Shang-Won Yu

Treatment of distal clavicle fracture using Kirschner wires and tension-band wires

BACKGROUNDnNonunion frequently follows distal clavicle fracture. Traditional pinning methods using the through acromioclavicular articulation may result in osteoarthritic changes or ankylosis. This study introduces a direct pinning technique in which the acromioclavicular joint is spared.nnnMETHODSnTwelve patients with displaced distal clavicle fractures received open reduction and fixation with Kirschner wires (K-wires) and tension-band wires, from May 1996 to March 1997. The indication for surgery was type IIa fracture or fracture with displacement. Unrestricted passive and active range of motion was performed as soon as possible after the operation. Stretching and exertional exercises were permitted after radiographs showed an osseous union and after the implants were removed.nnnRESULTSnEleven patients achieved osseous union with painless full motion. Union time ranged from 3 to 6 months. One patient suffered from more comminuted fracture because of a fall 2 months after operation. This patient received a revision surgery with distal clavicle resection and coracoclavicle reconstruction. Symptomless ossification around the coracoclavicle ligament was noted on radiographs in one patient. The ossification did not progress after the 9-month follow-up.nnnCONCLUSIONnEdwards reported a rate of 45% delayed union and 30% nonunion in type II fractures. Several techniques had been described in the relevant literature. In our practice, fixation with Kirschner wires and tension-band wires has been successful in the treatment for displaced distal clavicle fracture.

Impact of cement leakage into disks on the development of adjacent vertebral compression fractures.

Study Design A retrospective study assessing new adjacent vertebral compression fracture (VCF) after percutaneous vertebroplasty (PV). Objective To evaluate the relationship between cement leakage into the disk during initial PV and development of subsequent new adjacent VCF. Summary of Background Data Cement leakage outside the vertebral body during PV has been reported and usually responds to conservative treatment. Sometimes bone cement may leak into the intervertebral disk and result in painful new adjacent VCF that usually requires another PV for pain relief. Methods From January 2002 to December 2002, a total of 106 consecutive patients underwent PVs for osteoporotic VCFs. The risk of new fractures of adjacent vertebral bodies, the amount of cement injection, and the duration of development of new adjacent fractures in relation to cement leakage into the disk were retrospectively assessed and statistically compared. Results New adjacent VCFs occurred in 20 (18.9%) of 106 patients at 22 adjacent vertebral bodies after PVs during at least 24 months of follow-up. The difference in number of new adjacent fractures between both patients and vertebral bodies with cement leakage and those without leakage into the disk were statistically significant (P<0.001 and P<0.001). Amounts of cement injected and duration to development of new adjacent fractures differed between patients with or without cement leakage (P<0.001 and P=0.005, respectively). Conclusions PV is a simple and effective, but not risk-free or complication-free procedure for the treatment of osteoporotic VCF. Patients undergoing PV should be informed of the possibility of new adjacent fractures and the higher risk if cement leaks into the disk.

Biologic Plating Versus Intramedullary Nailing for Comminuted Subtrochanteric Fractures in Young Adults : A Prospective, Randomized Study of 66 Cases

BACKGROUNDnPublished reports about treatment of comminuted subtrochanteric fractures in young patients are few. This study compared the effectiveness of biologic plating and intramedullary nailing in the treatment of such fractures.nnnMETHODSnA prospective, randomized, and nonblinded study was conducted. Closed reduction and fracture osteosynthesis were performed with either a dynamic condylar screw (DCS) or a Russell-Taylor reconstruction nail (RTRN) in all 66 patients. The average age of the patients was 36.1 years. The average follow-up period was 28.1 months.nnnRESULTSnAll but two patients had uneventful bone union and the average time to union was 15.1 weeks. One implant failure in the RTRN group and one delayed union in the DCS group required additional surgery to achieve bone union. Shorter fluoroscopic time, reduced blood loss, and fewer patients requiring blood transfusion were found in the DCS group, though the DCS group had a higher hip pain score 2 years postoperatively. Otherwise, the surgical results and functional outcomes were comparable between groups.nnnCONCLUSIONSnWith the enhanced fixation properties demonstrated in the present study, the DCS proved to be a feasible fixation device for comminuted subtrochanteric fractures in young patients. Our results indicated that intramedullary nailing by a RTRN revealed no advantages over biologic plating by a DCS for treatment of such fractures.

Locked plating for proximal humeral fractures: differences between the deltopectoral and deltoid-splitting approaches.

BACKGROUNDnLocking proximal humerus plate (LPHP) fixation has recently become available for the treatment of proximal humeral fractures. However, the preliminary results were contradictory. The technical requirements for success when using LPHP remain to be defined. Maybe the approach to the proximal humerus plays an important role, not the implants. We analyzed two surgical approaches to proximal humeral fractures.nnnMETHODSnBetween April 2004 and October 2007, 63 consecutive patients with displaced proximal humeral fractures who underwent LPHP osteosynthesis in our institute were classified to two treatment groups retrospectively: the deltopectoral incision and the deltoid-splitting incision according to surgeons preference. The Constant and Disabilities of the Arm, Shoulder and Hand scores were recorded for clinical assessment. Quality of reduction, fracture union, and radiographic complications were recorded for radiographic assessment. Electrophysiological abnormalities were also assessed.nnnRESULTSnThere were no significant differences between the groups with regard to demographic data, preoperative radiographic findings, and duration of follow-up. There were also no significant differences between the groups with regard to operative time (p = 0.918), blood loss (p = 0.407), hospital stay (p = 0.431), postoperative head-shaft angle (p = 0.769), union time (p = 0.246), final head-shaft angle (p = 0.533), Constant score (p = 0.677), Disabilities of the Arm, Shoulder and Hand score (p = 0.833), radiographic complications (p = 1.000), and presence of electrophysiological abnormalities (p = 0.296). Avascular necrosis of the humeral head was found in three patients, all of whom in the deltopectoral approach group.nnnCONCLUSIONnWe found no statistically significant difference in clinical, radiographic, and electrophysiological outcomes between the deltopectoral approach and deltoid-splitting approach while surgical treatment of proximal humeral fractures.

Clinical evaluation of vertebroplasty for multiple-level osteoporotic spinal compression fracture in the elderly

IntroductionOutstanding results have been achieved using vertebroplasty for the treatment of osteoporotic spinal compression fractures. However, few reports are available in the management of multiple-level compression fractures due to severe osteoporosis. This study prospectively evaluated the clinical and surgical outcomes of patients receiving vertebroplasty due to multiple-level osteoporotic spinal compression fractures.Patients and methodsEighteen patients underwent more than four levels of vertebroplasty due to multiple-level osteoporotic spinal compression fracture. All patients received a preoperative magnetic resonance imaging (MRI) check-up to determine which level needed vertebroplasty. Detailed evaluations were made in accordance with the patients’ clinical tracking, pre- and postoperative daily activities, Denis pain scale, and Roland–Morris score.ResultsAfter an average follow-up period of 36xa0months, the group receiving multiple-level vertebroplasty showed significant improvement, as registered on the Denis pain scale, Roland-Morris score, and in the activity of daily living. No major complications occurred during operation or postoperation, except one patient who expired due to suffocation at the rehabilitation center 3xa0weeks after vertebroplasty.ConclusionsThe use of vertebroplasty with cement to treat multiple-level osteoporotic spinal compression fractures in the elderly does have value, and brings good results to patients which were previously unimaginable. Preoperative MRI to evaluate the non-union levels and determine which levels needed vertebroplasty is very important.

Inferior vena Cava Syndrome Following Percutaneous Vertebroplasty With Polymethylmethacrylate

Study Design. A case of inferior vena cava syndrome following percutaneous vertebroplasty is described herein. Objective. To alert clinicians to the potential occurrence of inferior vena cava syndrome following percutaneous vertebroplasty. Summary of Background Data. Vertebroplasty is a less invasive treatment solution for the osteoporotic compression fracture. There complications of the cement leakage would appear to have been rather infrequent. We report a case of inferior vena cava syndrome related to the cement leakage. Methods. A 59-year-old woman underwent percutaneous vertebroplasty for painful T11, L1, L2, and L3 compression fractures, under general anesthesia at a community hospital. A contralateral transpedicular approach was made in order to inject polymethylmethacrylate resin into the fractured vertebra. Results. Just subsequent to surgery, this patient developed dyspnea, arthralgia, myalgia, and progressive right lower-limb pain, redness, and swelling., conservative treatment being then undertaken, albeit in vain. One week after the attempted remediation of this patient’s condition, she was transferred to our hospital for further management. After admission, radiography of the patient’s lumbar spine (lateral view) revealed multiple cement leakage in the area of the posterior longitudinal ligament and also in the anterior paravertebral area. The abdominal and pelvic CT scan and venography revealed vertebroplasty cement leakage into the lumbar vein, the left renal vein, and the inferior vena cava. Thrombosis at the left common iliac vein and left femoral vein were noted with extension into the inferior part of the inferior vena cava. Intravenous heparin was then administered to our patient for the ensuing 20 days, at which time heparin was replaced by warfarin, in order to attempt to prevent progressive venous thrombosis. The patient’s leg edema appeared to improve 10 weeks subsequent to her surgery, she then being able to perambulate using a rigid walker. Conclusion. This case illustrates the need for clinicians to be critically aware of the potential occurrence of inferior vena cava syndrome among patients who have undergone percutaneous vertebroplasty, especially when multiple levels of vertebra are injected as part of the vertebroplasty procedure.

Open-door laminoplasty with suture anchor fixation for cervical myelopathy in ossification of the posterior longitudinal ligament.

Expansive laminoplasty was developed to achieve posterior spinal cord decompression while preserving cervical spine stability. In the classic Hirabayashi procedure, the lamina door is tethered open by sutures between the spinous process and facet capsule or paravertebral muscle. The authors present a modified technique, which enhances secure fixation and prevents restenosis owing to hinge closure. Twenty-seven patients (7 females, 20 males) with cervical myelopathy secondary to ossification of the posterior longitudinal ligament were enrolled. Each patient underwent unilateral open-door laminoplasty with suture anchor fixation. Tying and fixation of the sutures onto the holed lateral mass screws was used instead of the conventional method. Radiography, magnetic resonance imaging, and computed tomography scanning were used for imaging studies. The Nurick score was used to assess myelopathy severity, whereas the Japanese Orthopedic Association score was adopted to compare clinical outcome before and after surgery. Mean follow-up period was 38 months (range, 18 to 60). Ten patients had 5 levels of decompression (C3-7), and 17 patients had 4 (C3-6, 12 patients; C4-7, 5 patients). All patients experienced functional improvement of at least 1 Nurick score after surgery. The Japanese Orthopedic Association score increased significantly from 7.5±3.2 before surgery to 13.2±1.6 at final follow-up. Postoperative radiography and computed tomography scan demonstrated significantly increased sagittal diameter and canal expansion. No neurologic deterioration owing to hinge reclosure or major surgery-related complications were observed. In conclusion, unilateral open-door laminoplasty with suture anchor fixation effectively maintains expansion of the spinal canal and resists closure while preserving alignment and stability. This modified technique has a low complication rate and provides marked functional improvement in patients with cervical myelopathy owing to ossification of the posterior longitudinal ligament.

Open-door laminoplasty for multilevel cervical spon-dylotic myelopathy: Good outcome in 12 patients using suture anchor fixation

Background and purposeu2003In the classic Hirabayashi procedure, the lamina door is tethered open by sutures between the spinous process and facet capsule or para-vertebral muscle. Our early experiences showed, however, that the loosened sutures result in dislodgement and reclosure of the lifted lamina. We present a modified method to ensure secure fixation and prevent restenosis due to hinge closure. Patients and methodsu200312 patients with cervical spon-dylotic myelopathy underwent unilateral open-door laminoplasty using suture anchor fixation between 2000 and 2004. The sutures were tied and fixed onto the holed lateral mass screws, instead of using the conventional suture technique. We used radiography, MRI, and CT for imaging studies. The Nurick score was used to assess severity of myelopathy, and the Japanese Orthopedic Association (JOA) score was used to evaluate clinical outcomes before surgery and at the last follow-up visit. Resultsu2003All patients experienced functional improvement of at least 1 Nurick score after surgery. The JOA score for the 12 patients increased significantly from 6.9 (SD 3.0) before surgery to 13 (SD 1.6) at final follow-up. Postoperative radiography and CT showed increased sagittal diameter and canal expansion. Average preoper-ative and postoperative ranges of motion for the cervical spine were 48 (SD 4.6) and 36 (SD 2.7), respectively. No neurological deterioration due to hinge reclosure and no major surgery-related complications were observed during the follow-up period. Interpretationu2003Open-door laminoplasty using suture anchor fixation effectively maintains expansion of the spinal canal and resists closure while preserving alignment and flexibility. This modified technique is easy to use, has a low complication rate, and provides marked functional improvement for patients with cervical spon-dylolytic myelopathy.

Subpedicle decompression and vertebral reconstruction for thoracolumbar Magerl incomplete burst fractures via a minimally invasive method.

Study Design. Retrospective. Objective. To evaluate the clinical and radiographical results. Summary of Background Data. The evolution of posterior approach for burst fractures was from long-segment to short-segment and then to monosegmental fixation. Decompression of the spinal cord is performed by anterior or posterior approaches. The technique attempts to decompress the spinal cord by a paramedian subpedicle approach, and simultaneous vertebral reconstruction with pile-up titanium spacers (subpedicle decompression and body augmentation [SpBA]) was developed. Methods. Eighty patients with symptomatic single thoracolumbar Magerl incomplete burst fractures were included. After manual reduction, transpedicle body augmentation and shortsegment fixation (TpBA group) were performed in 38 patients and SpBA in 42 cases. The mean follow-up was 52.6 ± 18.7 (TpBA) and 42.1 ± 7.8 (SpBA) months, and the age was 57.9 ± 7.2 and 59.1 ± 8.3 years. Clinical and radiographical outcomes were analyzed. Results. The operation time was 66 ± 11 (TpBA) versus 34.5 ± 5.5 (SpBA) minutes. The initial anterior vertebral correction was 46.8 ± 12.2% (TpBA) versus 53.2 ± 15.0% (SpBA) (P = 0.03) and the final correction was 44.0 ± 10.8% versus 51.5 ± 15.3% (P = 0.01). Initial corrections of the lateral Cobb angle were 22.3° ± 2.6° versus 22.8° ± 2.7° and the final corrections were 19.1° ± 3.4° versus 20.5° ± 2.9°. The VAS score was 7.7 ± 1.2 versus 7.9 ± 1.2 preoperatively and 2.2 ± 0.7 versus 1.8 ± 0.6 (P = 0.02) at the final visit. Seventy-five patients maintained or recovered to Frankel grade E. Three patients in the TpBA group and 2 in the SpBA group improved from grade C to D. Technical complications included 1 root overstretch in the SpBA group and one incomplete decompression in the TpBA group. Conclusion. SpBA is a safe and fast technique to treat Magerl incomplete burst fractures and leads to good clinical results. Level of Evidence: N/A

Arthroscopic excision of wrist ganglions: does trans-cystic or cystic-sparing portal technique affect clinical outcomes?

IntroductionThe preliminary results of arthroscopic wrist ganglionectomy were contradictory. The approach used for the arthroscopic excision of wrist ganglions may play an important role. We analyzed two surgical approaches for arthroscopic excision of wrist ganglions.Materials and methodsBetween April 2009 and October 2014, 49 patients with wrist ganglions who underwent arthroscopic excision in our institute were retrospectively classified into two treatment groups, namely the trans-cystic portal technique (TCP) and cyst-sparing portal technique (CSP). The visual analog scale (VAS), Mayo wrist scores, and disabilities of the arm, shoulder, and hand (DASH) scores were measured for clinical assessment. Recurrence, residual pain, and complications were evaluated at follow-up.ResultsNo significant differences were found between the groups in terms of demographic data, and preoperative clinical assessment, as well as with regard to postoperative VAS score (pu2009=u20090.898), Mayo wrist score (pu2009=u20090.526), DASH score (pu2009=u20090.870), recurrence (pu2009=u20090.491), residual pain (pu2009=u20090.690), and complications (pu2009=u20090.352). Recurrence was found in 2 of the 47 patients and they were both in the CSP group. At the final follow-up, residual pain was found in four patients in the TCP group and three in the CSP group.ConclusionsFor performing arthroscopic resection of wrist ganglions, both techniques are safe regarding the complication rates. In recurrence rate, no significant difference was found between the two groups, but no recurrence was observed when the TCP technique was used.