Migration of Penrose Drain Following Anterior Cervical Spinal Surgery / 대한정형외과학회잡지

A retained surgical drain in the operation site is a rare complication that may cause clinical problems and result in medical disputes.The discovery of a retained drain is most often reported after abdominal and pelvis surgery but drain migration in the prevertebral space after anterior cervical spine surgery has not been reported. This paper reports a case of drain retained and migrated into the thorax level following anterior cervical spine surgery with a review of the relevant literature.

Recurrent Treatment Failure in Vancouver Classification Type C Periprosthetic Fractures around a Well Fixed Short Femoral Stem

A short femoral stem (type 1 cementless stem) is being increasingly used to perform total hip arthroplasty; however, various types of intra- or postoperative periprosthetic fractures have been reported in recent times. A 66-year-old woman with a history of bilateral total hip arthroplasties using a type 1B femoral stem was admitted 2 months post-operation for a Vancouver type C periprosthetic fracture. She underwent open reduction and internal fixation; however, we observed recurrent non-union and plate breakage at the same site. In this case report, we discuss the factors associated with treatment failure in patients with a Vancouver type C periprosthetic fracture following type 1 femoral stem im-plantation.

Arthroscopic Iliopsoas Tenotomy of Iliopsoas Impingement after Total Hip Arthroplasty / 대한정형외과학회잡지

Purpose@#The clinical outcomes were investigated to determine if arthroscopic management is a useful method for 19 hips with iliopsoas tendon impingement (IPI) after total hip arthroplasty (THA). @*Materials and Methods@#Eighteen patients (19 hips), who complained of groin pain and flexion pain that persisted after THA from September 2013 to December 2019, were the subjects of this investigation. The mean time to manifestation after THA was four months (range, 1–9 months) in patients of an average age of 60 years (range, 50–69 years). Thirteen out of 18 patients underwent THA using the direct anterior approach and five by the lateral approach. IPI was diagnosed by the medical history, physical examination, blood test, radiographic examination using X-ray and computed tomography, and topical injection therapy. All patients underwent arthroscopic treatment and a dynamic arthroscopic physical examination after exposure to the iliopsoas tendon revealed impingement. Tenotomy was then performed on the muscle portion through the total tendon portion. Symptoms and pain levels of preoperative, postoperative and follow-up period were investigated and compared. @*Results@#The Western Ontario and McMaster Universities Osteoarthritis Index score decreased from an average of 58.4 (range, 40–88) before surgery to an average of 35.0 (range, 15–76) after surgery. Similarly, the visual analogue scale decreased from an average of 4.0 (range, 2–6) before surgery to an average of 1.4 (range, 0–4) after surgery. Sixteen patients (88.9%) showed pain relief and improvement in the straight leg raise test, and two patients showed postoperative muscle weakness and sustained pain. In the follow-up period, muscle weakness improved. One patient underwent arthroscopic iliopsoas tenotomy at the lesser trochanteric level but the symptoms persisted.The clinical symptoms were improved after one more tenotomy at the joint level. @*Conclusion@#Arthroscopic iliopsoas tenotomy performed in patients with IPI after THA showed good clinical results.

Learning Curve of the Direct Anterior Approach for Hip Arthroplasty / 대한정형외과학회잡지

Purpose@#To evaluate the timing of the improvement in surgical skills of the direct anterior approach for hip arthroplasty through an analysis of the clinical features and learning curve in 58 cases. @*Materials and Methods@#From November 2016 to November 2018, 58 patients, who were divided into an early half and late half, and underwent hip arthroplasty by the direct anterior approach, were enrolled in this retrospective study. The operation time and complications (fracture, lateral femoral cutaneous nerve injury, heterotopic ossification, infection, and dislocation) were assessed using a chi-square test, paired t-test, and cumulative sum (CUSUM) test. @*Results@#The mean operation times in total hip arthroplasty (26 cases) and bipolar hemi-arthroplasty were 132.1 minutes and 79.7 minutes, respectively, demonstrating a significant difference between the two groups. CUSUM analysis based on the results revealed breakthrough points of the operation time, decreasing to less than the mean operation time because of the 16th case in total hip arthroplasty and 14th case in bipolar hemiarthroplasty. Complications were encountered in the early phase and late phase: five cases of fractures in the early phase, no case in the late phase; eight and two cases of lateral femoral cutaneous nerve injury, respectively; three and two cases of heterotopic ossification, respectively; and one case of dislocation, one case of infection and three cases of others in the early phase. The CUSUM chart for the fracture rate during operation in the early phase revealed the following: five cases fracture (17.2%) in the early phase and no case in the late phase (0%). This highlights the learning curve and the need for monitoring the inadequacy of operation based on the complications. @*Conclusion@#Hip arthroplasty performed by the direct anterior approach based on an anatomical understanding makes it difficult to observe the surgical field and requires a learning curve of at least 30 cases.

Intraspinal Extradural Cyst Subsequent to a Vertebral Compression Fracture - A Case Report -

Although a rare entity, intraspinal extradural cyst can cause severe deficit via neural compression. After reviewing available literature, the authors report a rare case of cord compression by intraspinal extradural cystic mass that developed after an osteoporotic vertebral compression fracture. An 80-year-old female patient had undergone vertebroplasty for osteoporotic vertebral compression fracture of T12, subsequent to a minor fall. However, the patient complained about sustained pain and progressive weakness of lower extremities even after the procedure. Follow-up magnetic resonance imaging revealed an intraspinal extradural cystic lesion compressing the spinal cord, and the patient had to undergo a surgical intervention via the posterior approach. Symptoms were relieved postoperatively, with no recurrence during the 1-year follow-up.

Early Onset Subsequent Vertebral Compression Fracture after Percutaneous Verteroplasty / 대한정형외과학회잡지

PURPOSE: To evaluate the characteristics and the risk factors of early onset subsequent vertebral compression fractures after percutaneous vertebroplasty. MATERIALS AND METHODS: A total of 44 patients, who had a new subsequent vertebral fracture after percutaneous vertebroplasty for an osteoporotic vertebral compression fracture between January 2013 and December 2015, were recruited. The patients were divided into two groups according to the onset period of subsequent fracture. The number of patients who had a fracture within 3 months following vertebroplasty were 22 cases (Group A); after 3 months were 22 cases (Group B). Variables, including age, sex, bone mineral density (BMD), body mass index (BMI), preexisting vertebral compression fracture, location of the initial fracture, intradiscal cement leakage, injected cement volume, restoration of vertebral body height, and correction of kyphosis, in the two groups were analyzed and compared retrospectively. RESULTS: The age, sex, BMD, BMI, preexisting vertebral compression fracture, location of the initial fracture, intradiscal cement leakage, and correction of kyphosis were similar in the two groups. Both a greater volume of bone cement injected and a greater degree of vertebral height restoration contributed significantly to the risk of fracture within 3 months. CONCLUSION: The cement volume and degree of height restoration are risk factors for early onset fracture at the adjacent vertebrae after percutaneous vertebroplasty and close attention is needed during the follow-up period.

Serratia marcescens Spinal Epidural Abscess Following Caudal Epidural Injection / 대한정형외과학회잡지

Spinal infection due to Serratia marcescens is very rare. A 78-year-old male patient withoutany risk factor was admitted to our hospital with chief complaints of severe back pain, fever, weakness in both legs, and bowel dysfunction, following caudal epidural injection. Magnetic resonance imaging revealed spondylodiscitis with epidural abscess. Surgical decompression was performed and the epidural abscess was removed. The cultures isolated S. marcescens, which can cause nosocomial infection in immunocompromised patient. However, to the best of our knowledge, we report the first case of S. marcescens spinal epidural abscess following epidural injection, with literature review.

Huge Intradural Lumbar Disc Herniation Mimicking an Intradural Spinal Tumor: A Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a case of cauda equine syndrome due to a lumbar intradural disc herniation. SUMMARY OF LITERATURE REVIEW: IDH is rare but there is a higher incidence of neurologic deficit in IDH. Therefore, it should be treated immediately. MATERIALS AND METHODS: A 34-year-old male patient was presented with cauda equina syndrome due to a lumbar intradural mass and underwent surgical excision. RESULTS: Operative findings and the histologic study revealed an intradural disc herniation. CONCLUSIONS: IDH is very rare lesion but should be considered in a differential diagnosis if preoperative MRI demonstrates an intradural lesion.

The Effect of Lumbar Spinal Stenosis on Results of Treatment in Peripheral Arterial Disease / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to evaluate the result of percutaneous transluminal angioplasty (PTA) in patients with concurrent lumbar spinal stenosis (LSS) and peripheral arterial disease (PAD). MATERIALS AND METHODS: Patients who underwent PTA for intermittent claudication were evaluated retrospectively. Twenty-two patients with severe LSS were included in group A and 23 patients with no or mild LSS in group B. The symptomatic improvement after PTA was comparatively evaluated. RESULTS: Visual analogue scale (VAS) and Walking Impairment Questionnaire (WIQ) scores showed significant improvement after PTA in both groups (p<0.001, <0.001). However, according to VAS, WIQ and modified MacNab scores, results of group A were less satisfactory (p<0.001, <0.001, p=0.03). Only 2 patients underwent additional spine surgery. CONCLUSION: In results of PTA, the PAD associated LSS group showed less improvement than the PAD only group, but most patients showed symptomatic improvement with conservative treatment.

Pulmonary and Renal Cement Embolisms During Balloon Kyphoplasty: A Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a case of simultaneous pulmonary and renal embolisms after balloon kyphoplasty and review relevant literature. SUMMARY OF LITERATURE REVIEW: Pulmonary or renal embolism caused by cement leakage during balloon kyphoplasty is a rare complication but can be fatal. MATERIALS AND METHODS: An 84-year-old female patient was treated with balloon kyphoplasty for an osteoporotic compression fracture. Pulmonary and renal embolisms were detected after the procedure and the patient was treated conservatively. RESULTS: After conservative treatment, embolism-related symptoms were not found during the follow-up period. CONCLUSIONS: We encountered a case of simultaneous pulmonary and renal cement embolisms which occurred during kyphoplasty. This is a very rare but potentially serious complication. However, the patient had no long-term sequelae after conservative treatment.

Current Concepts of Anterior Cervical Discectomy and Fusion: A Review of Literature

Anterior cervical discectomy and fusion (ACDF) is a safe and effective procedure for degenerative cervical spinal disease unresponsive to conservative management and its outstanding results have been reported. To increase fusion rates and decrease complications, numerous graft materials, cage, anterior plating and total disc replacement have been developed, and better results were reported from those, but still there are areas that have not been established. Therefore, we are going to analyze the treatment outcome with the various procedure through the literature review and determine the efficacy of ACDF.

Current Concepts of Anterior Cervical Discectomy and Fusion: A Review of Literature

Anterior cervical discectomy and fusion (ACDF) is a safe and effective procedure for degenerative cervical spinal disease unresponsive to conservative management and its outstanding results have been reported. To increase fusion rates and decrease complications, numerous graft materials, cage, anterior plating and total disc replacement have been developed, and better results were reported from those, but still there are areas that have not been established. Therefore, we are going to analyze the treatment outcome with the various procedure through the literature review and determine the efficacy of ACDF.

Intramedullary Osteosclerosis Mimicking Lower Leg Radiating Pain / 대한정형외과학회잡지

Intramedullary osteosclerosis is an uncommon benign condition characterized by endosteal new bone formation in long tubular bone of lower extremity and treatment as well as etiology is unknown. Due to the rarity of this disease, and because there is no specific clinical finding except leg pain, it is difficult to differentiate this entity from other causes presenting similar symptoms. We report on a case of intramedullary osteosclerosis mistaken for radiculopathy from lumbar disease with a review of the literature.

Pregnancy and Lactation-associated Osteoporosis with Vertebral Compression Fracture / 대한골다공증학회지

Pregnancy- and lactation associated osteoporosis is a rare condition. However, it may cause fragility fracture with severe pain. A 29-year-old woman had first delivery without any complications and she was breast-feeding her baby. In a postpartum one month, she had a severe back pain and it has gotten worse. She was diagnosed with multiple recent compression fractures in thoracic spines and treated with brace immobilization and bisphosphonate therapy. We report this rare case of pregnancy- and lactation associated osteoporosis with multiple vertebral compression fractures.

Calcified Angioleiomyoma on Sole: A Case Report / 대한족부족관절학회지

Angioleiomyomas are relatively uncommon benign tumors originating from smooth cells of a blood vessel. Although curative by surgical excision, they are rarely diagnosed definitely before surgery. We report on a case of calcified angioleiomyoma occurring on the sole, which was treated by surgical excision without recurrence and a review of literature is presented.

Factors Affecting Adjacent Level Ossification Development after Anterior Cervical Discectomy and Fusion / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to analyze the affecting factors of adjacent level ossification development (ALOD) after anterior cervical discectomy and fusion. MATERIALS AND METHODS: This study enrolled 75 patients who underwent anterior cervical discectomy and fusion and were followed-up for more than two years. Twenty-five patients were related with trauma and 47 patients were diagnosed as degenerative cervical disorder. We assessed the incidence, location and timing of ALOD, and compared the incidence of ossification between trauma and degenerative disease groups to know the effect of soft tissue damage. We also reviewed the correlation between the development of ossification at adjacent level and the factors, such as fusion level, age, operation time, duration of follow-up, and the presence of ossification of posterior longitudinal ligament (OPLL), as well as ossification of yellow ligament (OYL). RESULTS: Ossification developed in 33 patients (44%). Five cases (15%) were detected during the first year after surgery, 10 (30%) cases detected during the second year after surgery, 13 (40%) between second and third year, and 5 (15%) cases of more than three years after surgery. Only the fusion level was related with the development of ossification statistically (p<0.001). Age, operation time, duration of follow-up, sex ratio, presence of OPLL, and OYL were not related with the incidence of ossification significantly. There was no significant difference in the incidence of ALOD between the trauma group and degenerative disease group (p=0.3625). CONCLUSION: To detect ALOD, it needs a long time for follow-up after surgery. We thought that ALOD is affected by excessive loading at the adjacent level after fusion rather than severity of the soft tissue damage.

Differences in Thoracolumbar Burst Fractures by Falls from Height with Associated Foot and Ankle Fractures

STUDY DESIGN: This is a retrospective clinical study. OBJECTIVES: To know how the associated foot or ankle fracture influences the fracture pattern in the thoracolumbar burst fractures caused by falls from height. SUMMARY OF LITERATURE REVIEW: There were few studies on how the foot or ankle fracture influences the thoracolumbar fracture caused by falls from height. MATERIALS AND METHODS: We reviewed 46 subjects, who underwent surgery due to burst fracture of the thoracic or lumbar region, caused by fall accidents, from May 2004 to October 2008. Among them, we defined 19 cases that had associated foot or ankle fractures as group A, and the other 27 cases as group B. We analyzed the differences of radiological and clinical findings, and functional outcomes between the two groups. RESULTS: The falling heights were higher in group A than in group B (P<0.01). Thoracolumbar junction (T11-L2) was the most common location involved in both groups, but group A had more fractures on the lower lumbar region (L3-5), relatively (p=0.03). Kyphotic deformity was more severe in group B (p=0.01) but there were no significant differences in the wedge angle, amount of canal compromise, compression rate of anterior column between both groups (p=0.08, 0.46, 0.76). More segments were fused in group B (P=0.04). Neurologic deficit was more common in group B (p=0.03), but there were many complications related with foot or ankle fractures in group A (38%).There was no significant difference in the final clinical outcome between both groups (Pain scale p= 0.48, Work scale p=1.00). CONCLUSIONS: In patients who had burst fractures in the thoracic or lumbar region associated with foot or ankle fractures, there was a tendency to increase the incidence of lower lumbar fracture, relatively. The neurologic deficits were less common in this group of patients, but there was no difference in the functional outcome.

Efficacy of PEEK Cages and Plate Augmentation in Three-Level Anterior Cervical Fusion of Elderly Patients

BACKGROUND: To evaluate the clinical efficacy of three-level anterior cervical arthrodesis with polyethyletherketone (PEEK) cages and plate fixation for aged and osteoporotic patients with degenerative cervical spinal disorders. METHODS: Twenty one patients, who had undergone three-level anterior cervical arthrodesis with a cage and plate construct for degenerative cervical spinal disorder from November 2001 to April 2007 and were followed up for at least two years, were enrolled in this study. The mean age was 71.7 years and the mean T-score using the bone mineral density was -2.8 SD. The fusion rate, change in cervical lordosis, adjacent segment degeneration were analyzed by plain radiographs and computed tomography, and the complications were assessed by the medical records. The clinical outcomes were analyzed using the SF-36 physical composite score (PCS) and neck disability index (NDI). RESULTS: Radiological fusion was observed at a mean of 12.3 weeks (range, 10 to 15 weeks) after surgery. The average angle of cervical lordosis was 5degrees preoperatively, 17.6degrees postoperatively and 16.5degrees at the last follow-up. Degenerative changes in the adjacent segments occurred in 3 patients (14.3%), but revision surgery was unnecessary. In terms of instrument-related complications, there was cage subsidence in 5 patients (23.8%) with an average of 2.8 mm, and loosening of the plate and screw occurred in 3 patients (14.3%) but there were no clinical problems. The SF-36 PCS before surgery, second postoperative week and at the last follow-up was 29.5, 43.1, and 66.2, respectively. The respective NDI was 55.3, 24.6, and 15.9. CONCLUSIONS: For aged and osteoporotic patients with degenerative cervical spinal disorders, three-level anterior cervical arthrodesis with PEEK cages and plate fixation reduced the pseudarthrosis and adjacent segment degeneration and improved the clinical outcomes. This method is considered to be a relatively safe and effective treatment modality.

Significance of Mal-alignment after Anterior Cervical Arthrodesis in Degenerative Cervical Spinal Disorders / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to analyze the risk factors for postoperative sagittal mal-alignment after anterior cervical arthrodesis resulting from degenerative cervical disorders and its effect on radiological and clinical results. MATERIALS AND METHODS: We evaluated 50 patients who underwent anterior cervical arthrodesis for degenerative cervical disorder retrospectively. We assigned 25 patients who had sagittal mal-alignment after surgery to group A and 25 patients who had improvement of lordosis after surgery to group B. We evaluated the change of cervical lordosis, lordosis at fused segments, and lordosis at unfused segments. In addition, we evaluated radiological and clinical results. RESULTS: In group A, postoperative cervical lordosis worsened from 12.7+/-10.6 to 3.6+/-6.2degrees after surgery (p=0.002), but had recovered to 12.2+/-9.5degrees by the last Follow-up (p=0.859). In group B, cervical lordosis was improved from 9.6+/-10.5degrees to 22.5+/-9.7degrees (p=0.0003) after surgery and correction was maintained to 27.5+/-9.1degrees (p=0.0988) at the last follow up. Lordosis at fused segments were improved in both groups (p=0.001, 0.0001) but lordosis at unfused segments worsend in group A (p=0.0001). The factor associated with postoperative mal-alignment was symtoms of myelopathy (p=0.0436). Age, sex, fusion level, size of cage, and duration of symptoms were not significantly associated with postoperative changes in alignment. One nonunion occurred only in group A. Six cases of cage subsidences were found in group A, 3 cases in group B (p=0.4506). Adjacent segment degeneration was found in 8 segments in group A, 1 segment in group B (p=0.0048). The differences in clinical improvement evaluated by VAS, NDI between groups were not significant (p=0.88, p=0.91). CONCLUSION: Postoperative sagittal malalignment was a temporary and reversible change, and was not related to clinical results. However, it might be a factor in the increased incidence of adjacent segment degeneration.

Management of Facet Joint Fracture-Dislocation of the Lower Cervical Spine with Reduction Failure / 대한정형외과학회잡지

PURPOSE: This study examined the obstacles preventing a decrease in a facet joint fracture-dislocation of the lower cervical spine after skeletal traction to determine suitable treatment guidelines. MATERIALS AND METHODS: This study examined 19 fracture-dislocation cases of the facet joint in the lower cervical spine who failed closed reduction through skeletal traction. The following parameters were analyzed: obstacles preventing reduction, neurological recovery, complications and body to canal ratio of the injured site. RESULTS: The obstacles found on MRI were herniated discs in 17 cases and joint capsule in 2 cases. The surgical decision was based on an analysis of the size and location of the disc, the degree of spinal canal stenosis and damage of the posterior structures. Anterior reduction/fusion and posterior fusion after anterior reduction/fusion, anterior fusion after posterior reduction/fusion and posterior reduction/fusion was performed in 9, 2, 6 and 2 cases, respectively. There was significant neurological recovery at the final follow-up (p=0.000). The body to canal ratio also increased significantly after surgery (p=0.000). CONCLUSION: For the treatment of unreducible facet joint fracture-dislocation of the cervical spine, pre-reduction MRI is essential for a thorough evaluation of the various underlying pathologies. In addition the surgical methods should be determined according to not only the neurological status, obstacles and pathologic structures preventing reduction, but also the surgeon's experience.