Distal Radius Fractures Using Acu-Loc Volar Platejsms.sch.ac.kr/upload/pdf/SMS_17_1_1_6.pdf · ·...
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http://jsms.sch.ac.kr 1 Distal Radius Fractures Using Acu-Loc Volar Plate Kheng Mab 1 , Byung Sung Kim 2 , Eung Ha Kim 2 , Soo Jae Yim 2 , Kyoung Dae Min 2 , Young Koo Lee 2 , Sang Hyuk Lee 2 1 Department of Orthopaedic Surgery, Chhlong Referal Hospital, Kratie, Cambodia; 2 Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea Objective: We determined the radiographic outcome of distal radius fractures with Acu-loc volar plate. Methods: Forty-one patients were recruited between August 2009 and September 2010. There were 10 males and 31 females, with a mean age 61.2. Fractures were radiologically classification the Frykman. Fifteen fractures were group 8, eight were group 7, ten were group 6, four were group 5 and four were group 3. Distal part of the fractures was dorsally inclined in 37 wrists and inclined to volar side in four wrists. Lateral and anteroposterior radiographs taken after operated day, the fracture were compared with radio- graphs of the injured wrist and the differences in palmar tilt, ulnar variance; radial height; radial shift and radial inclination were mea- sured. Results: There was significant improvement in the measurements of radial height, radial inclination, volar tilt, ulnar variance and ra- dial shift postoperatively. The radial height improved from an average of 8.5 mm (range, 3 to15 mm) to 11.0 mm (range, 8 to15 mm), the radial inclination improved from an average of 21.5 degree (range, 10 to 40 degree) to 28.1 degree (range, 19 to 44 degree), the palma tilt improved from an average of 12.9 degree (range, 6 to 22 degree) to 17.2 degree (range, 7 to 27 degree), the ulnar vari- ance improved from an average of -2.3 mm (range, -6 to 4 mm) to 1 mm (range, -3 to 7 mm) and the radial shift improved from an average of 18.7 mm (range, 15 to 26 mm) to 17.3 mm (range, 12 to 21 mm). Conclusion: Acu-loc volar plate is a safe and effective device. Keywords: Distal radius fractures; Acu-loc volar plate INTRODUCTION Distal radius fractures are the most frequently seen upper ex- tremity fractures. Open reduction and internal fixation of distal radial fractures with an angular stable locking plate applied volar- ly has gained vast popularity recently [1-4]. It provides a stable fix- ation of osteoporotic bones, leading to anatomical restoration of the articular surface and extra articular alignment [5]. It also facil- itates immediate free mobilisation of the wrist joint. However, there are few systematic studies in the literature evaluating the efficacy of locking plate fixation using objective and subjective assessments. We have performed a prospective case study in Soonchunhyang University Hospital to document the outcomes of open reduction and internal fixation of distal radial fractures over a one year peri- od. Today, open positioning and plate fixation are the widely rec- ognized surgical methods [6,7]. Locked plates are in the progress of replacing conventional support plates. While facilitating the positioning, those anatomical plates with screw-plate interlocking feature have more biomechanical strength against forces applied on the fracture surfaces [8,9]. Because of their biomechanical strength, locked plates are preferred in osteoporotic and/or multiple frac- tures [6,7,10]. However, there is no consensus neither about how to approach to distal radius nor thepositioning of the plate. During the recent years, volar approach has become more popular [8,11- 13]. Our objective is to study the efficacy of this method of fixation by assessing its ability to maintain radiographic reduction. MATERIALS AND METHODS Between August 2009 and September 2010, we treated and pro- Soonchunhyang Medical Science 17(1):1-6, June 2011 pISSN: 2233-4289 I eISSN: 2233-4297 ORIGINAL ARTICLE Correspondence to: Byung Sung Kim Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, 1174 Jung-dong, Wonmi-gu, Bucheon 420-767, Korea Tel: +82-32-621-5262, Fax: +82-32-621-5016, E-mail: [email protected] Received: Jan 25, 2011 / Accepted after revision: Jun 14, 2011 © 2011 Soonchunhyang Medical Research Institute This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/).
Transcript of Distal Radius Fractures Using Acu-Loc Volar Platejsms.sch.ac.kr/upload/pdf/SMS_17_1_1_6.pdf · ·...
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Distal Radius Fractures Using Acu-Loc Volar PlateKheng Mab1, Byung Sung Kim2, Eung Ha Kim2, Soo Jae Yim2, Kyoung Dae Min2, Young Koo Lee2, Sang Hyuk Lee2
1Department of Orthopaedic Surgery, Chhlong Referal Hospital, Kratie, Cambodia; 2Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
Objective: We determined the radiographic outcome of distal radius fractures with Acu-loc volar plate. Methods: Forty-one patients were recruited between August 2009 and September 2010. There were 10 males and 31 females, with a mean age 61.2. Fractures were radiologically classification the Frykman. Fifteen fractures were group 8, eight were group 7, ten were group 6, four were group 5 and four were group 3. Distal part of the fractures was dorsally inclined in 37 wrists and inclined to volar side in four wrists. Lateral and anteroposterior radiographs taken after operated day, the fracture were compared with radio-graphs of the injured wrist and the differences in palmar tilt, ulnar variance; radial height; radial shift and radial inclination were mea-sured. Results: There was significant improvement in the measurements of radial height, radial inclination, volar tilt, ulnar variance and ra-dial shift postoperatively. The radial height improved from an average of 8.5 mm (range, 3 to15 mm) to 11.0 mm (range, 8 to15 mm), the radial inclination improved from an average of 21.5 degree (range, 10 to 40 degree) to 28.1 degree (range, 19 to 44 degree), the palma tilt improved from an average of 12.9 degree (range, 6 to 22 degree) to 17.2 degree (range, 7 to 27 degree), the ulnar vari-ance improved from an average of -2.3 mm (range, -6 to 4 mm) to 1 mm (range, -3 to 7 mm) and the radial shift improved from an average of 18.7 mm (range, 15 to 26 mm) to 17.3 mm (range, 12 to 21 mm). Conclusion: Acu-loc volar plate is a safe and effective device.
Keywords: Distal radius fractures; Acu-loc volar plate
INTRODUCTIONDistalradiusfracturesarethemostfrequentlyseenupperex-
tremityfractures.Openreductionandinternalfixationofdistalradialfractureswithanangularstablelockingplateappliedvolar-lyhasgainedvastpopularityrecently[1-4].Itprovidesastablefix-ationofosteoporoticbones,leadingtoanatomicalrestorationofthearticularsurfaceandextraarticularalignment[5].Italsofacil-itatesimmediatefreemobilisationofthewristjoint.However,therearefewsystematicstudiesintheliteratureevaluatingtheefficacyoflockingplatefixationusingobjectiveandsubjectiveassessments.
WehaveperformedaprospectivecasestudyinSoonchunhyangUniversityHospitaltodocumenttheoutcomesofopenreductionandinternalfixationofdistalradialfracturesoveraoneyearperi-od.Today,openpositioningandplatefixationarethewidelyrec-
ognizedsurgicalmethods[6,7].Lockedplatesareintheprogressofreplacingconventionalsupportplates.Whilefacilitatingthepositioning,thoseanatomicalplateswithscrew-plateinterlockingfeaturehavemorebiomechanicalstrengthagainstforcesappliedonthefracturesurfaces[8,9].Becauseoftheirbiomechanicalstrength,lockedplatesarepreferredinosteoporoticand/ormultiplefrac-tures[6,7,10].However,thereisnoconsensusneitherabouthowtoapproachtodistalradiusnorthepositioningoftheplate.Duringtherecentyears,volarapproachhasbecomemorepopular[8,11-13].Ourobjectiveistostudytheefficacyofthismethodoffixationbyassessingitsabilitytomaintainradiographicreduction.
MATERIALS AND METHODS
BetweenAugust2009andSeptember2010,wetreatedandpro-
Soonchunhyang Medical Science 17(1):1-6, June 2011 pISSN: 2233-4289 I eISSN: 2233-4297
ORIGINAL ARTICLE
Correspondence to: Byung Sung KimDepartment of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, 1174 Jung-dong, Wonmi-gu, Bucheon 420-767, KoreaTel: +82-32-621-5262, Fax: +82-32-621-5016, E-mail: [email protected]: Jan 25, 2011 / Accepted after revision: Jun 14, 2011
© 2011 Soonchunhyang Medical Research InstituteThis is an Open Access article distributed under the terms of the
Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/).
Mab K, et al. • Distal Radius Fractures Using Acu-Loc Volar Plate
Soonchunhyang Medical Science 17(1):1-62 http://jsms.sch.ac.kr
spectivelyevaluatedtheoutcomesofoperativetreatmentof41pa-tientswithdistalradiusfracturesusingAcu-locvolarplate(Fig.1).Ofthe41patients,10weremenand31werewomen,withmeanageof61.22years(range,34to81years).Twenty-twofracturesoc-curredontheleftsideandnineteenfracturesontherightside.Mostofthecauseofinjurywasslippeddownandroadtrafficaccidentinonepatient.FractureswereradiologicallyclassificationtheFryk-man[14].Fifteenfracturesweregroup8(36.58%),eightweregroup7(19.51%),tenweregroup6(24.39%),fourweregroup5(9.75%)andfourweregroup3(9.75%).Distalpartofthefractureswasdor-sallyinclinedin37wrists(90.24%)andinclinedtovolarsidein4wrists(9.75%)(Table1).
Lateralandanteroposteriorradiographstakenafteroperatedday,thefracturewerecomparedwithradiographsoftheinjured
wrist(Fig.2)andthedifferencesinpalmartilt,ulnarvariance;ra-dialheight;radialshiftandradialinclinationweremeasured.Pal-martiltistheanglebetweenalineperpendiculartothecentralaxisoftheradiusandalineconnectingthedorsalandpalmarmar-ginsofthearticularsurfaceofthedistalradiusonthelateralview.Itisdesignatedaspositiveifthetiltisinavolardirectionandnega-
Fig. 1. Acu-loc volar plate (Acumed).
Table 1. Clinical data for 41 patients with distal radius fractures treated by opened reduction using Acu-loc volar plate
Variable Value
Type of fracture (Frykman classification) Type 8 15 (36.58)Type 7 8 (19.51)Type 6 10 (24.39)Type 5 4 (9.75)Type 3 4 (9.75)
SexFemale 31 (75.60)Male 10 (24.39)
Side of fractureRight 19 (46.34)Left 22 (53.65)
Age (yr) 61.22 (34-81)Displace of fracture
Volar 4 (9.75)Dorsally 37 (90.24)
Values are presented as number (%) or mean (range).
Fig. 2. Lateral and anteroposterior radiographs of the injured wrist type 8 according to Frykman and after operated by using Acu-loc volar plate.
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tiveifthereisadorsaltilt.Ulnarvarianceandradialinclinationweremeasuredonanteroposteriorradiographs.Ulnarvarianceisthedistanceinmillimetersbetweentwoparallellinesperpendicu-lartothecentralaxisoftheradius,onelinepassingthroughthedistalarticularsurfaceoftheulnaandtheotherthroughtheme-dialarticularsurfaceofthedistalradius.Ulnarvarianceisnega-tivewhentheulnararticularsurfaceismoreproximalwithrespecttotheradialarticularsurfaceandpositiveifitismoredistal.Thisisanaccurateindicationofthedegreeofradialshortening.Radialinclinationistheanglebetweenalineperpendiculartothecentralaxisoftheradiusandthelineconnectingtheradialandulnarlim-itsofthearticularsurfaceofthedistalradius.Radialheightismea-suredonananteroposterior(AP)radiograph.Itisthedistancebe-tweentwolinesperpendiculartothelongaxisofthedistalradius;thefirstonegoingthroughthetipofthestyloidprocess,thesec-ondoneatthelevelofthearticularsurfaceoftheulnarhead.Ra-dialwidthisdefinedasthedistancebetweentwolinesparalleltothelongitudinalaxis,onegoingthroughthemostlateraltipofthestyloidprocessandonegoingthroughthecentreoftheradiusonanAPradiograph.Anincreasedradialwidthascomparedwiththenon-injuredsideisastrongindicationforrotationalmalalign-mentandassuchapredictorofbadfunctionaloutcome.Postop-erativeradiographsweretakenateveryvisit.Thesewerescheduledtheweeksaftersurgery,at2,at4to6weeksaftersurgery,atmonth-lyintervalsasneeded.
Themeanpre-surgicalperiodwas7.82days(range,2to26days).Theoperatingtimewas41.09minutes(range,20to65minutes),andthehospitalstaywas4.92days(range,2to10days).
1. Surgical Technique
Surgerywasperformedundergeneralanesthesiawithanarmtourniquet.Thepatient’sforearmissupinatedtoexposethesurgi-calsite.Tomaximizeexposure,atowelispositionedunderthewristplacingitinextension.Makealongitudinalincisionapproximate-lysixcentimetersinlengthjustradialtotheflexorcarpiradialistendontoprotectagainstinjurytothepalmarcutaneousbranchofthemediannerve.Thetendonsheathisopenedandthetendonisretractedradiallytoprotecttheradialartery.Theflexorpollicuslongusisidentifiedbypassiveflexion/extensionofthethumbin-terphalangealjointandisretractedulnarlytoprotectthemediannerve.Next,thepronatorquadratusisidentifiedbyitstransversefibersandisreleasedradialtoulnartoexposethefracturesite.Thefractureisreducedandevaluatedunderfluoroscopy.Thebrachio-
radialismayneedtobereleasedfromitsinsertionontheradialstyloidtofacilitatereductionandvisualizationofthefracture.Theplateisdesignedtositalongthedistalaspectoftheradiustosup-portthevolararticularfracturefragments.Oncetheappropriateplateisselected,attachthecorrespondingtargetingguideusingthesetscrew(80-0038).Thismaybedoneonthebacktablepriortoinsertion.Theplate’spositionisthensecuredproximallywitha.045″K-wireanddistallywitha.054″K-wire.Ifthetargetingguideisnotalreadyattachedtotheplate,youwouldthenslidetheguideoverthedistalK-wireandintoposition.Anothermethodistose-curetheplatetothebonewithacorticalscrewproximallyandthenattachthetargetingguide.Placethefirst3.5mmnon-lockingcor-ticalscrewthroughtheslotintheplate.Thepositionoftheplaterelativetothearticularsurfacecanthenbefinetunedbyslidingtheplateproximalordistalunderfluoroscopy.Usingthe2.8mmdrill(MS-DC28)andthedrillguide(PL-2018),drillthroughthefarcortex.Drilldepthismeasuredwiththedepthgauge(MS-9020).NotethatifprovisionalK-wiresareinplace,theymayinterferewithdrillingandscrewinsertion.Inserttheappropriatesilver3.5mmnon-lockingscrew(CO-3xx0),takingcarethatthescrewistheproperlength.Thescrewmayneedtobedownsizedaftertheplatehasbeenreduceddowntothebone.Toassessthepositionofthedistallockingscrewsrelativetothearticularsurfaceandthedor-sumoftheradius,a.054″K-wiremaybeplacedthroughthedistalholesonthetargetingguideandplate.Thefracturereduction,plateposition,andthelocationoftheK-wirerelativetothejointisas-sessedunderfluoroscopy.IfthedistalK-wiresdonotpenetratethejoint,thedistal2.3mmscrewswillnoteither.Careshouldbetak-ennottoanglethedistalK-wires.Targetoneofthefourdistalholesfirst.Insertthedrillguide(MS-DG23)intooneoftheholes,fol-lowedbythe2.0mmdrill(MS-DCR20).Screwlengthismeasuredbyusingthelasermarkonthedrillandthescaleonthedrillguide.Asanalternative,thedepthprobe(MS-DRPB)maybeusedbyhookingthefarcortexandmeasuringwiththelasermarkontheprobe.Therearethreetypesof2.3mmscrewsthatcanbeusedinanyoftheeightdistalholes:fully-threadedlockingscrews(gold),smoothlockingpegs(bronze)andnon-togglingscrews(silver).All2.3mmscrewsareinsertedusingthe1.5mmdrivertip(HPC-0015),sleeve(MS-SS23)anddriverhandle(MS-2210).Itisatthediscretionofthesurgeonwhentousethethreadedlockingscrews,thesmoothlockingpegs,andthenon-toggling(non-locking)screws.Thethreadpitchonthethreadedlockingscrewisthesamefromthetiptotheheadminimizingthe“differentialpitcheffect”asthe
Mab K, et al. • Distal Radius Fractures Using Acu-Loc Volar Plate
Soonchunhyang Medical Science 17(1):1-64 http://jsms.sch.ac.kr
screwisseatedintotheplate.Alleightdistalholesacceptthethreedifferentscrewdesigns.Theradialstyloidscrewsaredesignedspe-cificallytotargetandsupporttheradialstyloidfragmentatanglesof41and53degreesfromtheplate.AC-Armoverlayisavailableinthesystemtodeterminethetrajectoryofthedistal/radialscrewpriortoscrewinsertion.TheoverlayisusedwithanAPviewofthedistalradius.Thetworadialstyloidscrewsareapproachedfromthebackofthetargetingguide.Usingthedualslotonthebackoftheguide,thedistal/radialscrewistargetedbyinsertingthedrillguidetotheradialsideofthedualslot.Themoreproximal/ulnarscrewistargetedbyinsertingthedrillguidetotheulnarsideofthedualslot.Bothradialstyloidscrewsshouldbedrilledthroughthetargetingguide.Removetheguidetomeasureandinsertthescrews.Theguideisremovedtoincreasevisualizationofthedrillholeswheninsertingthescrews.Withthetargetingguideinplace,itmaybedifficulttoremovetheradialstyloidscrewsifadifferentsizescrewisneeded.Ifresizingisnecessary,removetheguideandthescrew,measurewiththedepthgaugeandinserttheproperscrew.Selectoneofthetworemainingproximalholesandinsertthethreadeddrillguide(MS-LDG35).Drillwiththe2.8mmdrill(MS-DC28)andmeasurewiththedepthgauge(MS-9020).Inserttheproperlength3.5mmlightbluelockingscrew(COL-3XX0)usingthe2.5mmdrivertip(HPC-0025),sleeve(MS-SS35)anddriverhandle(MS-3200),takingcarethatthescrewdoesnotexitthebonedorsally.Usingthesameprocess,drillandplacethefinallockingscrew.Followingthoroughradiographicevaluation,checkalignmentandrotation,thenclose.Startimmediatefingerrangeofmotionandforearmrotationpost-operation.Allowearlyfunc-tionaluseofthehandforlightadultdailylivings.Supportthewristaccordingtobonequalityandstability.
RESULTS
Therewerethirty-onefemalesandtenmaleswithameanageof61.22years(range,34to81years).Twenty-twofracturesoccurredontheleftsideandnineteenfracturesontherightside.Mostof
thecauseofinjurywasslippeddownandroadtrafficaccidentinonepatient.FractureswereradiologicallyclassificationtheFryk-man.Fifteenfracturesweregroup8(36.58%),eightweregroup7(19.51%),tenweregroup6(24,39%),fourweregroup5(9.75%)andfourweregroup3(9.75%).Themeanpre-surgicalperiodwas7.82days(range,2to26days).Theoperatingtimewas41.09minutes(range,20to65minutes),andthehospitalstaywas4.92days(ran-ge,2to10days).Therewasasignificantimprovementinthemea-surementofpalmartilt,ulnarvariance;radialheight;radialshiftandradialinclinationafteropenedreductionandinternalfixationusingAcu-locvolarplate.Themeasurementofthetwointervalswerestationary.Theradialheightimprovedfromanaverageof8.56mm(range,3to15mm)to11.04mm(range,8to15mm),theradialinclinationimprovedfromanaverageof21.53degree(range,10to40degree)to28.12degree(range,19to44degree),thepalmatiltimprovedfromanaverageof12.92degree(range,6to22de-gree)to17.24degree(range,7to27degree),theulnarvarianceim-provedfromanaverageof-2.31mm(range,-6to4mm)to1mm(range,-3to7mm)andtheradialshiftimprovedfromanaverageof18.78mm(range,15to26mm)to17.36mm(range,12to21mm)(Table2).
DISCUSSION
Usefulparameterstodeterminewhethertheanatomyofafrac-tureindicatesinstabilityandwillneedsurgicalstabilizationare:excessivecomminutioninitiallossof15mmormoreofradialleng-thinitialdorsaltiltof20°ormore[15,16].Surgicalinterventionbe-comesanimportantconsiderationwhenanacceptablereductioncannotbeeitherachievedormaintainedwithcastimmobiliza-tion.Post-operativeradiographicmeasurementsdemonstratethatjointcongruitywasrestoredtonormalinall.Theextra-articularparametersincludingpalmartilt,radialheightandinclinationwereimproveduniformly.Theseradiographicimprovementsweremaintainedinall.
Lockedplatesthatarewidelyusedprovidesuccessfulresultses-
Table 2. Distal radial measurements as determined by radiography at the two intervals (pre-operative, post-operative)
Measurement interval Radial height (mm) Radial inclination (degree) Volar tilt (degree) Ulnar variance (mm) Radial shift (mm)
Pre-operative 8.56 (2.61) 21.54 (6.94) 13.93 (4.18) -2.34 (2.60) 18.78 (2.34)Post-operative 11.05 (1.79) 28.12 (5.37) 17.24 (4.56) 1 (2.24) 17.37 (1.74)
Values are presented as mean (SD).Differences between pre-operative and post-operative for radial height, radial inclination, volar tilt, ulnar variance and radial shift were significant.
Distal Radius Fractures Using Acu-Loc Volar Plate • Mab K, et al.
Soonchunhyang Medical Science 17(1):1-6 http://jsms.sch.ac.kr 5
peciallyforthetreatmentofintraarticularunstablefracturesofdistalradius[1,6,10,13,17].Thismethod,whichiseffectiveinana-tomicrealignment,allowsearlyjointmotion,owingtoitsfixationstrength[18,19].Closeplacementtojointinterfaceandscrewingcapabilityindifferentordersareitsbiomechanicalsuperiorities.Volarapproachprovidesbothaccesswithminimalsurgicaltrau-maondistalradiusandfixationwithabetteradaptationtosur-roundingtissues[6-8,10,12,17,20,21].Inthesubjectsofourstudy,asuccessfulanatomicalignmentwasacquiredwithvolarapproach,regardlessofthedirectionoffractureangulation.Theabilityoflockedscrewstoresisttheloadsinthedistalradiushasbeenshowninseveralstudiesthatcomparedtheaverageconstructfailureloadofseveralplatesonthemarket.Acumedsimulatedthetestingme-thodsusedinthesestudiestodeterminethefailureloadoftheAcu-locplate.ThefailureloadoftheAcu-locplatewascomparedwiththeresultsoftworecentbiomechanicalstudies.Inthefirststudy,thebiomechanicalpropertiesofsixdorsalandvolarplatedesignswerecompared[22].Averageconstructfailureloadofthesixplateswasmeasured.Thestudystatedthatanestimated250Nistheamo-untofforcethatisappliedtothewristjointintheflexeddigitposi-tion.TestingconductedontheAcu-locplateresultedinacon-structloadof2,400Nwithoutfailure.ThisshowsthattheAcu-loccanwithstandnearly9Xtheforcethatisappliedtothewristdur-ingpatientrehabilitation.Allplates,includingtheAcu-loc,ex-ceededthis250Nbenchmark.Thesixplatesinthestudyfailedinasimilarfashion.Bendingoftheplatesoccurredwithoutscrewloosening.TheAcu-loc’sbiomechanicalresultswerealsocom-paredtotheresultsofasecondbiomechanicalstudy[23].Inthisstudy,theaverageconstructfailureloadofthreevolarplatede-signswerecompared.Screwlooseningandbendingoccurredatthepointoffailureforthethreeplatesstudied.
Inconclusion,webelievethat,ourstudywouldprovideaddi-tionalknowledgeandexperienceaboutthetreatmentofdistalra-diusfractures.Asaresult,Acu-locvolarplatesareeffectiveinthecorrectionandmaintenanceofdistalradiusanatomy.Byusingthoseplates,jointmotionanddailyfunctioningisrecoveredinashortertime.
ACKNOWLEDGEMENTS
Ishouldliketoacknowledgemygratitude,withmywarmestre-gard,toprofessorWonHanShin,formerdirectorofSoonchunhy-angUniversityBucheonHospital,Neurosurgicalprofessorand
professorDeaShikHongdirectorofSoonchunhyangUniversityBucheonHospitalwhosehelp,encouragementandstimulatingsuggestionshavehelpedmegreatlyaswellasallCambodiandoc-torsstudyinghereinalltimeofresearchandwritingofthispre-sentation.
Iwouldliketoexpressmygratitudetothosewhogivenmetheopportunitiestocompletethispresentation:myspecialthanksgotoprofessorEungHaKim,professorSooJaeYim,professorKyo-ungDaeMin,professorByungSungKim,YoungKooLee,andSangHyukLee.
IwanttothanktheDepartmentofOrthopedicSurgeryofSoon-chunhyang,Bucheon,forgivingmepermissiontocommencethispresentation,todothenecessaryresearchworkandtousedepart-mentdata.
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