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The use of commercial products such as a cup and liner for total hip arthroplasty for patients with severe bone defects has a high probability of failure. In these patients the cup alone cannot cover the bone defect, and thus, an additional augment or cage is required. In this study, we designed three-dimensional (3D) printable bone augments as an alternative to surgeries using reinforcement cages. Thirty-five sharp-edged bone augments of various sizes were 3D printed. A biporous structure was designed to reduce the weight of the augment and to facilitate bone ingrowth. Two types of frames were used to prevent damage to the augment’s porous structure and maintain its stability during printing. Furthermore, two types of holes were provided for easy augment fixation at various angles. Fatigue tests were performed on a combination of worst-case sizes derived using finite element analysis. The test results confirmed the structural stability of the specimens at a load of 5340 N. Although the porosity of the specimens was measured to be 63.70%, it cannot be said that the porous nature was uniformly distributed because porosity tests were performed locally and randomly. In summary, 3D-printable biporous bone augments capable of bonding from various angles and bidirectionally through angulation and bottom-plane screw holes are proposed. The mechanical results with bone augments indicate good structural safety in patients. However, further research is necessary to study the clinical applications of the proposed bone augment. Graphic abstract

Owing to an increase in the number of hip arthroplasty surgeries, the number of implant replacement surgeries is increasing rapidly as well. This necessitates the study of hip joint conditions. Therefore, Paprosky defined a classification system to indicate the degree of damage to the hip joint. In this study, a customised hip implant suitable for Paprosky classification Type ⅡC and over was designed. The shape, suitability, and mechanical safety of the worst-case model for the implant were evaluated.To identify the implant size depending on states over Type ⅡC acetabulum bone loss, a size range was selected and a customised implant was designed according to the computed tomography data within the size range. The implant was designed for the flange, hook, and flattened model types. The worst-case selection test was conducted using finite element analysis. The von Mises stresses of the flange, hook, and flattened models were found as 76.223, 136.99, and 80.791 MPa, respectively. Therefore, the hook-type model was selected as the worst case for the mechanical performance test.A bending test was conducted on the hook-type model without fracture and failure at 5344.56 N. The proposed customised implant was found suitable for Type ⅢA acetabulum bone loss, whereas the shape suitability and mechanical safety were verified for the worst case.The shape of a customised implant suitable for Paprosky ⅢA type was designed. The shape suitability and mechanical safety were evaluated using finite element method analysis and bending tests. Clinical validation is required through subsequent clinical evaluation.

Recently, the combination of a press-fit acetabular cup and ceramic articulation has been widely used for implanting cementless acetabular components and has been shown to provide good initial stability. However, this combination may lead to the failure of ceramic liners by their non-concentric seating due to acetabular cup deformation. To reduce the risk of this, we applied direct metal tooling (DMT)-based additive manufacturing (AM) with the hypothesis that DMT-based AM would minimize the deformation of the acetabular cup by increasing its strength, which would ultimately prevent the ceramic liner from fracturing. To confirm this, we performed post-fatigue tests simulating a press-fit situation for the acetabular cups subjected to DMT-based AM and compared them with the cups treated with titanium plasma spray (TPS). The post-fatigue tests were then performed under a maximum load of 14 kN for 20 × 107 cycles. The roundness and inner diameter of the cups and liners were measured in all testing phases. The results revealed no differences between the acetabular cups subjected to DMT-based AM and TPS. However, when comparing only the mean values directly, the results for the acetabular cup subjected to DMT-based AM indicated that it might have increased the strength of the acetabular cup, compared with those treated with TPS, thereby minimizing the possibility of fracture of the ceramic liner. In conclusion, DMT-based AM was shown to be at least equivalent to TPS, or could possibly supersede it. Additionally, via DMT-based AM, it is possible to control the porous structure freely, so this approach allows a greater range of applications and potential for further improvement than TPS.

Purpose: We attempted to determine the degree of rotation of the femoral component to achieve an ideal rectangular flexion gap with minimal medial collateral ligament (MCL) release using a modified measured technique. Materials and Methods: Group I consisted of 60 osteoarthritis patients (72 cases) who underwent total knee arthroplasty (TKA) with minimal MCL release and Group II consisted of 48 patients without osteoarthritis (61 cases). We performed computed tomography (CT) scanning of the knee with 90 degree flexion in all of the patients and analyzed the angles between the distal femur landmarks and the tibial mechanical axis using a Picture Archiving Communication system. External rotation of the femoral component from the Whiteside line and posterior condylar line was measured in group I who underwent TKA with minimum MCL release. The variance in the mediolateral flexion gap according to the degree of rotation was also measured using an Auto-Computer Aided Design program. Results: The CT scans showed that the Whiteside line, posterior condylar line, and transepicondylar line was more internally rotated on average from the longitudinal axis of tibia by 4.12°, 5.54°, and 4.64°, respectively, in group I compared to group II. In group I, the femoral component was inserted with an average external rotation of 5.6° from the posterior condylar line and with an average external rotation of 2.0° from the Whiteside line with minimal MCL release. From the measurements of the femoral component size and the variance in the degree of rotation using an Auto-CAD program, it was found that the change in the mediolateral flexion gap was greater when the rotation angle was greater and it was greater when the size of femoral component was larger at the same rotation angle. Conclusions: The average rotation angle of the femoral component to achieve an ideal rectangular flexion gap with minimal MCL release in TKA was an external rotation of 5.6° from the posterior condylar line and an external rotation of 2.0° from the Whiteside line. We concluded that when a femoral component is small in size, greater than average external rotation needs to be applied and when a femoral component is large in size, less than average external rotation needs to be applied.

We modified the posterior approach by preserving the external rotator muscles to enhance joint stability after primary THA. We asked whether this modified posterior approach would have a lower dislocation rate than the conventional posterior approach, with and without a repair of external rotator muscles. We retrospectively divided 557 patients (670 hips) who had undergone primary THA into three groups based on how the external rotator muscles had been treated during surgery: (1) not repaired after sectioning, (2) repaired after sectioning, or (3) not sectioned and preserved. The minimum followup was 1 year. In the group with preserved external rotator muscles, we observed no dislocations; in comparison, the dislocation rates for the repaired rotator group and the no-repair group were 3.9% and 5.3%, respectively. This modified posterior approach, which preserves the short external rotator muscles, seemed effective in preventing early dislocation after primary THA.Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Background : Controversy continues regarding the best treatment for compression and burst fractures. The axial distraction reduction utilizing the technique emplying the long straight rod or curved short rod without derotation to reduce fracture are practised together with short segment posterolateral fusion (PLF). Effects of the early postoperative mobilization without posterolateral fusion on reduction maintenance and fracture consolidation were not evaluated so far. The present prospective study is designed to assess the effectiveness of i) reduction and restoration of sagittal alignment, ii) no posterolateral fusion on the reduced, fractured vertebral body and injured disc, iii) fracture consolidation and iv) the fate of the unfused cephalad and caudal injured motion segments of the fractured vertebra. Materials and Methods : The study includes 15 Denis burst and two Denis type D compression fractures between T 12 and L 3 . The lordotic distraction technique was used for ligamentotaxis utilizing the contoured short rods and pedicle screw fixator. Three vertebrae including the fractured one were fixed. The patient′s after surgery were braced for ten weeks with activity restriction for 2-4 weeks. The patients were evaluated for change in body height, segittal curve, reduction of retropulsion, improvement in neural deficit. The unfused motion segments, residual postoperative pain and bone and metal failure were also evaluated. Results : The pre-operative and postreduction percentile vertebral heights at, zero (immediate post-operative), at three, six and 12 months followup were 62.4, 94.8, 94.6, 94.5 and 94.5%, respectively. The percentages of the intracanal fragment retropulsion at pre operative, and post operative at zero, 3, 6 and 12 months followup were 59.0, 36.2,, 36.0, 32.3, and 13.6% respectively. The pre-operative and postreduction percentile loss of the canal dimension and at zero, three, six and 12 months were 52.1, 45.0, 44.0, 41.0 and 29% respectively suggesting that the under-reduced fragment was being resorbed gradually by a remodeling process. The mean initial kyphosis of 33° became mean 2° immediately after reduction and mean 3° at the final follow-up. The fractured vertebral bodies consolidated in an average period of ten weeks (range 8-14 weeks). The restored disc heights were relatively well maintained throughout the observation period. All paraparetic patients recovered neurologically. There were no postoperative complications. Conclusion : Instrument-aided ligamentotaxis for compression and burst fractures utilizing the short contoured rod derotation technique and the instrumented stabilization of the fractured spine are found to be effective procedures which contribute to the fractured vertebral body consolidation without recollapse and maintain the motion segment function.

Wear particles generated after total joint arthroplasty activate monocyte/macrophages and incite formation of a granulomatous periprosthetic tissue associated with bone loss and implant loosening. This study tested the hypothesis that selective opsonization of orthopedic implant biomaterial wear particles by human serum proteins influences monocyte/macrophage activation. Serum protein binding to metallic, polymeric, and ceramic particles was determined by one-dimensional sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE). Individual proteins bound to particles were subsequently identified using two-dimensional SDS-PAGE, microsequencing techniques, and SWISS-PROT analysis. Effects of selective protein opsonization on particle-induced monocyte/macrophage activation were assessed by quantification of interleukin-1beta, interleukin-6, and tumor necrosis factor-alpha release. Results from one-dimensional gel analyses revealed distinct serum protein-binding patterns specific for each material tested. Two-dimensional gel analysis together with amino acid sequencing of the prominent protein species confirmed the presence of albumin and alpha-1-antitrypsin bound to all particles tested. In contrast to the metallic particles, apolipoprotein was a major species associated with polymeric particles. Opsonization of PMMA particles with purified preparations of each of the identified proteins showed that albumin significantly enhanced particle-induced monocyte/macrophage activation. These data confirm orthopedic biomaterial specific binding of human serum proteins and demonstrate that albumin exacerbates particle-induced monocyte/macrophage activation. Alterations in the chemical and surface properties of orthopedic biomaterials to modulate protein interactions may improve implant longevity.

Fifty-six adults (average age, 38 years) with active tuberculosis of the lumbar and lumbosacral spine were treated conservatively with triple chemotherapy for 12 to 18 months. The minimum followup was 3 years. Three methods of assessments of the chronologic changes of sagittal spinal deformity were used on lateral radiographs of the lumbar spine obtained with the patient standing: deformity, kyphos angles, and total lumbar lordosis. The lumbosacral joint angle was measured for tuberculosis of the lumbosacral joint. The disease healed in all patients with a minimum increase of kyphosis, although in 23 patients there was minimal new involvement of the adjacent vertebral bodies within 6 months of treatment. The pattern of the involved vertebral body collapse in tuberculosis of the lumbar and lumbosacral joints was vertical (telescoping), along a longitudinal axis that minimized the progression of kyphosis. The outcome was judged on the basis of residual kyphosis (British Medical Research Council criteria) and found to be favorable in 96.4% (54 patients). Triple chemotherapy for lumbar and lumbosacral tuberculosis is effective in curing the disease and in minimizing the residual kyphosis through early diagnosis and immediate initiation of chemotherapy. The pattern of vertebral body collapse is the telescoping type, which is the determining factor in minimizing residual spinal deformity.

This study tested whether macrophages respond differently to retrieved titanium-alloy particles than they do to machined titanium-alloy particles and assessed whether pretreatment of machined titanium-alloy particles with human serum would influence macrophage activation and cytokine release in vitro. Human monocyte/macrophages were isolated from normal healthy donors and exposed to increasing concentrations of machined and retrieved titanium-alloy particles. The profile of cytokine release was determined by commercially available ELISA kits. Machined titanium-alloy particles were opsonized with human serum and added to macrophage cultures. Serum protein binding was confirmed by SDS-PAGE analysis. The results showed that machined titanium-alloy particles and retrieved titanium-alloy particles stimulate a similar level of cytokine release when tested at comparable concentrations. Opsonization of the machined particles with human serum increased the macrophage release of cytokines in the first 12 h after exposure compared to nonopsonized particles. At 24 h, the opsonized particles stimulated significantly higher levels of cytokine release, but only at the greatest particle concentrations. This study demonstrates that machined titanium alloy induces a metabolic response in macrophages similar to that of titanium-alloy particles retrieved from failed total hip arthroplasty. In addition, these data show that serum protein binding to orthopedic biomaterial debris alters the macrophage reaction to the particles.

This study was carried out to assess the effect of bone marrow transplant into the 47 ununited fracture sites of the long bones of the extremities in 46 patients on bone healing. Among 46 cases, there were 43 pure fractures; a case of simultaneous ipsilateral femoral and tibial osteotomies for leg lengthening; a case of ununited repositioned cryo-treated proximal half of tibia as a limb salvage; and a case of internal transport of proximal tibia. Among the 43 pure fractures, there were 11 hypertrophic, 30 oligotrophic, and 2 gap nonunions. Bone marrow transplant was performed for any type of the delayed union and nonunion, and was also indicated in the distraction callotasis site of poor osteogenesis. Overall union rate in 43 fractures was 55.8% (24 cases). In two gap nonunions, no callus was formed. Union was obtained in all the 11 hypertrophic nonunions and 13 (46.4%) of the 30 oligotrophic nonunions. The oligotrophic and gap nonunions responded poorly to the marrow transplant. One of the two tibial osteotomy gaps healed with good evidence of endosteal callus formation. In a femoral osteotomy site for lengthening and in an ununited repositioned site of the cryo-treated tibia, there were no visible callus at all. The average time for clinical and radiological unions in the fracture cases were 5 and 7 months on average. In our series, there were no complications, including infection. The results in this series suggest that bone marrow transplant is a good source of callus formation or stimulant in treating the delayed union and hyper- and oligotrophic nonunions of any origin, and also enhances the callus formation at the gap of the early stage of the internal transport.

Sixty-seven patients were treated for Pott's paraplegia: 58 were adults and 9 were children. Sixty-four patients had active disease, and 3 had healed disease. All patients had triple chemotherapy with or without decompression surgery. Thirteen patients, including 9 children, were treated conservatively, whereas 54 patients who met the selection criteria for surgery were treated surgically. Fifty-two patients had anterior radical decompression surgery, and for 14 of them, anterior surgery was preceded by posterior instrumental stabilization surgery. Two patients with healed disease had posterior decompressive corpectomy. There was functional recovery in 60 (89.6%) patients, including 13 who had active disease that was treated conservatively. In 47 of the 54 surgically treated patients there was neurologic recovery, and 2 of these recovered incompletely with some residual spasticity. In the remaining 7 patients, there was no recovery. It took 2 to 6 months for recovery for the patients with conservative treatment, whereas it took

Background: The aim of this study was to evaluate causes of unstable total knee arthroplasty and results of revision surgery. Methods: We retrospectively reviewed 24 knees that underwent a revision arthroplasty for unstable total knee arthroplasty. The average follow-up period was 33.8 months. We classified the instability and analyzed the treatment results according to its cause. Stress radiographs, postoperative component position, and joint level were measured. Clinical outcomes were assessed using the Hospital for Special Surgery (HSS) score and range of motion. Results: Causes of instability included coronal instability with posteromedial polyethylene wear and lateral laxity in 13 knees, coronal instability with posteromedial polyethylene wear in 6 knees and coronal and sagittal instability in 3 knees including post breakage in 1 knee, global instability in 1 knee and flexion instability in 1 knee. Mean preoperative/postoperative varus and valgus angles were 5.8°/3.2° (p = 0.713) and 22.5°/5.6° (p = 0.032). Mean postoperative α, β, γ, δ angle were 5.34°, 89.65°, 2.74°, 6.77°. Mean changes of joint levels were from 14.1 mm to 13.6 mm from fibular head ( p = 0.82). The mean HSS score improved from 53.4 to 89.2 (p = 0.04). The average range of motion was changed from 123° to 122° (p = 0.82). Conclusions: Revision total knee arthroplasty with or without a more constrained prosthesis will be a definite solution for an unstable total knee arthroplasty. The solution according to cause is very important and seems to be helpful to avoid unnecessary over-constrained implant selection in revision surgery for total knee instability.

Stainless steel is one of the most widely used biomaterials for internal fixation devices, but is not used in cementless arthroplasty implants because a stable oxide layer essential for biocompatibility cannot be formed on the surface. We applied a Ti electron beam coating, to form oxide layer on the stainless steel surface. To form a thicker oxide layer, we used a microarc oxidation process on the surface of Ti coated stainless steel. Modification of the surface using Ti electron beam coating and microarc oxidation could improve the ability of stainless steel implants to osseointegrate.The ability of cells to adhere to grit-blasted, titanium-coated, microarc-oxidated stainless steel in vitro was compared with that of two different types of surface modifications, machined and titanium-coated, and microarc-oxidated.We performed energy-dispersive x-ray spectroscopy and scanning electron microscopy investigations to assess the chemical composition and structure of the stainless steel surfaces and cell morphology. The biologic responses of an osteoblastlike cell line (SaOS-2) were examined by measuring proliferation (cell proliferation assay), differentiation (alkaline phosphatase activity), and attraction ability (cell migration assay).Cell proliferation, alkaline phosphatase activity, migration, and adhesion were increased in the grit-blasted, titanium-coated, microarc-oxidated group compared to the two other groups. Osteoblastlike cells on the grit-blasted, titanium-coated, microarc-oxidated surface were strongly adhered, and proliferated well compared to those on the other surfaces.The surface modifications we used (grit blasting, titanium coating, microarc oxidation) enhanced the biocompatibility (proliferation and migration of osteoblastlike cells) of stainless steel.This process is not unique to stainless steel; it can be applied to many metals to improve their biocompatibility, thus allowing a broad range of materials to be used for cementless implants.

The purpose of this study was to determine the mortality rate and factors related to mortality in elderly patients with acute and monotraumatic femoral neck fractures. This study included 241 patients with femoral neck fractures after bipolar hemiarthroplasty. We analyzed the mortality rate and the relationship between postoperative mortality and risk factors, such as age, sex, body mass index, the time to surgery, and the Society of Anesthesiologists' score. The postoperative mortality rate 1 and 3 years after surgery was 11.2% and 19.5%, respectively. There proved to be a relationship between postoperative mortality and age, the time to surgery, and the Society of Anesthesiologists score. We recommend that surgery should not be delayed, and caution should be exercised for the high-risk group patients.

Microarc oxidation (MAO) is a surface treatment that provides nanoporous pits, and thick oxide layers, and incorporates calcium and phosphorus into the coating layer of titanium alloy. We presumed such modification on the surface of titanium alloy by MAO would improve the ability of cementless stems to osseointegrate. We therefore compared the in vitro ability of cells to adhere to MAOed titanium alloy to that of two different types of surface modifications: machined and grit-blasted. We performed energy-dispersive x-ray spectroscopy and scanned electron microscopy investigations to assess the structure and morphology of the surfaces. Biologic and morphologic responses to osteoblast cell lines (SaOS-2) were then examined by measuring cell proliferation, cell differentiation (alkaline phosphatase activity), and alpha v beta 3 integrin. The cell proliferation rate, alkaline phosphatase activity, and cell adhesion in the MAO group increased in comparison to those in the machined and grit-blasted groups. The osteoblast cell lines of the MAO group were also homogeneously spread on the surface, strongly adhered, and well differentiated when compared to the other groups. This method could be a reasonable option for treating the surfaces of titanium alloy for better osseointegration.

The aim of this research was to characterize micro arc oxidized titanium (MAO-Ti), accompanied by biocompatibility test in vivo as well as in vitro in comparison to the different types of surface modification; machined, blasted and plasma spray.

Thirty-two adult patients with dens fractures (30 type II and 2 type III) were treated from 1983 to 2002 at the authors' institutions. The age of the patients ranged from 23 to 58 years. The postoperative follow-up period ranged from 1 to 10 years. The objective of this retrospective study was to evaluate the effectiveness of the osteosynthesis after screw fixation and postoperative bracing. In the 32 cases, 19 patients underwent single screw and 13 underwent double screw fixation. Postoperatively, light head halter traction was applied with the patients in bed for 1 to 4 weeks followed by a halo-vest for 8 to 14 weeks. Fractures healed in 9 weeks on average. There were no cases of delayed union. The overall results were excellent in 26 cases (81.3%), good in 5 (15.6%), and fair in 1 (3.1%) patient (who had a type Il fracture). There were no difference in dens union patterns between those receiving one-screw and two-screw fixation, and there were no complications during or after the operative procedure. Postoperatively there were no restriction of motion in the neck and no residual neck pain. Direct osteosynthesis of the fractured dens with screws is an effective procedure for unstable type II and III fracture of the dens. Postoperative external immobilization with a cervical brace seems to be an important contributing factor to the equal fusion rates in both groups of patients.

Study design: Pott's paraplegic patients with severe spinal deformity were reviewed retrospectively after being treated with chemotherapy and/or decompressive surgery. Objectives: To determine the most appropriate treatment protocol and to predict the prognosis for Pott's paraplegics with severe spinal deformity. Setting: Catholic University of Korea Medical Center and Moon-Kim's Institute of Orthopedic Research, Seoul, Korea from 1971 to 1996. Method: In this study, there were 33 patients (eight children and 25 adults), ranging from 13 to 56 years of age. They developed spinal tuberculosis at the age of 9 years (range, 2–29 years), and remained neurologically symptom free from an average of 16 years (range, 4–27 years). Four adults who responded well to treatment initially suffered relapses of paraplegia. Only six patients had previously received a full course of triple chemotherapy. Seven (two children, five adults) had healed disease, and 26 (six children, 20 adults) had active disease. Eleven cases had frequent drainage from the sinuses. Kyphoscoliosis was found in 11 patients: four children and seven adults. The remaining patients had kyphosis only. Among the 26 patients with active tuberculosis, 10 had triple chemotherapy itself and the rest had additional decompression surgery (10 anterior and six posterior). All seven patients with healed tuberculosis were subjected only to surgery (two anterior and five posterior). Results: In seven patients with healed tuberculosis, surgery did not improve neurologically except in one child patient. In four patients, the severity of paralysis remained unchanged and two patients, deteriorated neurologically after surgery. In six children with active tuberculosis, there were remarkable neurological recoveries by either conservative treatment or surgical decompression. Seven adults with active tuberculosis recovered slowly, improving by one or two Frankel grades (three Frankel C, three D, one E). In 11 out of 13 surgically treated adults with active disease, paralysis that had persisted for less than 3 months gradually improved by one or two Frankel grades. One Frankel A and one Frankel B paraplegic patients who had paralysis that had lasted through 6 months did not recover after surgery. Conclusion: The neurological recovery of Pott's paraplegics with severe spinal deformity resulted in three different outcomes: (1) severe deformity is different from moderate and mild deformities; (2) patients with healed tuberculosis had poorer prognosis than patients with active tuberculosis; (3) children had better prognosis than adults. Furthermore, patients with paralysis persisting over 6 months did not recover neurologically after surgery.

Purpose: The purpose of this study is to evaluate the clinical and radiologic results after high flexion Lospa (Corentec Inc.) and Scorpio NRG (Stryker Inc.) total knee arthroplasty. Materials and Methods: We prospectively compared 205 knees in 128 patients who underwent arthroplasty using Lospa (group A) and 164 knees in 102 patients who underwent arthroplasty using Scorpio NRG (group B) from September 2010 to March 2012 at Department of Orthopaedic Surgery, Sun General Hospital (Daejeon, Korea). Mean follow-up period was 23 months in group A and 24 months in group B. The radiologic analysis included the change of mechanical axis deviation and femoro-tibial angle, implant position (α, β, γ, δ), and patellar tilt. The clinical results were evaluated according to hospital for special surgery (HSS), knee society score (KSS), and range of motion. Results: Mechanical axis deviations were change in varus from 34.8 mm to 2.6 mm (p=0.02) in group A, and change in varus from 34.3 mm to 3.1 mm (p=0.04) in group B; no statistically significant difference was observed between them (p=0.13). Femoro-tibial angles were varus 4.3 to valgus 6.6 (p=0.02) in group A, and varus 4.4 to valgus 6.5 (p=0.03) in group B; no significant difference was observed between them (p=0.25). No significant difference in implant position was observed between the two groups (p=0.25 in α, p=0.17 in β, p=0.12 in γ, p=0.17 in δ). Mean HSS improved from 48.5 to 93.6 (p=0.02) in group A, and from 41.4 to 94.4 (p=0.01) in group B. Conclusion: Lospa total knee arthroplasty showed excellent early radiologic, clinical results and no statistically significant difference in the results was observed between Lospa and Scorpio NRG.

Study design Thirty-nine adults and five children with active spinal tuberculosis and resulting kyphosis of the dorsal and lumbar spine who had combined posterior instrumentation and anterior interbody fusion were observed to determine whether the corrected spinal deformity could be maintained until solid fusion. Objective To evaluate the effectiveness of the combined two-stage procedure for treating kyphosis due to active spinal tuberculosis. Summary of background data Until 1970, with all methods of treatment, kyphosis due to active spinal tuberculosis tended to increase during therapy. Most of the patients treated with these methods were not happy with this residual kyphosis, even though their disease was arrested or cured. Kyphosis became their main concern regarding further treatment. Methods A combined two-stage procedure, under the cover of 18 months of triple chemotherapy, was used for all patients. For posterior stabilization, the Harrington distraction system, Rush nails or Steinmann pins and wires, and Texas Scottish Rite Hospital instrumentation were used. The diagnosis of successful interbody fusion was made if there was no loss of correction, no graft resorption or graft bed resorption, and if there was visible graft remodeling, such as trabeculation between the graft beds and graft and the graft hypertrophy. Results In the 39 adults, average preoperative, immediate postoperative, and last follow-up kyphosis angles were 37 degrees, 16 degrees, and 18 degrees, respectively. In four children, the average preoperative, immediate postoperative, and last follow-up kyphosis angles were 55 degrees, 28 degrees, and 31 degrees, respectively. The loss of correction did not exceed 3 degrees. For one-segment spondylodesis, the average fusion times were 4 months in adults and 3.5 months in children. For a two-segment fusion, the average fusion times were 6 months in adults and 6.3 months in children. Conclusion Posterior instrumental stabilization and anterior interbody fusion were found helpful in arresting the disease early, providing early fusion, preventing progression of kyphosis, and correcting the kyphosis.

목적: 고령의 환자들에서 불안정한 대퇴골 전자간 골절의 치료로써 무시멘트 고관절 인공관절 전치 환술은 대퇴골 전자간 골절 치료로써 금속판이나 금속정 등의 내고정술 이외의 또 하나의 수술법으로 생각되고 있으며 대전자부 골편의 유합이 중요한 관심사 중의 하나이다. 이에 저자들은 이중 강선, 이중 고리, 8자 고정술을 이용한 대전자부 골편의 고정에 있어서 고정 방법에 따른 임상 및 방사선학적 결과를 발표하고자 한다. 대상 및 방법: 2010년 4월부터 2012년 2월까지 고관절의 불안정한 전자간 골절로 무시멘트 인공관절 전치환술 및 직경 1.0 mm의 이중 강선, 이중 고리, 8자 고정술을 시행 받은 20명 20예를 대상으로 하였다. 평균 연령은 71.1세(57-86세)였고 남자가 9명, 여자가 11명이었으며, 평균 추적관찰 기간은 6개월이었다. 술 후 환자들의 상태를 Harris hip score를 이용하여 평가하였다. 결과: 본 연구에서 수술 시간은 평균 95분, 수술 시 실혈량은 평균 800 cc였다. 최종 추시에서 Harris hip score는 평균 92.7점이었으며, 15예에서 보행거리의 감소없이 일상생활이 가능하였다. 술 후 고관절 탈구가 발생한 것은 1예였고, 고정 강선의 파손은 1예였다. 욕창과 심부정맥 혈전증 및 폐색전증이 발생한 사례는 없었다. 또한, 방사선학적으로 모든 사례에서 대퇴 주대는 해리 없이 잘 유지되었고, 13예에서 골절주위의 골생성을 확인할 수 있었으며, 골용해 소견을 보인 예는 없었다. 결론: 불안정성 대전자 골절 치료시 무시멘트형 인공고관절 치환술을 시행할 때 대전자부 골편을 고정하는데 이중강선, 이중고리, 8자 고정술을 이용한 강선 결박술이 유용한 방법으로 사료된다. 그러나 정복 방법의 개발과 함께 장기간의 추시결과에 대한 연구가 더욱 필요 할 것으로 사료된다.

대표적으로 측방 또는 전측방 도달법과 후방 도달법으 로 분류되는 인공 고관절 전치환 술의 수술적 도달법은 도 달의 용이성, 수술시간의 단축, 수술 시 출혈의 감소, 술 후 합병 발생 등의 다양한 조건을 고려하여 술자의 선호도 를 선택한다. 본 논문에서는 국내 및 미국 등의 여러 술자 들에 의하여 널리 사용되고 있는 후방 도달법에 대한 요 약을 통해 장단점을 설명하고, 이를 개선하기 위해 최근 김 등에 의해 소개된 바 있는 고관절 주위 단외회전근 (short external rotator)의 절단을 최소화하여 술후 관절 탈구 등의 합병증을 현저히 감소시켰다고 보고한 수정 후 방 도달법을 소개하고자 한다. 후방 도달 법은 술기가 용 이하고 수술시 출혈이 적고 감염이나 고관절 주위 화골성 근염 발생이나 외전근 손상, 감염률, 전색 등의 합병이 다 른 도달법에 비하여 적은 큰 장점을 가지고 있어 많은 술 자들이 선호하고 있는 도달 방법이지만 비구 노출이 제한적이고 좌골신경 손상의 위험이 있으며 특히 탈구율 0.3~2%로 보고 되는 측방 도달법에 비하여 술 후 관절 탈 구의 위험이 2~7%로 다소 증가한다는 단점을 가지고 있 는 것이 사실이다. 따라서 여러 장점과 더불어 관절 탈구의 위험을 현저히 감소 시킬 수 있다면 후방 도달법은 훨씬 더 많은 술자들이 가장 선호하는 수술 도달법이 될 것이며 본 논문에 소개하는 수정 후방 도달법은 하나의 좋 은 대안이 될 것으로 사료된다.

Various internal fixation devices have been developed and used clinically to stabilize unstable spines [1–3], regardless of whether the cause is congenital or acquired. The more popular posterior fixation devices are pedicular fixation types, such as the Zielke, Cotrel-Dubousset (C–D), Puno-Winter, Rogozinski, modular segmental spinal instrumentation (MOSS), and Graf systems. All these devices have been known to provide secure fixation if they are properly applied, though each device has its disadvantages.

The objective of this study is to report on a case of a huge epidermoid cyst in the conus medullaris and cauda equina in a 43 year-old lady with the characteristic MRI and histologic findings. She suffered from low back pain, hypoesthesia around the anus and urinary incontinence for over 20 years. Since 15 years previously, she gradually developed right foot drop and muscle atrophy. She underwent surgery and unfortunately, she developed complete paralysis below T12 after complete tumor excision. At postoperative 4 weeks, evidence of partial neurological recovery down to the L3 roots was observed, but as yet there has been no further neurological recovery. Although total surgical excision is thought to be the only radical treatment, we recommend partial tumor excision to avoid damaging the spinal cord and cauda equina during the surgical procedure, than the radical excision, because this cyst is a very slowly growing benign tumor.

A Brodie's abscess is a localized form of subacute or chronic osteomyelitis that occurs most often in the long bones of the lower extremities of young adults. Before physeal closure, it most commonly occurs in the metaphysis. In adults, the metaphyseal-epiphyseal area is involved. Rarely Brodie's abscess traverses the open growth plate, affecting the epiphysis, although such extension does not commonly result in growth disturbance. We reported a subacute osteomyelitis that traversed the physis of the distal tibia in a child, which was treated by surgical curettage and intravenous antibiotics.

The outcome of total joint arthroplasty is determined by biological events at the bone-implant interface. Macrophages phagocytose implant or wear debris at the interface and release proinflammatory mediators such as interleukins 1 and 6, tumor necrosis factor-alpha, and prostaglandin E2. These mediators are thought to contribute to the resorption of periprosthetic bone. Previous studies of tissues harvested from the bone-implant interface of failed orthopaedic implants demonstrated a possible role for two other cytokines, granulocyte-macrophage colony-stimulating factor and interleukin-4. The present study examined the effects of in vitro challenge with polymethylmethacrylate particles on the expression of granulocyte-macrophage colony-stimulating factor by primary human monocytes/macrophages and the role of interleukin-4 in regulating this expression. The polymethylmethacrylate particles caused a dose-dependent release of granulocyte-macrophage colony-stimulating factor at 48 hours. This release was accompanied by increased expression of interleukins 6 and 1beta and tumor necrosis factor-alpha. Release of the lysosomal enzyme hexosaminidase also increased in response to the particles. Interleukin-4 inhibited the expression of granulocyte-macrophage colony-stimulating factor, interleukin-6, and tumor necrosis factor-alpha at 48 hours in a dose-dependent manner. The data presented in this study confirm the hypothesis that interleukin-4 downregulates particle-induced activation of macrophages, as demonstrated by the decreased release of proinflammatory mediators.