Metastatic tumors involving the spine cause severe pain and paraplegia. Vertebral body collapse results in spinal collapse results in spinal instability. In order to promote stability and improve pain, anterior fusion with bone cement and posterior fusion with instruments were used. Retrospective study was carried out of 16 cases of the metastatic tumor of the spine in Ewha Womans University Hospital Orthopedic Surgical dept. from Jan. 1982 to Dec. 1988. We have analyzed the results of treatment and obtained following conclusions.

The results were as follows :

1) Of the 16 patients, the ratio of men to women approximately 3:5 and the high incidence was over 5th. decades.

2) According to tumor classification, reproductive tract tumor was in 4 cases(25%), gastric, lung and hepato-biliary tumors in 2 cases each(12%), thyroid tumor in 1 case(7%) unknown origin in 5 cases(31%).

3) The thoracic spine commonly involved in 12 cases(75%).

4) Anterior fusion with bone cement was in 11 cases and posterior fusion with instrument in 4 cases. Both anterior and posterior fusion was in 1 case.

5) In functional results, the ambulation was achieved in 14 cases postoperatively, in 12 cases at 6 months, and 10 cases finally.

6) The surgical treatment was valuable, because the good results were appeared in 62.5% finally with loss of pain.

The treatment of herniated lumbar disc has been a challenging problem in spite of various methods of treatments such as conservative, chymopapain injection, percutaneous automated nucleotome method and surgical removeal of discs. Among the above listed treatment, Smith and Brown reported the clinical experience by way of intradiscal injection of chymopapain with beneficial result and clinical reports followed thereafter.

On the other hand, the serious neural adverse effects were reported by Smith laboratories since the clinical application of chymopapain such as transverse myelitis, paralysis, seizures and hemiplegia which is not fully clarified but may be due to chymopapain itself and improper technique. This study was carried out to clarify the effect of chymopapain on the spinal cord and peripheral nerves by way of application topically in rabbits.

The results were as follows :

1) There were no abnormal gross or histological findings when the chymopapain was spread around the sciatic nerve and spinal cord extradurally.

2) In the group of the chymopapain injected into the sciatic nerve sheath, there was immediate nerve paralysis and severe necrosis of the axon. But the schwann's sheath was intact and no hemorrhage was observed.

3) In the group of intradural chymopapain injection, there was massive hemorrhage, perivascular neutrophil infiltration and necrosis of the gray mater of spinal cord.

In conclusion with this experimental study, the chymopapain induced peripheral neuropathy followed by axonal necrosis when injected into peripheral nerve. The central neuropathy was developed with hemorrhage and necrosis of the gray mater of the cord when the chymopapain injected intradurally.

The tibial condylar fractures involving the articular surface can produce disability of knee joint bacause of its incongrousity and accompanied soft tissue injuries such as ligaments & menisci.

Accurate anatomical reduction and rigid internal fixation followed by early motion is known to get a best result and minimize the complications.

The author analyzed the 57 cases of the tibial condylar fractures treated at the Department of Orthopaedic Surgery, Ewha Womans Medical College and following results were obtained.

1) The highest incidence was in 4th decade(28%) and the most frequent cause was traffic accident (74%).

2) The most common fracture site was lateral condyle(77%).

3) The most common type of fracture was total condylar depression(25%). and next common type was split compression(13%) by hohl & Luck classification.

4) According to Porter's criteria, the satisfactory result was obtained in 31 cases(77%) out of 40 by the operated treatment and above all satisfactory result was 47 cases(83%) out of 57.

5) The most important factor in the end result was the accurate anatomical reduction, rigid fixation and the early joint motion.

Clinical studies have indicated that the non-operative treatment is the best method for clavicle fracture and the operative treatment may contribute to the development of non-union. But some clavicle fractures may be difficult to treat only by non-operative method.

From March, 1980 to May, 1989, 42 patients with clavicle fractures were treated by open reduction and internal fixation with threaded steinmann pin and plate & screws at Department of Orthopaedic Surgery of Ewha Womans University Hospital.

The results were as follows;

1) The avarage duration of union of fracture was 6.7 weeks.

2) By open reduction & internal fixation, gross deformity such as large bone hypertrophy, joint stiffness and shortening was minimized.

3) The plate & screws fixation is more satisfactory result than threaded steinmann pin fixation.

Metastatic tumors of the spine often cause severe pain and paralysis because of deformity and neural encroachment. As oncology now extends the life expectancies of these patients, spinal decompression and stabilization are necessary.

2 patients who had vertebral metastases of hepatocarcinoma were operated on by decompressive corporectomy and firm stabilization. They had significant neural recovery and pain relief immediately.

Now, 2 cases are presented with a brief review of literatures.

There were many instruments for the treatment of spondylolisthesis. Recently, the Cotrel-Dubousset system was introduced and it showed satisfactory stability and efficient reduction of displacement. Nine patients were treated with CD system at the department of orthopaedic surgery, college of Medicine, Ewha Womans University between October, 1987 and July, 1988. The results were as follows.

1) In 9 cases, 4 cases were male and 5 cases were female and age distribution was from 31 years old to 52 years old, the average was 41 years of age.

2) The displacement between L4 and L5 was observed in 5 cases and the degenerative type predominant.

3) The symptoms of back pain only was in 1 case, back pain and radiating pain in 4 cases back pain, radiating pain and neurological sign in 3 cases and radiating pain only in 1 case.

4) The amount of displacement measured by Boxall was from 12.7% preoperatively to 3.4% postoperatively and the amount of angle by Meschan was from 8.3 degrees preoperatively to 2.2 degrees postoperatively.

5) The overall results were satisfactory except 1 case.

Spina bifida occulta at the lumbosacral area of a growing child is often associated with a low lying spinal cord that is tethered by one or more forms of intradural abnormalities without producing overt clinical manifestation for a long time. The diagnosis therefore requires a strong clinical suspicision and aggressive investigarion. We reported one case of tethered core syndrome in spina bifida occulta woth brief review of literature.

Postirradiation fracture of pelvis and femoral neck is a rare complication of malignant carcinoma of pelvic organs. According to Leabhart and Bonfiglio(1961), femoal neck fracturare after radiotherapy of pelvic organ carcinoma is about 1.5% among the involved patients and the common sites of primary neoplasms are cervix, uterus, ovary and urethra in order. Acase of 53-year-old female with postirradiation femoral neck fracture was treated at department of orthopedic surgery, Ewha womans University Hospital after 5,000 rad. of radiotherapy for the treatment of urethral malignancy.

Low back pain and radiating pain are mainly due to nerve root compression in herniated nucleus pulposus(H.N.P) and treatment of H.N.P is determined by several factors. Recently, many patients can be managed with another conservative treatment, i.e. chemonucleolysis, without surgical risk if selected properly and prepared to prevent anaphylactic shock. During past 1(1/2) years from November 1984 to June 1986, 46 patients with H.N.P. were evaluated managed chemonucleolysis in 38 cases excluding 8 cases of rupture types. And following results were obtained with follow up of 6 months over. 1) Of 46 patients, 30 patients(65%) were between 20-30th age group, and male was predominent. 2) The site was most common in L4-5 space(30 patients, 65%). 3) Of 38 patients excluding 8 patients of rupture cases, 30 patients(79%) were excellent and good. 4) As soon as the procedures were performed in 22cases(good results), radiating pain and neurologic symptoms were disappeared but dull low back and buttock pain were remained in 12 patients(55%) after 6 weeks. 5) The intervertebral disc space narrowing was found from 3rd day on lateral radiograph and this narrowing was noticed above 30% by 1st month. 6) Symptoms were improved in 3 cases among 8 cases of rupture cases in discogram. 7) In 38 cases, there was no complication except chest tightness and skin prickling sensation of 8 cases (21%) on whole body there after the injection of chymopapain, but they were soon disappeared. In summary, chemonucleolysis is indicated in patients with acute onset and predominently radiating pain.

Early detection of bone and joint infection is very important in establishing early therapeutic intervention and prevention of complications. Bone scan with Tc 99m-MDP was done in 35 cases for the confirmation of infections on bone and joints at Ewha Womans University Hospital from January 1985 to July 1986 and analysed both clinically and roentgenographically, and following results were obtained. 1) In 15 cases of bone scan for early diagnosis of acute osteomyelitis, positive was 13 cases, and the sensitivity in acute osteomyelitis with bone scan was 86.7%. 2) In 6 cases of bone scan for chronic osteomyelitis, all were positive in bone scan and in X-ray. 3) In 13 cases of suspected infection of joints, 9 were positive in bone scan. In 7 cases of tuberculous arthritis, positive bone scan was 4 cases(55.6%), and in 5 cases of pyogenic arthritis, positive bone scan was 4 cases(80%). From above data, bone scan is very important in establishing early diagnosis and appropriate treatment in the cases of bone and joint infections especially in acute and chronic osteomyelitis and pyogenic arthritis.

Gold therapy is employed primarily in progressive rheumatoid arthritis which is refractory to the conventional measures such as aspirin-like agents. The benefical effects of gold therapy have been demonstrated by careful double blind trials on rheumatoid arthritis. However, its mechanism of action is poorly understood. A limitation to use the gold salt is its potential hazards and toxicity and great care should be given during gold therapy. This study was done to evaluate the effectiveness of gold salt on rheumatoid arthritis and its adverse effect during therapy. Forty-five rheumatoid arthritis patients who received gold sodium thiomalate at Ewha Womans University Hospital from. December 1983 to June 1985 were analyzed in this study. The results are as follows: 1) The incidence of rheumatoid arthritis was higher in female than in male with the ratio of 5:1 and the higher incidence was seen in the thirties and fourties(58%). 2) The mean duration of disease was 3.1 years, ranging 2 weeks to 11 years. 3) Common type of rheumatoid arthritis were the Classic and Definite type, and they were 18 cases(40%) and 15 cases(40%), respectively. The Probable(9 cases) and the Possible types(3 cases) were less common. 4) The average onset of clinical improvement was 12 weeks after gold therapy and the mean cumulative dose at this period was 550mg. 5) Thirty patients out of 45 patients showed marked to moderate clinical improvement after completion of gold therapy, whereas 12 patients did not respond. 3 patients were intolerated to gold therapy and discontinued due to severe adverse reactions. 6) The adverse reaction was observed in 32 of 45 patients receiving gold therapy for rheumatoid arthritis and the most common side reaction was dermatologic manifestations(21 cases). 7) There was no correlation between eosinophilia and the occurrance of the side effects.

There are many methods for treatment of solitary bone cyst. But the recurrence rate was relatively high and beside, serious complications may be followed. Recently, simple topical of steroid into cyst was contrived and the result was know as same or even better than surgical management. A patient of solitary bone cyst who had been failed two times by surgical intervention was treated with topical steroid injection for several times. Two years following up, the result was good. No evidence of recurrency was seen and was shown good healing process

Diseases or traumas involving the spine occasionally cause severe vertebral body collapse to result in either spinal instability or neural deficit, or both. In methods of treatment, conventional decompressive laminectomy results in neural improvement, but it can cause local instability of spine and lead progressive neural deficit. Vertebral stabilization by using bone cement(methylmethacrylate) provides immediate stabilization and avoids bulky external-fixation devices and external supports. We report two cases of thoracic spinal stabilization by using bone cement.

From march 1980 to August 1983, fourteen patients with fractures of the clavicle were treated by open reduction and internal fixation with threaded steinman pin at department of orthopadic surgery of Ehwa university hospital. The results were as followings; 1) Average duration of union of the fractures was 8.9 weeks. 2) Non-union was occured in one case, which was united by autogenous bone graft. 3) By open reduction and internal fixation, abnormal external appearance, such as bony protrusion and shortening was not noted and with early motion of the shoulder joint, disturbance of the joint function was minimized. 4) Open reduction and internal fixation in fractures of the clavicle was recommended in severe comminuted fracture, clinical non-union and heavy worker.

The authors experienced three cases of posterior hip dislocations associated with femoral head fractures which are very rare condition. One of them was treated with closed method and the others were treated with surgical method. The result of treatment in three cases was good.

Tuberculous tenosynovitis of the hand is a rare condition and it should be differentiated from other soft tissue mass. The authors treated the case with surgical treatment and antituberculous chemotherapy.

Management of bed-ridden patients with polyarticular rheumatoid arthritis poses a considerable challenge to the orthopaedic surgeon. Current techniques of total joint replacement provide for the potential restoration of joint function in patients previously considered inoperable due to far-advanced joint destruction. Because many patients with far advanced polyarticular rheumatoid arthritis will predictably require more than one total joint replacement before an improved functional status will occur, the question of multiple joint replacement arises. We have had a bilateral total kneereplacement in the chronic polyarticular rheumatoid patient. Three years after the operation, the patient has slight pain and motion of full extension to 90'flexion. Bilateral total knee replacement improved mobility and reduced pain in this patient.

The rate of the spine fracture tends to be increased as the rate of traffic and industrial accidents are increased. One hundred and fifteen thoracolumbar spine fractures and fracture-dislocations out of 81 patients were evaluated from March, 1976 to September, 1981 treated at the Department of Orthpaedic Surgery of Ewha University Hospital. 1. The majority(64.1%) of the spine fracture was found in the age group of 20 to 50 years. 58% of the cases were coused by fall down injury. There was no difference between sex. 2. Most common site of the lesion occured getween T12 and L2 vertebrae(65.2%) and flexion fracture(56%) was most common. 3. Thirteen cases of the total were complicated by paraplegia, of which 76.9% was caused by rotational frecture-dislocation. 4. Prognosis for neurological recovery in initially complete lesion was poor, regardless of treatment. About 15% initially complete lesion showed complete recovery and 47% showed incomplete recovery.

The spinal tuberculosis has been decreased because of development of anti-tuberculosis drugs and the new surgical procedures but still have challenging problems in Korea. Fourty-eight cases of spinal tuberculosis were treated with conservative and surgical treatments during 6 years from 1976 to 1981 at Ewha Univ. Hospital with following results ; 1. The age distribution showed the peak incidence in the first decade. 2. The predilection site was the thoracic area(49.2%) 3. In 35.4% of the cases, anti-TB drug was taken befure surgery. 4. Paraplegia showed in 29.2% of cases. 5. In paraplegia, most involved bodies were in the thoracic and lumbar vertebra and the percentage was 85.7%. 6. The recovery rate of the paraplegia was 92.9%. 7. Anterior fusion was performed in 35.4%, and the posterior fusion was performed in 31.3%. 8. The kypotic angle was increased according to the numbers of involved vertebra.

The sequelae of unstable fracture of the cervical spine were tragic. The first objective of treatment is protection of the spinalcord during reduction and stabulization. Since 1933, skeletal traction which was introduced by Crutchfield and modified by Vinke, Barton and others, has been used for reduction of fracture-dislocation of the cervical spine. 4 cases of fracture and dislocation of the cervical spine were treated at this department. 2 cases of them, one was quadriplegic and the other revealed nerve root irritation sign, were performed posterior spine fusion and recovered. The third who had fracture-dislocation between C5 and C6 with ankylosing spondylitis was died in the early course. The 4th who hadfracture-dislocation between C5 and C6 with transsection of the spinal cord was also died at home 7 weeks after trauma.

Experiences in the adjuvant chemotherapy with adriamycin on two cases of osteogenic sarcoma of the femur and tibia and one case of Ewing's sarcoma of the femur are presented.

The two cases of the osteogenic sarcoma were treated by a combination of radical amputation and chemotherapy.

One case of the Ewing's sarcoma was treated by the megavoltage radiotherapy and chemotherapy.

One patient with the osteosarcoma died of late pulmonary metastasis 13 months after the diagnosis and treatment, however, this patient had discontinued hie chemotherapy in three months. And also his initial amputation was delayed four months from initial diagnosis because of his hesitation.

Other two cases of osteogenic and Ewing's sarcoma are carrying on normal active daily life without local recurrance or pulmonary metastasis 11-17 months after the diagnosis of the osteogenic and Ewing's sarcoma respectively.

The observation and follow up period of our cases are too short to permit definite conclusions. However, preliminary results and the review of the literatures strongly support the possibility that adjuvant chemotherapy has improved the prognosis of the patients with the malignant bone tumors.

Initial report of Milkman's syndrome was in 1930 with the characteristic findings of multiple, symmetrical, spontaneous, pseudofractures as a mild type of osteomalacia. However, the exact cause of the disease is not clearly defined yet. A case report was made on the cases of Milkman's syndrome of 24 and 44 year old women. Both of them had pseudofracture on proximal part of femur bilaterally and normal walking were disturbed due to pain. The younger patient had additional looser's zone on the ulna and the older case had on the scapula and rib. They are responded well to the treatment with Vitamin D₂ and D₃ 50,000 I.U. Daily each. The looser's zone had disappeared completely or almost all on radiological examination in seven to ten months of treatment.