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.

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.

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.

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.

Prevalence of Neuropathic Pain and Patient-Reported Outcomes in Korean Adults with Chronic Low Back Pain Resulting from Neuropathic Low Back Pain

STUDY DESIGN: A noninterventional, multicenter, cross-sectional study. PURPOSE: We investigated the prevalence of neuropathic pain (NP) and patient-reported outcomes (PROs) of the quality of life (QoL) and functional disability in Korean adults with chronic low back pain (CLBP). OVERVIEW OF LITERATURE: Among patients with CLBP, 20%–55% had NP. METHODS: Patients older than 20 years with CLBP lasting for longer than three months, with a visual analog scale (VAS) pain score higher than four, and with pain medications being used for at least four weeks before enrollment were recruited from 27 general hospitals between December 2014 and May 2015. Medical chart reviews were performed to collect demographic/clinical features and diagnosis of NP (douleur neuropathique 4, DN4). The QoL (EuroQoL 5-dimension, EQ-5D; EQ-VAS) and functional disability (Quebec Back Pain Disability Scale, QBPDS) were determined through patient surveys. Multiple linear regression analyses were performed to compare PROs between the NP (DN4≥4) and non-NP (DN4 < 4) groups. RESULTS: A total of 1,200 patients (females: 65.7%; mean age: 63.4±13.0 years) were enrolled. The mean scores of EQ-5D, EQ-VAS, and QBPDS were 0.5±0.3, 55.7±19.4, and 40.4±21.1, respectively. Among all patients, 492 (41.0%; 95% confidence interval, 38.2%–43.8%) suffered from NP. The prevalence of NP was higher in male patients (46.8%; p < 0.01), in patients who had pain based on radiological and neurological findings (59.0%; p < 0.01), and in patients who had severe pain (49.0%; p < 0.01). There were significant mean differences in EQ-5D (NP group vs. non-NP group: 0.4±0.3 vs. 0.5±0.3; p < 0.01) and QBPDS (NP group vs. non-NP group: 45.8±21.2 vs. 36.3±20.2; p < 0.01) scores. In the multiple linear regression, patients with NP showed lower EQ-5D (β=−0.1; p < 0.01) and higher QBPDS (β=7.0; p < 0.01) scores than those without NP. CONCLUSIONS: NP was highly prevalent in Korean patients with CLBP. Patients with CLBP having NP had a lower QoL and more severe dysfunction than those without NP. To enhance the QoL and functional status of patients with CLBP, this study highlights the importance of appropriately diagnosing and treating NP.

The Relationship between the Progression of Kyphosis in Stable Thoracolumbar Fractures and Magnetic Resonance Imaging Findings

STUDY DESIGN: Retrospective study. PURPOSE: To investigate the relation between the progression of kyphotic deformity and magnetic resonance imaging (MRI) findings in conservatively treated stable thoracolumbar fractures. OVERVIEW OF LITERATURE: When treated conservatively, excessive progression of kyphotic deformity and vertebral compression can emerge during follow-up. We sought to identify predictors of vertebral body deformation using MR images. METHODS: The presence in MR images of anterior longitudinal ligament (AL) or posterior longitudinal ligament (PL) injury, superior or inferior endplate disruption, superior or inferior disc injury in fractured vertebral bodies, the existence of low signal intensity on T2 weighted images, and bone edema of intravertebral bodies were assessed. RESULTS: The presence of superior endplate disruption and a higher level of bone edema were found to cause the progressions of kyphotic angle (KA), wedge angle (WA), and anterior vertebral compression (AVC) rate. When AL or superior disc injury was observed, only KA increased meaningfully. When low signal intensity was present on T2 weighted images WA and AVC increased significantly, but PL injury, inferior endplate disruption, and inferior disc injury showed no notable correlation with kyphotic deformity progression. The risk factors found to be associated with an increase of KA to >5degrees were AL injury, superior endplate disruption, superior disc injury, and a bone edema level of over 1/3, and their associated risks versus no injury cases were 14.1, 3.7, 6.8, and 10.4-fold, respectively. CONCLUSIONS: AL injury, superior endplate and disc injury, or a high level of bone edema, were critical factors that determine kyphotic deformity progression.

Vertebral Recompression after Vertebroplasty or Kyphoplasty

PURPOSE: The purpose of this study was to examine incidence of recompression and risk factors in the patients with osteoporotic vertebral compression fracture (OVCF) after vertebroplasty or kyphoplasty. MATERIALS AND METHODS: This study was conducted on 179 vertebral bodies of 126 patients who underwent vertebroplasty or kyphoplasty on OVCF from January 2004 to August 2013. RESULTS: When anterior vertebral height of fractured vertebrae declined by more than 3 mm from the height immediately after vertebroplasty or kyphoplasty, it was judged that recompression had occurred. Recompression was observed in a total of 58 vertebrae (32.4%). Recompression occurrences were found to be decreasing significantly when fractured vertebrae were the thoracic spine. In addition, osteonecrosis occurred in the preoperative vertebrae and restoration degree of anterior vertebral height immediately after vertebroplasty or kyphoplasty affected recompression occurrences significantly. The other factors (age, sex, bone mineral density, steroid medication history, follow-up duration, cement volume, vertebroplasty or kyphoplasty, and approach method) were compared, but no statistical significance was found. CONCLUSION: The risk of vertebral recompression is more common, especially when osteonecrosis occurred in preoperative vertebrae or when vertebroplasty or kyphoplasty achieved remarkable restoration of anterior vertebra height. When performing vertebroplasty or kyphoplasty, such conditions should be considered carefully.

Outcomes of Severe Comminuted Distal Radius Fractures with Pronator Preserving Approach

PURPOSE: We investigate the outcomes of treatment of patients with severe comminuted distal radius fractures with volar plate fixation using a pronator-preserving approach. MATERIALS AND METHODS: Fourteen patients with severe comminution of the distal radius fractures for whom anatomical reduction of the fractures was deemed difficult to achieve with traditional approaches were enrolled. The gender ratio was 8 males to 6 females, and the average age of the patients was 64.9 years. According to the AO/OTA classification of fractures, 2 patients had 23-A3 fractures, 7 patients had 23-C2, and 5 patients had 23-C3. Radial length, radial inclination, and volar tilt were measured for radiologic evaluation. Modified Mayo wrist score (MMWS) was used for clinical outcome. RESULTS: Bony union was achieved in all 14 patients without signs of complications. The average time-to-union was 4.3 months (3-6 months). The radiological findings at the final follow-up were as follows: the average radial inclination was 20.5degrees; the average volar tilt, 7.57degrees; and the average radial length, 11.8 mm. At the final follow-up, the results of the MMWS were 'Fair' in 1 patient, 'Good' in 4, and 'Excellent' in 9. CONCLUSION: We propose that a pronator-preserving approach is an effective treatment for severe comminuted distal radius fracture.

Practical Use of Bone Scan in Patients with an Osteoporotic Vertebral Compression Fracture

Rib fractures are one of main causes of chest or flank pain when related to an osteoporotic vertebral compression fracture (OVCF). The authors investigated the incidence and risk factors of rib fracture in 284 patients with OVCF using bone scans and evaluated the feasibility as to whether bone scans could be utilized as a useful screening tool. Hot uptake lesions on ribs were found in 122 cases (43.0%). The factors analyzed were age, sex, number and locations of fractured vertebrae, BMD, and compression rates as determined using initial radiography. However, no statistical significances were found. In 16 cases (5.6%), there were concurrent multiple fractures of both the thoracic and lumbar spines not detected by single site MRI. Sixty cases (21.1%) of OVCF with the a compression rate of less than 15% could not be identified definitely by initial plain radiography, but were confirmed by bone scans. It is concluded that a bone scan has outstanding ability for the screening of rib fractures associated with OVCF. Non-adjacent multiple fractures in both thoracic and lumbar spines and fractures not identified definitely by plain radiography were detected on bone scans, which provided a means for determining management strategies and predicting prognosis.

Practical Use of Bone Scan in Patients with an Osteoporotic Vertebral Compression Fracture

Rib fractures are one of main causes of chest or flank pain when related to an osteoporotic vertebral compression fracture (OVCF). The authors investigated the incidence and risk factors of rib fracture in 284 patients with OVCF using bone scans and evaluated the feasibility as to whether bone scans could be utilized as a useful screening tool. Hot uptake lesions on ribs were found in 122 cases (43.0%). The factors analyzed were age, sex, number and locations of fractured vertebrae, BMD, and compression rates as determined using initial radiography. However, no statistical significances were found. In 16 cases (5.6%), there were concurrent multiple fractures of both the thoracic and lumbar spines not detected by single site MRI. Sixty cases (21.1%) of OVCF with the a compression rate of less than 15% could not be identified definitely by initial plain radiography, but were confirmed by bone scans. It is concluded that a bone scan has outstanding ability for the screening of rib fractures associated with OVCF. Non-adjacent multiple fractures in both thoracic and lumbar spines and fractures not identified definitely by plain radiography were detected on bone scans, which provided a means for determining management strategies and predicting prognosis.

Posterior Direct Decompression and Fusion of the Lower Thoracic and Lumbar Fractures with Neurological Deficit

STUDY DESIGN: A retrospective study. PURPOSE: To analyze the treatment outcome of patients with lower thoracic and lumbar fractures combined with neurological deficits. OVERVIEW OF LITERATURE: Although various methods of the surgical treatment for lower thoracic and lumbar fractures are used, there has been no surgical treatment established as a superior option than others. METHODS: Between March 2001 and August 2009, this study enrolled 13 patients with lower thoracic and lumbar fractures who underwent spinal canal decompression by removing posteriorly displaced bony fragments via the posterior approach and who followed up for more than a year. We analyzed the difference between the preoperative and postoperative extents of canal encroachment, degrees of neurologic deficits and changes in the local kyphotic angle. RESULTS: The average age of the patients was 37 years. There were 10 patients with unstable burst factures and 3 patients with translational injuries. Canal encroachment improved from preoperative average of 84% to 9% postoperatively. Local kyphosis also improved from 20.5degrees to 1.5degrees. In 92% (12/13) of the patients, neurologic deficit improved more than Frankel grade 1 and an average improvement of 1.7 grade was observed. Deterioration of neurologic symptoms was not observed. Although some loss of reduction of kyphotic deformity was observed at the final follow-up, serious complications were not observed. CONCLUSIONS: When posteriorly displaced bony fragments were removed by the posterior approach, neurological recovery could be facilitated by adequate decompression without serious complications. The posterior direct decompression could be used as one of treatments for lower thoracic and lumbar fractures combined with neurologic injuries.

Intramedullary Kirschner Wire Fixation for Forearm Fractures in Children

PURPOSE: To evaluate the clinical and radiological results of intramedullary fixation using Kirschner wires (K-wires) for the treatment of unstable forearm fractures in children. MATERIALS AND METHODS: Forty-three children who underwent intramedullary fixation using K-wires for the treatment of a forearm bone fracture were evaluated. The rodiological results were based on the time to union and angular deformity at last follow-up. The clinical results were analyzed according to Price criteria. RESULTS: Average union time was 6.9 weeks. Preoperatively, average angular deformity of radius is 11.4 degrees in anteroposterior (AP) view and 15.3 degrees in lateral view. In case of the ulna, arerage angular deformity was 8.3 degrees in AP view and 12.7 degrees in lateral view. At last follow up, average angular deformity of radius was 1.5 degrees in AP view and 1.6 degrees in lateral view. In case of the ulna, arerage angular deformity was 1.3 degrees in AP view and 2.5 degrees in lateral view. According to the criteria of Price et al., 42 patients (97%) were excellent and one patient (3%) was good. No specific complication was observed. CONCLUSION: An intramedullary fixation using K-wires is an attractive treatment option for unstable forearm fractures in children in terms of safety, excellent cosmesis, short hospitalization, easy hardware removal, and providing excellent radiological and clinical results.

Radiologic Adjacent Segment Degeneration and Clinical Outcome after Two Level Fusion (L3-4-5 and L4-5-S1) in Degenerative Lumbar Spinal Disease

OBJECTIVE: We retrospectively analyzed correlation of the development of radiologic adjacent segment degeneration (ASD), clinical outcome, and the vertebral level of fusion in two-level posterior lumbar fusion cases. Furthermore, risk factors of ASD were investigated. METHODS: From 2000 to 2007, a total of 50 patients were evaluated. Their mean age was 55.0 years and mean follow-up period was 52.7 months. The patients were divided into two groups according to the vertebral level of the fused segment. Group I included 35 patients with L3-4-5 fusion, while 15 patients with L4-5-S1 fusion were categorized into group II. The patients were also divided into two groups, according to the development of ASD. Odom's criteria was used to study clinical outcome, and Cobb's angle was used to evaluate radiologic outcome RESULTS: Of 50 patients, radiologic ASD was found in 24 (48.0%) patients. Group I showed 16 (45.7%) patients with ASD, while Group II showed 8 (53.3%) patients with ASD, and they did not show a significant difference in development of ASD and clinical outcome. Clinical outcome of patients with ASD and the ones without ASD did not show significant difference. Meanwhile, patients with ASD were older and showed decrease of the lordotic angle, as well as significant hypermobility in the cranial adjacent segment, during follow-up. CONCLUSION: Different vertebral regions of fusion in two-level posterior lumbar fusion did not show significant difference in development of radiologic ASD and clinical outcome. In the development of ASD, decrease of the lordotic angle, hypermobility in the cranial adjacent segment and age were significant factors.

Radiological and Clinical Comparison of 1 Cage versus 2 Cages for Posterior Lumbar Interbody Fusion with PEEK Cage and Local Bone Graft / 대한척추외과학회지

STUDY DESIGN: This is a retrospective study. OBJECTIVES: We wanted to compare and evaluate the results of using one cage and two cages with local bone grafting for each segment when performing posterior lumbar interbody fusion (PLIF). Summary of Literature Review: Some authors have reported that unilateral one-caged PLIF with local bone grafting and posterior instrumentation was no difference from bilateral two-caged PLIF regard to the fusion rates and the radiologic or clinical results. MATERIALS AND METHODS: From March 2005 to February 2006, PLIF was performed on 36 patients who had lumbar degenerative disease. They were categorized as the cases for which one cage was used for a segment and the cases for which 2 cages were used for a segment. The clinical and radiological results in each group were compared. RESULTS: There was complete union in 11 segments with using one cage (55%), complete union in 12 segments using two cages (77%) and incomplete unions in 9 segments with using one cage (45%) and incomplete union in 4 segments with using 2 cages (25%), and there wasn't any case of nonunion (p>0.05). The postoperative changes of the intervertebral disc space were a 2.0 mm increase with using one cage and a 2.2 mm increase with using two cages, yet these values decreased by 0.4 mm and 0.3 mm, respectively, on the last follow-up. The mean operation time was 89 minutes for one segment with one cage and 105 minutes for one segment with two cages. The blood loss was a mean of 602 ml with one cage and 802 ml with two cages (p<0.05). There was no significant difference between the one cage group and the two cages group for the Kirkadly-Willis criteria. CONCLUSION: Posterior decompression and PLIF with one PEEK cage for treating degenerative lumbar disease was more effective for the operation time and the amount of blood loss than that with two cages, but the fusion rate, the alteration of the intervertebral disc space, the improvement of pain and the clinical results were no different. However, these results are from short term follow up, so continuous follow up will be necessary in the future for assessing the long term prognosis.

The Value of Local Flaps in Lower Extrimity Reconstruction

PURPOSE: The aim of this study was to evaluate the outcome and the effectiveness of local flaps in lower extremity reconstruction. MATERIALS AND METHODS: We have performed lower extremity reconstruction with local flap in 14 cases (10 males and 4 females) from May 2006 to February 2008. The mean age was 40.1 years (range, 16~67). The defect site was the tibia in 5 cases, the ankle in 1 case and the foot in 8 cases. The local flaps were reverse flow sural artery flap in 7 cases, gastrocnemius flap in 3 cases, lateral supramalleolar flap in 2 cases, dorsalis pedis flap in 1 case and medial hemisoleus flap in 1 case. RESULTS: All flaps were survived. Venous congestion was developed in 1 case of the rerverse flow sural artery flap but healed with secondary rotational flap. Other flaps were good without any complications. CONCLUSION: If we choose precisely indicated local flap in lower extremity reconstruction, the resultant coverage of defect would be excellent.

The Usefulness of Bone Scan in the Osteoporotic Vertebral Compression Fracture Patients Treated With Kyphoplasty / 대한척추외과학회지

STUDY DESIGN: Retrospective study. OBJECTIVES: To compare the clinical results of kyphoplasty between osteoporotic patients with compression fractures and rib hot uptake on bone scan and patients without rib hot uptake. SUMMARY OF LITERATURE REVIEW: The incidence of osteoporotic rib fractures is 0.3% in postmenopausal women. MATERIALS AND METHODS: Between July 2005 and July 2006, 72 kyphoplasties for osteoporotic vertebral compression fractures were performed, and all patients had a bone scan study. On bone scan study, 41 patients (57.7%) had hot uptake in their ribs. Results were assessed by visual analog scale (VAS). RESULTS: The incidence of hot uptake was 67.8% in thoracic fractures, 40.0% in lumbar fractures, and 72.7% in thoracolumbar fractures. Hot uptake was significantly more common with thoracic and thoracolumbar fractures than with lumbar fractures (p0.05). CONCLUSIONS: Thoracic and multiple osteoporotic compression fractures are often accompanied by rib fractures. Bone scan is a useful tool to detect rib fractures and predict the prognosis of kyphoplasty.

Comparison of Unipedicular versus Bipedicular Kyphoplasty for Osteoporotic Vertebral Compression Fractures / 대한척추외과학회지

STUDY DESIGN: A retrospective study OBJECTIVES: To compare the radiological and clinical results of the unipedicular and bipedicular approach of kyphoplasty for osteoporotic vertebral compression fractures. SUMMARY OF LITERATURE REVIEW: A unipedicular rather than a bipedicular technique has been suggested to decrease the risks associated with surgical procedures. MATERIALS AND METHODS: Between July 2005 and May 2006, 136 vertebrae of 97 patients, who underwent kyphoplasty for osteoporotic vertebral compression fractures, were analyzed. Group 1, with the bipedicular approach, consisted of 86 vertebrae of 67 patients with a mean age of 72.2 years. Group 2, with unipedicular approach, consisted of 50 vertebrae of 30 patients with mean age of 73.4 years. The plain radiographs, MRI and surgical records were reviewed. RESULTS: The mean operation time of the single vertebral body in group 2 was statistically lower than in group 1(p0.05). CONCLUSION: There were no significant differences in clinical satisfaction and radiological results between the unipedicular and bipedicular kyphoplasty. The advantage of a unipedicular approach is the shorter procedure time than the bipedicular approach. This is particularly useful in multi-level compression fractures. The rate of the unipedicular approach in upper and mid thoracic spine is higher because of the higher convergence of the pedicle and the lower volume of vertebral body despite the disadvantages of instrument insertion through the medial pedicle wall.

Thoracolumbar Fracture with Posterior Ligament Complex Injury

PURPOSE: To evaluate the clinical features and radiographical landmarks of patients who has a thoracolumbar fracture combined with posterior ligament complex injury retrospectively. MATERIALS AND METHODS: The preoperative plain radiographys, axial CT, MRI and medical records of 27 patients were reviewed who were confirmed the posterior ligament complex injury in operation from January, 2002. to December, 2004. RESULTS: The patients were from 15 years to 75 years of age (mean 39.1 years), 20 males and 7 females. The mechanisms of injury were 17 falls from a height, 7 traffic accidents and 3 direct blow injuries. There were 17 cases (63%) in thoracolumbar transitional zone, such as 11 cases in T11-T12, 6 cases T12-L1. There were 9 cases of compression fracture and 18 cases of burst fracture according to the shape of fractured vertebra. In the plain radiograph, the degree of kyphotic angle was between 6~49 degrees (mean 22 degrees), anterior vertebral height loss was 7~70% (mean 39%), and posterior vertebral height loss was 0~8% (mean 3%). 21 cases (78%) were the anterior vertebral height loss below 50%, 23 cases (85%) were the degree of kyphotic angle below 30 degrees. Neurological deficits were not registered. 23 cases (85%) were positive in MRI and 24 cases (89%) were positive in direct focal tenderness in the view of posterior ligament complex injury. Conclusions: The posterior ligament complex injury is common finding of the thoracolumbar fracture. The high resolution MRI findings and direct focal tenderness are very importance in identifying the posterior ligament complex injury that is important prognostic factor particularly in mild anterior vertebral height loss and mild kyphotic angle in the plain radiograph.

The Effect of Pedicle Screw Instrumentation on Fractured Vertebrae in Unstable Thoracolumbar Burst Fractures with Canal Encroachment and Clinical Result / 대한척추외과학회지

STUDY DESIGN: A retrospective study. OBJECTIVES: To evaluate the canal encroachment of fractured bony fragments and neurological deficits of pedicle screw instrumentation for the treatment of unstable thoracolumbar burst fractures with pedicle screws inserted into the fractured vertebrae. MATERIALS AND METHODS: The authors evaluated 18 patients treated surgically with posterior fusions using pedicle screws for unstable thoracolumbar burst fractures, from March 2000 to September 2004. The ratios of the areas occupied by the fractured bony fragments in the canals were analyzed, before and after pedicle screw insertion, by computed tomography scans of the fractured vertebrae. The kyphotic angles, anterior vertebral heights, and neurological deficits were evaluated. RESULTS: The areas occupied by the fractured fragments in the canals were improved significantly after surgery and there were no neurological complications resulting from the placement of pedicle screws or fragment displacements. The kyphotic angles and anterior vertebral heights at the last follow-up visits were improved significantly compared with the preoperative radiographs. The neurological deficits were not aggravated after pedicle screw insertion. CONCLUSION: Our results suggest that pedicle screw instrumentation in fractured vertebrae is safe and effective for the treatment of unstable thoracolumbar burst fractures.