Lumbar Interbody Fusion and Osteobiologics for Lumbar Fusion

Lumbar interbody fusion (LIF) is an excellent treatment option for a number of lumbar diseases. LIF can be performed through posterior, transforaminal, anterior, and lateral or oblique approaches. Each technique has its own pearls and pitfalls. Through LIF, segmental stabilization, neural decompression, and deformity correction can be achieved. Minimally invasive surgery has recently gained popularity and each LIF procedure can be performed using minimally invasive techniques to reduce surgery-related complications and improve early postoperative recovery. Despite advances in surgical technology, surgery-related complications after LIF, such as pseudoarthrosis, have not yet been overcome. Although autogenous iliac crest bone graft is the gold standard for spinal fusion, other bone substitutes are available to enhance fusion rate and reduce complications associated with bone harvest. This article reviews the surgical procedures and characteristics of each LIF and the osteobiologics utilized in LIF based on the available evidence.

Intractable Psoas Abscess due to Delayed Diagnosis of Tuberculosis of the Colon: A Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a rare case of intractable psoas abscess due to delayed diagnosis of colon tuberculosis. SUMMARY OF LITERATURE REVIEW: Most psoas abscesses occur primarily or secondarily due to infection of the vertebral body or discs; however, in rare cases, the etiology is not musculoskeletal in nature. In such cases, since diagnosis and treatment of the causal factor can be delayed, the psoas abscess may recur multiple times and eventually become difficult to treat. MATERIALS AND METHODS: An 18-year-old female patient visited our institution complaining of right lower quadrant abdominal pain and right hip pain. On abdominal computed tomography (CT), a psoas abscess was observed and colon tuberculosis was suspected. She was treated with a ultrasonographically guided percutaneous drainage procedure. Considering the possibility of colon tuberculosis and related fistulae, a barium enema was performed; nonetheless, no fistula was found. After 2 months, the psoas abscess recurred, and thus incision and drainage were performed. Symptoms redeveloped 4 months after the incision and drainage; the patient was further evaluated with magnetic resonance imaging and recurrence of psoas abscess was again observed; incision and drainage were performed once again. A gross draining sinus developed on the right lower abdomen 11 months after the last procedure. On barium enema and abdominal CT scan, an enterocutaneous draining sinus was spotted at the right ascending colon, and right hemicolectomy was thus performed. RESULTS: The psoas abscess did not recur during an 8-year follow-up period after right hemicolectomy. CONCLUSIONS: In treatment of secondary psoas abscess, diagnosis and treatment of the etiology is crucial.

Irreducible Open Dorsal Dislocation of the Proximal Interphalangeal Joint: A Case Report

Dorsal dislocation of the proximal interphalangeal joint is a common injury in the orthopedic department. In most cases, the joint is reduced simply by closed manipulation. However, in rare cases, the joint is not reducible by closed manipulation, therefore, surgery is required. We report on a case of irreducible open dorsal dislocation of the proximal interphalangeal joint which was surgically treated. Because the flexor tendon interposed between the head of the proximal phalanx and the base of the middle phalanx, we could reduce the joint only after repositioning of the flexor tendon.

Biochemical Aspirin Resistance Affect on Stroke Severity in Acute Stroke Patients Who Had Taken Aspirin

BACKGROUND: There are conflicting data in the literature regarding aspirin resistance. This study evaluated the effect of biochemical aspirin resistance on initial stroke severity in acute stroke patients who had taken aspirin. METHODS: We reviewed acute ischemic stroke patients who were already on aspirin. Biochemical aspirin resistance was defined as an aspirin reaction unit score of > or =550, as evidenced by the VerifyNow-Aspirin assay, which was performed after 4 days of continuous aspirin medication. Initial stroke severity was evaluated using National Institutes of Health Stroke Scale (NIHSS) scores at day 4, which were dichotomized into mild (0-7) and severe (> or =8). Modified Rankin Scale scores were determined at 3 months. The Alberta Stroke Program Early CT Scores (ASPECTS) were assessed on initial diffusion-weighted imaging (DWI). We examined the relationships between biochemical aspirin resistance and initial stroke severity. RESULTS: Nine of 106 patients (8.5%) had biochemical aspirin resistance. The initial stroke severity was significantly associated with DWI-ASPECTS (p or =8). However, biochemical aspirin resistance was not associated with clinical outcome at 3 months (p=0.366). CONCLUSIONS: Biochemical aspirin resistance was independently associated with initial stroke severity. This suggests that detection of biochemical aspirin resistance in acute ischemic stroke is useful when choosing the optimal treatment.

Bilateral Anterior Cerebral Artery Infarction Associated with Reversible Cerebral Vasoconstriction Syndrome

No abstract available.

Surgical Excision of the Lumbar Disc Herniation in Elementary School Age

STUDY DESIGN: A retrospective study. PURPOSE: To assess the radiological, clinical features and surgical outcomes of six patients of elementary school age with lumbar disc herniation (LDH). OVERVIEW OF LITERATURE: LDH is common in people in their fourth and fifth decades. However, the condition is extremely rare in children of elementary school age. Moreover, the clinical symptoms and treatments are different from those of adults. METHODS: We reviewed a series of 6 patients under the age of 12 years, who underwent surgery for LDH at our institution between 1992-2002. Initially, all patients were treated conservatively. The indications for surgery were failure of conservative treatment for 3 months, intractable pain and/or progressive neurological impairment. RESULTS: The surgical findings revealed a protruding disc in five cases and a ruptured disc in one. In addition, separation of the vertebral ring apophysis was observed in 3 cases. The symptoms had disappeared completely at the last follow-up. At the last follow-up, the Japanese Orthopaedic Association score was 10 points in 5 cases and 9 points in 1, and the Kirkaldy-Willis criteria was excellent in all patients. No intervertebral disc space narrowing was observed in any patient at last follow up. In addition, there were no degenerative changes in the vertebral endplate and facet joint. CONCLUSIONS: Patients with symptoms that persist for more than 3 months or those with a progressive neurological deficit must be considered for surgical discectomy.

The Clinical Effect of Gait Load Test in Two Level Lumbar Spinal Stenosis

STUDY DESIGN: This study is a prospective, clinical study assessing the efficacy of selective decompression of the level responsible in a two-level stenosis in accordance with the neurological findings defined by the gait load test with a treadmill. PURPOSE: To clarify the clinical features of multilevel lumbar spinal stenosis (LSS) regarding the neurological level responsible for the symptoms, neurogenic claudication, and outcomes of selective decompression. OVERVIEW OF LITERATURE: Most spine surgeons have reported that multilevel compression of the cauda equina induces a more severe impairment of the nerve function than a single-level compression. However, the clinical effects of multilevel LSS on the cauda equine and nerve roots are unknown. METHODS: A total of 21 patients with lumbar spinal canal stenosis due to spondylosis and degenerative spondylolisthesis were selected. The level responsible for the symptoms in the two-level stenosis was determined from the neurological findings on the gait load test and functional diagnosis based on a selective nerve root block. All patients underwent a prospective, selective decompression at the level neurologically responsible only. The average follow-up period was 2.6 years (range, 1 to 6 years). The postsurgical outcome was defined using the Visual Analogue Scale (VAS) at the post-gait load test, 2 weeks after surgery, 3 months after surgery and at the last follow up. RESULTS: Before surgery, the mean threshold distance and mean walking tolerance was 34.3 m and 113 m, respectively. All patients had neurogenic claudication and 19 of the patients had cauda equina syndrome, including hypesthesia in 11 cases, muscle weakness in 5 cases and radicular pain in 7 cases. Selective nerve blocks to determine the level responsible for the lumbosacral symptoms in 2 cases revealed a mean VAS score of 7.1, 2.61, 3.04, and 3.47 at the post-gait load test, 2 weeks after surgery, 3 months after surgery and at the last follow up, respectively. All subjects underwent surgery. After the operation, neurogenic claudication with or without cauda equna syndrome subsided in all patients. CONCLUSIONS: The gait load test allows an objective and quantitative evaluation of the gait characteristics of patients with lumbar canal stenosis and is useful for determining the appropriate level for surgical treatment.

Insufficiency Stress Fractures of the Femoral Neck in Elderly Patients

PURPOSE: We wanted to compare the insufficiency stress fractures of the femoral neck (group I) with the traumatic femoral neck fractures (group II) in patients who were 70 years of age and older. MATERIALS AND METHODS: Between January 2000 and October 2006, we evaluated 10 insufficiency stress fractures among 191 femoral neck fractures in patients who were 70 years of age and older. We compared these fractures with the traumatic femoral neck fractures by using the bone mineral density (BMD), neck-shaft angle, the hip axis length (HAL) and the ratio of the HAL to the femoral neck width. RESULTS: The incidence of insufficiency stress fracture was 5.2%. There were 6 cases of displaced fractures and 4 cases of non-displaced fractures. All of non-displaced fractures revealed the tension (transverse) type. The mean neck-shaft angle was 130.45 degrees in group I and this was 131.94 degrees in group II. The mean HAL was 117.6 mm in group I and 115.3 mm in group II, and the ratio of the HAL to the femoral neck width was 0.30 in each group. The BMD (T-score) was -3.73 in group I and -3.4 in group II. CONCLUSION: The BMD of the insufficiency fracture group was significantly lower than that of the traumatic femoral neck fracture group. However, there were no significant differences in the neck-shaft angle, the HAL and the ratio of the HAL to femoral the neck width between the 2 groups.

Comparison of the Results between Distal Chevron Osteotomy and Proximal Metatarsal Osteotomy for the Treatment of Moderate Hallux Valgus / 대한족부족관절학회지

PURPOSE: The purpose of this study is to compare the treatment outcomes of distal chevron osteotomy with those of proximal metatarsal closing wedge osteotomy in patients with moderate severity hallux valgus. MATERIALS AND METHODS: Forty-two patients (51 feet) who were underwent either distal chevron osteotomy (Group I, 22 patients, 27 feet) or proximal metatarsal closing wedge osteotomy (Group II, 20 patients, 24 feet) for the correction of moderate hallux valgus deformity were evaluated retrospectively. We assessed the radiographic results with several parameters including hallux valgus angle (HVA), intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA). And clinical results with modified AOFAS score at last follow-up. RESULTS: There were no significant differences in IMA, HVA and DMAA between two groups preoperatively. We can achieve the good results with both procedures, but mean HVA and IMA of group II was significantly lower than those of group I. There was some loss of correction in group I at the last follow-up. There was no significant difference in clinical results according to modified AOFAS scoring between two groups at the last follow-up. CONCLUSION: The proximal metatarsal closing wedge osteotomy for the hallux valgus with moderate severity is better treatment option to achieve better radiographic correction and to prevent loss of correction or recurrence than distal chevron osteotomy.

Acute Osteomyelitis following Closed Femoral Shaft Fracture in a Child: A Case Report / 대한정형외과학회잡지

Acute osteomyelitis following a closed fracture is very rare. Only one case has been reported that trivial trauma (contusion) may be associated with the subsequent development of acute osteomyelitis in Korea. Authors report an acute osteomyelitis in the shaft of the femur after closed fracture in a child.

Distal Transfer of Greater Trochanter in Patients with High-Standing Greater Trochanter by Legg-Calve-Perthes (LCP) Sequelae

PURPOSE: To evaluate the clinical and radiological results of distal transfer of the greater trochanter in patients with a high-standing greater trochanter as a sequela of LCP disease. MATERIALS AND METHODS: Between 1994 and 2005, ten cases (nine patients) underwent distal transfer of a highstanding greater trochanter and were followed up for more than 2 years after surgery. The clinical findings, such as the abduction of the hip, VAS score, and Trendelenburg sign, were evaluated. In addition, the centrotrochanteric distance (CTD) and Lever arm ratio (LAR) were used for the radiographic assessment. RESULTS: The mean range of abduction improved from 27.5degrees to 40degrees , and the VAS score improved from 4.1 to 1.2. Seven cases with positive Trendelenburg sign before surgery showed negative Trendelenburg sign after the surgery. At the last follow-up, the CTD improved from -1.52 cm to -0.2 cm and the LAR decreased from 2.2 to 1.8. CONCLUSION: The distal transfer of the greater trochanter in patients with a high standing greater trochanter as a consequence of LCP is an effective procedure that can reduce the level of hip pain and improve the hip abduction if careful patient selection is performed.

Free Vascularized Fibular Grafts for Treatment of Infected Nonunion of the Tibia

PURPOSE: To analyze the result of free vascularized fibular grafting for treatment of infected nonunion of the tibia with radical bone and soft tissue defect. MATERIALS AND METHODS: 17 patients with infected nonunion of the tibia who underwent a reconstruction using free vascularized fibular grafting were reviewed retrospectively. The mean follow-up period was 70.3 months. We analyzed the results radiographically which included the time of bone union, the amount of hypertrophy of grafted bone and complications. RESULTS: The average length of bone defect was 8.8 cm (5~15 cm), and the average length of fibular graft was 14.1 cm (10~17.5 cm). Bony union was achieved in 11 of 17 cases and the average time of bone union was 5.2 months (4~6 months). There were 6 cases of nonunion. All nonunions developed at the proximal end of graft in patients who underwent fixation using pin and external fixator. Union was eventually achieved in all cases in 6.0 months (5~8 months) after the cancellous bone graft and plate internal fixation. Hypertrophy of grafted bones with more than 20% developed only in 4 cases out of 17. There were 3 cases of stress fracture, however there was no recurrence of infection or serious donor site morbidity. CONCLUSION: Free vascularized fibula grafting is one of the most effective reconstruction options for the infected nonunion of the tibia with radical bone and soft tissue defect. Strong internal fixation using plate and screws is required to reduce the rate of nonunion and stress fracture of grafted fibulas.

Treatment of Subtrochanteric Fractures with Compression Hip Screw

PURPOSE: To evaluate the effectiveness of the compression hip screw, we reviewed the clinical results of cases of femoral subtrochanteric fracture which were treated with compression hip screw. MATERIALS AND METHODS: From May 1997 to June 2004, 20 cases of femoral subtrochanteric fracture, which were treated with compression hip screw and followed up more than 12 months, were reviewed. By the Seinsheimer's classification, there were 1 case of type IIa, 4 cases of type IIb, 2 cases of type IIIa and IIIb, 4 cases of type IV and 7 cases of V. We analyzed the treatment results by bony union time, range of motion, ambulation status and complications. RESULTS: All 20 cases were gained bony union without serious complications and secondary operation. The average bony union time was 19.8 weeks. 17 of 20 cases were recovered pre-injury ambulatory status level. CONCLUSION: The compression hip screw may be effective in treatment of the femoral subtrochanteric fracture with very narrow intramedullary canal, proximal femoral deformity, comminuted fracture with large butterfly fragment, long spiral fracture with medial cortical comminution and combined intertrochanteric fracture.

Morphometry of the Cut Surface of the Proximal Tibia for Total Knee Arthroplasty in Korea / 대한정형외과연구학회지

PURPOSE: To provide the morphometric data about the Korean proximal tibia to design a total knee prosthesis for Korean population. MATERIALS AND METHODS: We measured morphologic data from the proximal part of the tibia from 60 knees of 30 male and 30 female cadavers. The 3D images were reconstructed from the data obtained by computed tomography scanning from femoral head to ankle joint. These image were processed as a ideal tibial resection surface which was made during a total knee arthroplasty operation. Then, antero-posterior lengths, medio-lateral lengths and aspect ratios of the cut surface were measured. Measurements were analyzed and compared with those of five popular total knee prosthesis models. RESULTS: The average medio-lateral length, lateral antero-posterior length, aspect ratio of male was 79.4 +/- 3.8 mm, 39.6 +/- 5.0 mm, 49.8 +/- 5.1% respectively. And that of female was 70.4 +/- 3.7 mm, 34.3 +/- 3.6 mm, 48.8 +/- 4.7% respectively. Component size of medio-lateral length of 65~85 mm and lateral antero-posterior length of 30~45 mm, would be required for the Korean population. Aspect ratios were correlated to antero-posterior lengths positively (p < 0.05). CONCLUSION: No prostheses had fulfilled all the requirements for Korean knees in this study. These data could be used for design the optimal components for Korean.

Morphometry of the Cut Surface of the Proximal Tibia for Total Knee Arthroplasty in Korea / 대한정형외과연구학회지

PURPOSE: To provide the morphometric data about the Korean proximal tibia to design a total knee prosthesis for Korean population. MATERIALS AND METHODS: We measured morphologic data from the proximal part of the tibia from 60 knees of 30 male and 30 female cadavers. The 3D images were reconstructed from the data obtained by computed tomography scanning from femoral head to ankle joint. These image were processed as a ideal tibial resection surface which was made during a total knee arthroplasty operation. Then, antero-posterior lengths, medio-lateral lengths and aspect ratios of the cut surface were measured. Measurements were analyzed and compared with those of five popular total knee prosthesis models. RESULTS: The average medio-lateral length, lateral antero-posterior length, aspect ratio of male was 79.4 +/- 3.8 mm, 39.6 +/- 5.0 mm, 49.8 +/- 5.1% respectively. And that of female was 70.4 +/- 3.7 mm, 34.3 +/- 3.6 mm, 48.8 +/- 4.7% respectively. Component size of medio-lateral length of 65~85 mm and lateral antero-posterior length of 30~45 mm, would be required for the Korean population. Aspect ratios were correlated to antero-posterior lengths positively (p < 0.05). CONCLUSION: No prostheses had fulfilled all the requirements for Korean knees in this study. These data could be used for design the optimal components for Korean.

Juvenile Lumbar Intervertebral Disc Herniation: Five Cases Report / 대한정형외과학회잡지

Lumbar intervertebal disc herniation is common in the fourth to fifth decades because the intervertebral disc undergoes degenerative change. However juvenile lumbar intervertebal disc herniation (under 12 years old) is rare because there is no degenerative change, and the clinical symptoms and treatments are different from those of adults. Herein, our experience of five juvenile lumbar intervertebal disc herniation cases are analyzed and reported.

The Relationship between Anti-Pityrosporum IgE Level and Clinical Manifestations in Atopic Dermatitis Patients with Head and Neck Dermatitis / 대한피부과학회지

BACKGROUND: Head and neck dermatitis is a variant of atopic dermatitis often seen in young adult. Though the pathogenesis of atopic dermatitis is still not well elucidated, Pityrosporum is considered to be one of the triggering factors for head and neck dermatitis. OBJECTIVE: We investigated the relationship between Pityrosporum infection and clinical features of head and neck dermatitis patients. METHODS: We evaluated anti-Pityrosporum IgE levels using RAST method in 68 outpatients with atopic dermatitis and other allergen specific antigens with MAST-CLA techniques. RESULTS: Among the 68 atopic dermatitis, 36 were diagnosed as atopic dermatitis with head and neck dermatitis and 24 out of 36 head and neck dermatitis patients showed RAST positive for Pityrosporum and the level of RAST was higher than atopic dermatitis patients without head and neck dermatitis with correlation coefficient (p<0.05). The severity of erythema and eczematous reaction was also correlated with the positivity of RAST with statistical significance (p<0.05). CONCLUSION: From these results, we speculate Pityrosporum can influence the severity and clinical manifestations in atopic dermatitis patients with head and neck dermatitis.

Clinical Comparison of Ankle Fractures Between the Young and the Elderly / 대한족부족관절학회지

PURPOSE: We compared the clinical features of the ankle fractures treated by operation between the elderly and the young, and reviewed the principles of treatment of the ankle fractures in the elderly. MATERIALS AND METHODS: We reviewed 49 cases of the ankle fractures, which were treated by open reduction from August 1991 to July 2002. Patients aged more than 60 were designated as the elderly, and patients aged between 15 and 33 were designated as the young. The average follow-up period was 13.2 months. Using the Lauge-Hansen classification, We defined stage I or II fractures as low stage and stage III or IV fractures as high stage fractures. RESULTS: There were 15 cases of high stage fractures (78.9%) in the elderly and 11 cases (36.7%) in the young. High stage fracture rate was significantly higher in the elderly (P=0.004). Hospital day, period between primary injury and operation, and union time were significantly longer in the elderly (P<0.001). However, there was no statistical difference in immobilization time between the two groups. The results of treatment were satisfactory clinically and radiologically by the Meyer's criteria in both groups. CONCLUSION: In the elderly, high stage fractures were more common and longer hospitalization and union time were needed than the young. However, the result of surgical treatment was satisfactory.

Early duodenal carcinoma successfully resected by endosopic mucosal resection / 대한내과학회지

Primary duodenal adenocarcinoma is rare disease with a poorly defined natural history. It represents less than 0.35% of all gastrointestinal tract malignant neoplasms and accounts for up to 33 to 45% of small bowel cancers. Diagnosis is always late because of the non-specific symptoms, consequently leading to poor prognosis. Surgical resection is the only potentially curative treatment, but not all patients whose tumor is removed necessarily survive long term. Recent widespread use of endoscopy has increased early detection of duodenal adenocarcinoma. Thanks to early detection, duodenal adenocarcinoma can now be treated endoscopically, which allows the patient's quality of life to be maintained. We have experienced one case of the primary early duodenal adenocarcinoma of the first portion, which was diagnosed by biopsy with endoscopic examination as part of a routine medical evaluation and was resected by endoscopic mucosal resection technique. We report the first primary early duodenal adenocarcinoma successfully treated by EMR method in Korea.

Selective Spinal Nerve Block for the Treatment of Lumbar Spinal Stenosis that indicated Operation / 대한정형외과학회잡지

PURPOSE: This study evaluated the effectiveness of a selective nerve root block (SNRB) for a lumbar spinal stenosis (LSS) that indicated surgery. MATERIALS AND METHODS: Twenty-one LSS patients, who were indicated for surgery but could not be operated on due to a high anesthetic risk, were evaluated retrospectively an evaluated on average of 19.5 months (range, 12 to 60 months) following the SNRB from April 1998 to October 2002. There were 9 males and 12 females with a mean age of 66.4 years (range, 59 to 78 years). The medical records and radiologic studies were reviewed, and a telephone interview was carried out where needed. The anesthetic risk was evaluated by the American Society of Anesthesiologists (ASA) physical status classification. The Kirkaldy-Willis criteria (at 9 months after SNRB and last FU) and the recurrence of symptoms (at 2 weeks, 1 month, 3 months, 5 months, 9 months after the SNRB, and the last FU) were analyzed. RESULTS: Among the 21 patients, 8 patients were in the ASA class 3, 13 in class 4. The major physical conditions that indicated a high anesthetic risk was cardiac problems in 17 patients, renal problems in 2, and endocrine problem in 2. The interval between the onset of symptom and the SNRB ranged from one month to 30 years (average, 41.6 months). All but 3 patients had a recurrence of their symptoms at an average 1.9 months (range, 1 day to 9 months) after the SNRB. According to the Kirkardy-Wills criteria, 9 months after SNRB, the results were good in 1 patient, fair in 2, and poor in 18. At the last follow-up, all but 4 patients did not show a chang in their status according to the Kirkardy-Wills criteria, and 4 patients improved (poor to good in 2, poor to fair in 2) without treatment. CONCLUSION: The symptoms of LSS improved for a very short period (average, 1.9 month) by SNRB. These results suggest that SNRB suitable for the LSS patients who require need surgery.