide Poisoning

PURPOSE: This study examined the association between smoking and delayed neuropsychological sequelae (DNS) in acute carbon monoxide (CO) poisoning. METHODS: Patients admitted to the medical center emergency department from March 2016 to March 2017 because of CO poisoning were examined retrospectively. The patients were divided into two groups: DNS and Non-DNS group. Multiple factors were analyzed to explain DNS, which was assessed by motor disturbances, cognitive impairment, dysphagia, Parkinson-like syndromes, epilepsy, and emotional lability in CO poisoning. RESULTS: A total of 120 patients were included. The factors related to DNS were smoking (pack-years) (p=0.002) and initial carbon monoxide-hemoglobin level (p=0.015). On the other hand, after multivariate logistic regression analysis, smoking (Odds ratio 1.07; 95% CI, 1.02-1.13; p=0.004) was the only factor associated with DNS. CONCLUSION: Smoking is a very reliable factor for predicting the occurrence of DNS. A history of smoking in patients who suffer from CO intoxication is important. If a patient smokes, treatment should be started actively and as soon as possible.

A Long, Solitary, Rosary-Shaped Spinal Neurofibroma

STUDY DESIGN: Case report. OBJECTIVES: We report the case of a long, solitary, rosary-shaped neurofibroma that was misdiagnosed as another disease due to the patient's surgical history involving repetitive procedures and its abnormal appearance. SUMMARY OF LITERATURE REVIEW: Neurofibroma is an intradural-extramedullary spinal tumor. It is generally not difficult to diagnose due to its frequent occurrence and specific magnetic resonance imaging (MRI) findings. However, to date, neurofibromatosis stigmata and long, solitary, rosary-shaped neurofibromas have rarely been reported. MATERIALS AND METHODS: A 60-year-old woman was admitted to our hospital due to persistent pain, despite previous surgery and repetitive procedures. On physical examination, vision loss, hearing loss, skin discoloration, or subcutaneous nodules were not observed. A neurologic examination revealed normal motor and sensory function and voiding sensation. No pathologic reflexes such as the Babinski sign were observed. Previous sequential MRIs revealed intradural lesions that progressed from the thoracic vertebra 11 to the lumbar vertebra 3. She had no signs of neurofibromatosis stigmata, and the neurologic examination was unremarkable. The initial diagnosis was based on serial MRIs, which revealed a parasite infestation, a spinal cord tumor (myxopapillary-type ependymoma with hemorrhage), arachnoiditis, and vascular malformations. Total mass excision was performed, and the final diagnosis was neurofibroma. RESULTS: There were no signs of a tumor remnants or local recurrence in a 1-year follow-up MRI study. CONCLUSIONS: Although intradural spinal tumors are very rare, their clinical features are nonspecific and resemble other degenerative spinal diseases, including spinal stenosis and disc herniation. These diseases may easily be overlooked by physicians.

A Study on the Estimation of Calcaneal Width Using a Correlation of Calcaneal Length and Width / 대한족부족관절학회지

PURPOSE: The purpose of this study was to determine the correlation and ratio between the calcaneal length and width for predicting the width of calcaneus. MATERIALS AND METHODS: A total of 190 feet (190 patients) were included based on computed tomography scans. The length of calcaneus (CL) was measured on the line connecting the center of a circle tangent to the cortical margin in the anterior and posterior parts of the calcaneus in a sagittal plane (W1, W2). The width of the calcaneus was defined as the horizontal line of each part (W1, W2, W3) on the same axial plane. The relationship between the measurement was determined through a correlation analysis. The reliability was assessed based on intraclass correlation coefficients. RESULTS: The CL and widths of calcaneus (W1, W2, W3) had a good positive correlation (r=0.848 [W1/CL], r=0.738 [W2/CL], r=0.769 [W3/CL]; p<0.001). The mean CL and widths ratios were 0.33 (W1/CL), 0.37 (W2/CL), and 0.37 (W3/CL). Using these ratios to estimate the widths by multiplying each ratio by the measured calcaneal length, we found a difference between the estimated calcaneal widths and the actual measured calcaneal widths values was 0.25 mm, 0.43 mm, and 0.16 mm. All measurements showed good-to-excellent inter- and intraobserver reliability. CONCLUSION: This study analyzed the correlation and ratio between the length and width of the calcaneus. The results will help orthopedic surgeons fixate screws in a stable manner to prevent iatrogenic injuries to the medial neurovascular structures of the calcaneus.

Outcomes of Degenerative Lumbar Spine Surgery in Patients with Chronic Kidney Disease Undergoing Hemodialysis

STUDY DESIGN: Retrospective study. OBJECTIVES: To analyze the outcomes of degenerative lumbar spine surgery in patients undergoing hemodialysis due to chronic kidney disease (CKD). SUMMARY OF LITERATURE REVIEW: Patients who undergo hemodialysis due to chronic renal disease tend to exhibit accelerated changes in bone quality, deterioration of spinal stenosis, and accompanying neurological degeneration. The surgical treatment of chronic spinal diseases is also becoming more necessary with the increased lifespan of these patients. MATERIALS AND METHODS: We reviewed the medical records and radiographs of patients with CKD undergoing hemodialysis who were followed-up for more than 1 year after posterior lumbar spinal surgery. We evaluated clinical, laboratory, and radiologic variables. For a comparative analysis, patients were classified into subgroups according to age (65 years old), duration of hemodialysis (10 years), and type of surgery (simple decompression or fusion). RESULTS: We included 21 patients (5 men, 16 women) with a mean age of 66.2 years (range, 48-87 years). The mean duration of hemodialysis and follow-up was 18.9 years and 43 months, respectively. Decompressions with fusion were performed in 11 patients and simple decompressions in the other 10. The mean visual analog scale (VAS) of leg pain and the Oswestry Disability Index (ODI) significantly improved after surgery at time of the last follow-up; meanwhile, the mean VAS score for lower back pain did not show a statistically significant improvement. The postoperative ODI was correlated with age (correlation coefficient=0.71, p=0.006). In patients less than 65 years old, the ODI improvement was greater (p=0.035) than in those 65 years of age or older. There was no significant difference in the clinical outcomes according to the duration of hemodialysis. Complications were observed in 11 patients (52.4%, 7 in fusion and 4 in simple decompression), of which 2 cases were infections, and reoperations were performed in 5 patients. The union rate of the fusion cases at the 1-year follow-up was 81.8%. CONCLUSIONS: Appropriate spine surgery improved radicular pain and the ODI in patients with degenerative lumbar disease undergoing hemodialysis. However, postoperative complications were frequent and the improvement of clinical outcomes was minimal, especially in patients over 65 years of age and in those who underwent fusion. Therefore, the surgical treatment of patients with chronic renal disease undergoing hemodialysis requires adequate consideration of age and the duration of hemodialysis.

Work-Related Musculoskeletal Disorders among Spine Surgeons / 대한정형외과학회잡지

PURPOSE: To investigate the prevalence and risk factors of musculoskeletal disorder (MSD) among spine surgeons. MATERIALS AND METHODS: A modified version of discomfort survey was sent via e-mail to surgeons that belong to the Korean Society of Spine Surgery. The survey questionnaires were composed of demographics, factors relating to spine surgery, and MSD. We investigated the common sites of occurrence of MSD and its risk factors. RESULTS: The survey was sent to a total of 420 subjects; of which, 80 subjects (19.0%) responded. About 78.8% of the respondents had MSD for the past year. The common sites of occurrence included the neck (52.5%), back (46.3%), and shoulder (18.8%). The prevalence of pain in the elbow joint/forearm was higher in the group performing a higher frequency of spine surgeries (p=0.033). Moreover, the prevalence of pain in the wrist/hand (p=0.008) and in the back (p=0.042) was higher in those with greater frequency of major surgeries (>10 case/year) as compared with those with lower frequency of major surgeries. CONCLUSION: As shown, about 78.8% of spine surgeons experienced MSD for the past one year. Its prevalence was higher as compared with the general population. Thus, more attention should be paid to the prevention of MSD among spine surgeons.

The Clinical Outcome of Soft Tissue Solitary Fibrous Tumor / 대한정형외과학회잡지

PURPOSE: Solitary fibrous tumors (SFT) represent a rare entity of soft tissue tumors which are exclusively located in the thoracic cavity as pleural fibrous tumors. Extrathoracic SFT in the soft tissues are very rare. We analyzed the oncologic outcome of the soft tissue SFT. MATERIALS AND METHODS: Between January 2009 and December 2014, we treated 6 soft tissue SFT cases. Patients' clinical data, magnetic resonance imagings and pathologic findings were reviewed. RESULTS: The patients included two women and four men. The average age of the patients was 45 years (range, 32-56 years). The mean tumor size is 7.2 cm (range, 3.5-13.0 cm). One patient received wide excision of the tumor and remaining 5 patients marginal excision. After the excision, pathologic report confirmed that 4 patients showed margin positive. However, no patient received further surgery or adjuvant treatments. After the immunohistochemistry, 2 out of 6 patients identified as malignant soft tissue SFT. The mean follow-up period was 25.8 months (range, 6-66 months). Although 4 patients revealed margin positivity, no subsequent local recurrence or distant metastasis was observed. CONCLUSION: Since the SFT are categorized as intermediated biological potential with a low risk of metastasis and recurrence, marginal excision can be a one of the surgical options for these tumors which are located adjacent to vital structures. However, close observation is needed because local recurrence can be significantly higher the patients with positive resection margins.

Unusual Presentation of Bilateral Foraminal Disc Herniation

A 64-year-old woman was admitted to Soonchunhyang University Seoul Hospital due to the aggravation of bilateral radicular pain for one month prior to her visit. She had a 30 years history of low back pain and intermittent bilateral radiating pain. A magnetic resonance imaging scan revealed a bilateral space-occupying lesion in the L5 foramen. A sagittal computed tomography scan showed a disc space-narrowing, vacuum-containing, and widening of the neural exit foramen with thinning of the pedicle and posterior vertebral body scalloping. An axial scan showed that the space-occupying lesion contained calcification and had eroded the surrounding bony structure. During surgical exploration, the atrophic L5 nerve root was identified over the mass-like lesion, and the lesion was shown to be a result of a hard, extruded disc fragment. A bilateral foraminal disc is a very rare condition that when it progresses chronically and gradually, can erode adjacent bony structures. Specific precautions are necessary during fusion surgery with a pedicle screw.

The Amputation Rate and Associated Risk Factors within 1 Year after the Diagnosis of Diabetic Foot Ulcer / 대한족부족관절학회지

PURPOSE: This study investigates the amputation rate within 1 year after the diagnosis of diabetic foot ulcer and its associated risk factors. MATERIALS AND METHODS: This study enrolled 60 patients with diabetic foot ulcer. The mean and standard deviation age was 64.4±12.8 years (range, 32~89 years); the mean and standard deviation prevalence period for diabetes mellitus was 21.0±7.5 years (range, 0.5~36 years). The amputation rate was evaluated by dividing the subjects into two groups—the major and minor amputation groups—within 1 year following the initial diagnosis of diabetic foot ulcer. Multivariate Cox proportional hazards regression analysis was used to identify the risk factors for amputation. RESULTS: The total amputation rate of 38.3% (n=23) was comprised of the amputation rate for the major amputation group (10.0%) and rate for the minor amputation group (23.8%). There was a high correlation between peripheral artery disease (toe brachial pressure index <0.7) and amputation (hazard ratio [HR] 5.81, confidence interval [CI] 2.09~16.1, p<0.01). Nephropathy was significantly correlated with the amputation rate (HR 3.53, CI 1.29~9.64, p=0.01). CONCLUSION: Clinicians who treat patients with diabetic foot complications must understand the fact that the amputation rate within 1 year is significant, and that the amputation rate of patients with peripheral artery disease or nephropathy is especially high.

Giant Cell-Rich Osteosarcoma: A Tumor Simulating Borderline Lesion / 대한정형외과학회잡지

PURPOSE: Giantcell-rich osteosarcoma (GCRO) is a rare subtype of osteosarcoma. We reviewed; 1) radiological finding of GCRO and clinical impression-related diagnostic workup at referral center, 2) diagnostic delay until a proper diagnosis is made, 3) impact of diagnostic delay on the oncologic outcome. MATERIALS AND METHODS: We reviewed 17 patients with GCRO. We investigated the plain radiographic finding, tumor size and location, presence of pathologic fracture, clinical impression and pathological diagnosis at referral center, diagnostic delay, definitive treatment, local recurrence, metastasis, and survival rate. RESULTS: Eleven cases (64.7%) showed a plain radiographically, purely osteolytic pattern while 6 cases (35.3%) showed mixed osteolytic and sclerotic lesion. Diagnosis at primary center was osteosarcoma in 7 (41.2%), giant cell tumor in 7 (41.2%), and benign bone tumor in 3 (17.6%). Six patients (35.3%) experienced diagnostic delay. Mean diagnostic delay was 3.1 months (1 to 8). At final follow-up 5-year actuarial survival rate of 17 patients was 65%+/-25%. Although 11 patients without diagnostic delay showed a tendency of high survival over 6 patients with diagnostic problem, there was no statistical significance (p=0.14). CONCLUSION: GCRO is a rare subtype of osteosarcoma simulating giant cell tumor both pathologically and radiologically. Careful diagnostic approach is required in order not to misdiagnose this malignant tumor.

Adjacent Segment Pathology after Lumbar Spinal Fusion

One of the major clinical issues encountered after lumbar spinal fusion is the development of adjacent segment pathology (ASP) caused by increased mechanical stress at adjacent segments, and resulting in various radiographic changes and clinical symptoms. This condition may require surgical intervention. The incidence of ASP varies with both the definition and methodology adopted in individual studies; various risk factors for this condition have been identified, although a significant controversy still exists regarding their significance. Motion-preserving devices have been developed, and some studies have shown their efficacy of preventing ASP. Surgeons should be aware of the risk factors of ASP when planning a surgery, and accordingly counsel their patients preoperatively.

Uremic Tumoral Calcinosis around the Hip Joint in a Patient on Hemodialysis / 대한고관절학회지

The term tumoral calcinosis in used to describe the deposition of nodular calcareous masses in the soft tissue around large joints, such as the hips, shoulders, and elbows. Although the cause has not yet been clearly determined, according to the hypothesis, failure of phosphorus metabolism in the proximal tubule in kidney, chronic renal disease and hyperparathyroidism may cause tumoral calcinosis. No cases of tumoral calcinosis treated with surgical resection in chronic renal failure patients on hemodialysis, so called uremic tumoral calcinosis, have been reported in Korea. The authors experienced the case of a 57-year-old woman with chronic kidney disease on hemodialysis who presented with a mass around the hip. We made a diagnosis using plain radiographs, magnetic resonance imaging, and computed tomography of tumoral calcinosis, and treated the patient successfully with surgical resection. We report on a case of uremic tumoral calcinosis with a review of the literature.