Original Article J Korean Bone Joint Tumor Soc 2011; 17: 36-43 DOI:10.5292/jkbjts.2011.17.1.36 www.kbjts.or.kr Functional and Radiological Results of Intermediate-term Follow Up in MUTARS Tumor Endoprostheses 강동준 김정일 오종석 문태용 * 이인숙 * 부산대학교의과대학정형외과학교실, * 영상의학교실 목적 : 사지의악성골종양에서 MUTARS 종양대치물을이용한사지구제술의중기추시에서합병증발생과기능적및방사선학적결과를평가하고자하였다. 대상및방법 : MUTARS 종양대치물을이용한사지구제술을받은환자 31명을대상으로하였다. 평균연령은 49.2 세였으며, 추시기간은평균 39.8 개월이었다. 후향적으로최종추시에서합병증을분석하고 Enneking 기능점수와 ISOLS 방사선학적대치물평가체계를이용하여기능적, 방사선학적평가를시행하였다. 결과 : 3명이사망하였고 4명에서원격전이가발생하였으며, 1명이국소재발하였다. 12명에서합병증이발생하였는데, 창상및심부감염 6 명, 하지부동 2명, 방사선학적이완 2명, 대퇴골골절이 1명, 나사못의이완이 1명이었다. 최종추시시기능적분류척도의평균점수는근위대퇴골에서 81.2%, 원위대퇴골에서 77.4%, 근위경골에서 78.1%, 근위상완골에서 80.2% 였으며방사선학적결과는전반적으로우수한결과를보였다. 결론 : MUTARS 종양대치물을이용한사지구제술은기능적, 방사선학적으로만족할만한방법이지만감염등의합병증에주의를해야할것으로생각된다. 색인단어 : 사지, 골종양, 종양대치물, 기능적방사선학적평가 서 론 최근에는골종양및연부조직종양의치료로사지의기능을보존 하면서종양을적출하는사지구제술이보편화되는추세이다. 1,2) 종양대치물을이용한사지구제술은다른여러가지방법들에비 하여조기에안정성을얻어빠른시간내에환자의관절운동및 체중부하를가능하게하는장점이있다. 이로인해환자가조기 에사지의기능을회복하여환자의만족도를향상시킬수있다. 3-8) 최신종양대치물은규격화된제품을조립하여만들수있게되 접수일 2011 년 3 월 21 일심사수정일 2011 년 5 월 3 일게재확정일 2011 년 5 월 30 일교신저자김정일부산시서구아미동 1 가 10 번지, 부산대학교병원정형외과 TEL 051-240-7248, FAX 051-247-8395 E-mail Osteokim@yahoo.co.kr * 본논문의요지는 2011 년도대한정형외과학회춘계학술대회에서발표되었음. * 본논문은 2011 년도부산대학병원의임상연구비의지원을받아이루어졌음. 면서재건술후의길이의유연성및기능적결과에서좋은결과를보고하고있다. 최근 30년간종양대치물의 5년유지율 (5-year survival rate) 은환자의생존율및활동적인환자의증가에도불구하고 20% 에서 85% 로증가하였다. 1) 하지만종양대치물을통한재건술후광범위한골및연부조직의결손, 긴수술시간, 삽입물크기등의문제로무균성이완, 심부감염, 기계적인결함등의합병증이높은것으로보고되고있다. 9-11) 본연구의목적은사지의악성골종양에서 MUTARS 종양대치물 (Implantcast, Buxtehude, Germany) 을이용한사지구제술후의중기추시에서합병증발생과기능적및방사선학적결과를평가하고자한다. 대상및방법 2005 년 5월에서 -2009 년 10월까지사지의악성골종양으로 MU- TARS 종양대치물을이용하여사지구제술을시행한환자중 1 년이상추시가가능하였던 31명을대상으로하였다. 남자가 12예 대한골관절종양학회지 : 제 17 권제 1 호 2011 Copyrights 2011 by The Korean Bone and Joint Tumor Society 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/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
37 여자가 19예였으며, 삽입술시평균연령은 49.2 세 (10-79 세 ), 평균추시기간은 39.8 개월 (12-65 개월 ) 이었다. 12 예는전이성골종양이었으며 19예는원발성골종양이었다 (Table 1). 8예에서병적골절을동반하였으며이중 7예가전이성골종양, 1예가원발성골종양이었다. 종양에따라술전및술후항암화학요법을시행하였다. 골결손부는 MUTARS 종양대치물을이용하여재건되었다. 술전에전후, 측면영상을촬영하고가늠자 (template) 를이용하 여정확한스템의크기를계획하였다 (Fig. 1). 골수강내스템을통해고정하였으며 6예에서무시멘트방법으로, 25예에서는시멘트와함께삽입하였다. 무시멘트방법에서는충분한안정성을갖기위해압박고정 (Press-fit technique) 을통해스템을삽입하였고이로인해스템으로골내성장이일어나도록하였다. 스템은단면상 6각형이며무시멘트종양대치물은 Titanium 합금 (TiAl6V4) 으로, 시멘트종양대치물은 CoCrMo 합금으로제작되었다. 이환된사지의길이와관절의기능을회복하기위해다양한연결부를이 Table 1. Primary Tumors and Metastases Before MUTARS Implantation Diagnosis Tumor entity Frequency Primary tumor Osteosarcoma 12 Malignant fibrous histiocytoma 4 Chondrosarcoma 2 Giant cell tumor 1 Metastasis Hepatocellular cancer 3 Renal cell cancer 2 Prostate cancer 2 Lung cancer 2 Stomach cancer 1 Breast cancer 1 Thyroid cancer 1 Total 31 Figure 2. An intraoperative photograph shows a proximal tibia replacement and the Trevira (Implantcast) tube placed around the prosthesis. The patellar tendon was refixated to the tube by sutures. Figure 1. (A) An AP radiograph with digital planning of a MUTARS tumor prosthesis is shown for a 67-year-old man with an malignant fibrous histiocytoma of the left distal femur. (B) Anteroposterior and (C) lateral radiographs show a cemented distal femur replacement.
38 강동준ㆍ김정일ㆍ오종석외 2 인 용하여스템과연결하였으며골수강은스템직경보다 1 mm 작게확공을하였으며특수 rasp 을이용하여스템과피질골사이의접촉을좋게하였다. 고관절외전근, 슬관절신전근, 회전근개등의연부조직구조물들이절제된후에는 Trevira tube (Implantcast, Buxtehude, Germany) 를이용하여치환물주위로봉합하여고정을시행하였다 (Fig. 2). 원위대퇴골치환술을시행한 15명의환자중 11명에서시멘트형스템을이용하였고 Trevira tube 는이용하지않았다. 근위대퇴골치환술을시행한 8명의환자중 5명에서시멘트형스템을이용하였고 4명에서 Trevira tube 를이용하여고관절주위근육을재건하였다. 근위경골치환술을시행받은 5명의환자중 3명에서시멘트형스템을이용하였고, 4명은 Trevira tube 를이용하여비복근과슬개건을부착하였다. 근위상완골치환술을시행한 3명모두시멘트를이용하여스템을고정한후회전근개를 Trevira tube 로재건하였다. 술후모든환자들은 cephalosporin 을 3-7 일간정맥주사하였으며상처치유까지경구투여하였다. 근위상완골재건술후에는 4주간의팔걸이를이용하여고정시켰다. 하지의무시멘트스템고정을시행받은환자에서는 6주까지는체중부하를제한하였으며근위대퇴골치환술을시행받은환자에서는탈구방지를위해운동범위를제한하였다. 환자들의기능적평가는최종외래방문시작성한설문조사및전화를통한설문조사를바탕으로기능적결과를평가하였으며, Enneking 등 12) 이 1993 년에 ISOLS (International Symposium on Limb Salvage) 에서제창한기능적분류척도 (Musculoskeletal Tumor Society Functional Classification Scale) 를기준으로하였다. 방사선학적평가로는최종외래방문시얻은단순방사선영상을통해 1988 년 International Symposium On Limb Salvage (ISOLS) 에서제창한방사선학적대치물평가체계 (Radiological Implants Evaluation System) 를사용하였다. 13) 평가항목중골교형성은골 교형성을의도하는형태의대치물에적용하는것으로, 본연구에 서사용한대치물은대부분이골교형성을의도하지않았고과거 에는이를정확히측정하지않았으므로, 이번연구에서는이항목 을평가에서제외하였다. 합병증들에대한분석과 Trevira tube 사용여부에따라기능 적결과및심부감염의차이가있는지평가하기위해 SPSS 통계 시스템 (SPSS, Inc., Chicago, IL) 을이용하여 t-test, chi-square test 로분석을실시하였으며, 유의수준은 0.05 이하로하였다. 결 과 31 명중추시도중에종양으로인하여 3 명이사망하였고 28 명이 최종추시까지생존하였다 (90.3%). 4 명에서원격전이가발생하 였으며 (12.9%), 원위대퇴골치환술을시행한 1 명에서국소재발 하여 (3.2%) 슬관절상부절단술을시행하였다. 평균골절제율은 근위대퇴골에서 45.8%, 원위대퇴골에서 42.6%, 근위경골에서 Table 2. Complications in All 31 Patients Distal femur Proximal femur Proximal tibia Proximal humerus Infection Tube (+) Tube (-) Stem loosening 1 2 Periprosthetic fracture Mechanical failure 2 1 1 3 Total 5/11 (45.5%) 1/20 (5%) 2/31 (6.9%) 1/31 (3.2%) 1/31 (3.2%) Figure 3. (A) An intraoperative photograph shows a antibiotic-impregnated cement spacer (B) Anteroposterior and (C) lateral radiographs.
39 40.1%, 근위상완골에서는 39.8% 였다. 12예에서합병증이발생하였는데 (38.7%), 창상및심부감염 6 예 (19.4%) 로가장많이발생하였으며, 하지부동 2예, 방사선학적이완 2예, 대퇴골골절이 1예, 스템연결부 (connecting part) 나사못의이완이 1예있었으며그외의합병증은발생하지않았다 (Table 2). 창상및심부감염은근위대퇴골에서 1예 (12.5%), 원위대퇴골 Figure 4. Aseptic loosening after cemented fixation of MUTARS. 에서 2예 (13.3%), 근위경골에서 3예 (60%) 였다. 조기에배농술및변연절제술및 Trevira tube 를시행한경우에는제거술을시행하고항생제를투여하여 5명은치유되어삽입물을보존할수있었으나, 1예에서는삽입물제거후자체제작한항생제혼합시멘트충전물을삽입하고 (Fig. 3) 2단계에걸쳐삽입물재치환술을시행하였으나감염의진행으로슬관절상부절단술을시행하였다. 6 예의감염을분석해보면 Trevira tube 를사용한군에서 45.5% 로사용하지않은군의 5% 보다높은감염율을보였다 (p=0.022). 하지부동은 2예에서 3 cm 범위에있어신발높임 (shoe lift) 으로치료하면서경과를관찰중이다. 종양대치물주위의방사선학적이완은 2예 (6.9%) 에서있었으며, 모두원위대퇴골이었고 (14.3%) 무균성이완으로발생하였다 (Fig. 4). 2예모두시멘트를사용한군에서발생하였으나통계학적유의성은없었다 (p=0.83). 2예모두증상이없어계속추시관찰중이다. 원위대퇴골치환술을받은환자 1명이낙상으로인해대퇴골골절이발생하였으며 Vancouver 분류에따라 B1이었다. 환자는시멘트형의스템으로금속판과나사못, 환형강선을통해내고정을시행하였으며술후 5개월에유합이발생하였다 (Fig. 5). 원위대퇴치환술을시행한환자가슬관절의불안정성을호소하여탐색술을시행하였으며스템연결부나사못의이완을발견하고나사못을조은후에는증상없이추시관찰중이다. 최종추시시기능적분류척도의평균점수는근위대퇴골에서 78.2% (14-28 점 ), 원위대퇴골에서 74.4% (12-27 점 ), 근위경골 Figure 5. Roentgenographic findings after femoral shaft periprosthetic fracture (Vancouver classification B1). (A) Preoperative anteroposterior view. (B) Postoperative anteroposterior view. (C) The radiograph taken 5 months later shows healing of the fracture.
40 강동준ㆍ김정일ㆍ오종석외 2 인 Table 3. Radiographic Analysis by ISOLS Radiologic Implant Evaluation System Bone remodeling Interface Anchorage Implant body problem Implant articular problem Poor 1 (3.5%) 2 (6.9%) 1 (3.5%) 0 (0%) 0 (0%) Fair 8 (27.6%) 5 (17.2%) 1 (3.5%) 1 (3.5%) 2 (6.9%) Good 17 (58.6%) 17 (58.6%) 7 (24.1%) 3 (10.3%) 4 (13.8%) Excellent 3 (10.3%) 5 (17.2%) 20 (68.9%) 25 (86.2%) 23 (79.3%) 에서 75.1% (10-27 점 ), 근위상완골에서 80.2% (12-28 점 ) 였으며부위에따른통계적차이는없었다. Trevira tube 를사용한군에서기능적분류척도의평균점수가 (79.4%) 사용하지않은군에비해 (74.5%) 유의하게높았다 (p<0.05). 방사선학적결과는골재형성 (bone remodelling), 접촉면 (interface), 고정 (anchorage), 대치물체 (implant body problem), 대치물관절 (implant articular problem) 모두전반적으로우수한결과를보였으나골재형성과접촉면의결과가다른항목에비해좋지않았다 (Table 3). 고찰 최근항암화학요법과사지구제술의발달로인해악성종양의치료에정상주변조직을포함한종양의광범위절제술후종양대치물을이용한재건술이보편화되었다. 종양대치물을이용한사지구제술은규격화된제품의제조, 수술기법 ( 근피판술 ) 및술자의경험의향상으로인해수년간비약적인발전을해왔다. 14) 그러나종양대치물을이용한재건술후의합병증 ( 무균성이완, 스템골절, 감염, 탈구 ) 의발생또한여전히높은것으로알려져있다. 따라서본연구에서는 MUTARS 종양대치물을이용하여합병증발생및기능적, 방사선학적결과를확인하고자하였다. MU- TARS 종양대치물의단면상 6각형인스템은회전력에안정성을주어이완율과스템의파괴빈도를낮추고 Trevira tube 는탈구를감소시키고기능적결과를향상시키는것으로알려져있다. 15) 종양대치물삽입술은통상적인고관절이나슬관절치환술보다감염율이유의하게높은것으로알려져있다. 그원인은통상적관절치환술에비해범위가크고수술시간이길며광범위한연부조직손상이발생하기때문이다. 또한수술전후에시행하는화학요법및방사선요법으로면역력이감소되기때문이다. 대퇴골의종양대치물치환후의감염은 4-12% 정도로보고되는데, 9,13,16-18) 근위상완골및근위대퇴골이일반적으로감염율이낮은편이며, 근위경골종양대치물의경우는연부조직의부족등으로인해감염의빈도가높다. 18-24) 저자들의경우에도근위대퇴골에서는 12.5% 의감염율을보여, 원위대퇴골 (13.3%) 이나근위경골 (60%) 보다낮은경향을보였다. 본연구에서 Trevira tube 를이용하여낮은탈구율및기능의향상을확인하였으나 Trevira tube 를사용한군에서 45.5% 로사용하지않은군의 5% 보다높은 감염율을보였다 (p=0.022). 이러한결과는일반적으로감염율이높은근위경골에 Trevira tube 를많이사용하므로높은감염율을보인것으로생각된다. 무균성이완은큰골결손부를위한대치물삽입술후의가장중요한문제로남아있다. 24-27) 무균성이완의발생은종양대치물의위치와관련이있으며원위대퇴골의치환시높은발생률을보고하고있다. 1) 대퇴골에무균성이완이많은이유는슬관절굴곡시종양대치물에더큰지렛대힘이작용해기계적응력 (mechanical stress) 이증가되기때문이다. Plotz 등 21) 은무시멘트고정법을선호하였으며하지의종양대치물삽입시 8.4-11% 의무균성이완을보고하였다. 본연구에서는육각형의스템과특수 rasp 을이용하여골수강내를전처리하여좋은회전안정성을보였으며단지 6.9% 의이완율을보였다. 또한해부학적으로곡선형 Pe의대퇴스템은압박고정 (fit press anchorage) 작용을한다. 구속형치환물과는달리회전경첩형슬관절치환물은제한된내회전과외회전을허용하면서회전력이스템대신에관절에의해흡수된다. 이러한이유로무균성이완이낮게보고된다. 14,19,28,29) Kawai 등 17) 은원위대퇴골에서 40% 의무균성이완를경험하였고이로인하여평균 51개월에 20% 의환자에서재치환술을시행하였다고보고하였으나, Robert 등 30) 은 4.4% 의낮은무균성이완율을보고하면서이의원인으로골시멘트압축법 (cement ressurization technique) 의사용을통한견고한고정과규격화된스템의사용을제시하였다. 골간단절제술시무시멘트방법을통한압박고정은가능하지않은경우가많아서안정된고정을얻기위해시멘트를사용하게된다. 원위대퇴골의문헌고찰에서시멘트군과무시멘트군을비교한것은찾아보기힘든데 Capanna 등 31) 은종양대치물에서무시멘트성이고정 (anchorage) 면에서생물학적고정을얻을수있으므로시멘트보다우수하다고하였으나 Rechl 등 32) 은슬관절주위의종양대치물에서무시멘트성수술시골수강내스템에의한피로골절의위험에대하여말하였고이로인해골소실, 골절등의문제가발생되어재치환술의원인이된다는상반된의견을제시하고있다. 종양대치물을제거하는가장흔한원인은스템골절 (3.3-16%) 이다. 21,30) 하지만본연구에서는얇은코팅을통해큰직경의스템이가능하도록하고, 단조 (forged) 된티타늄스템을사용하여안정성을주어 24) 스템파손은한예도발생하지않았으나스템과연결부를연결하는나사못의이완으로불안정성이발생하여나사못
41 을조아서안정성을회복하였다. 탈구는근위대퇴종양대치물삽입후에발생하는가장흔한합병증으로 1.7-20% 의발생률을보인다. 20,33.34) 하지만본연구에서는근육부착및관절낭의재건을위한 Trevira tube 의사용으로탈구는발생하지않았다. Bickels 등 33) 의연구에서탈구율이 1.7% 로보고하였으며근위상완골치환술에서 Trevira tube 의사용으로 tube 에남아있는근육들을부착함으로써이전의연구에서높았던탈구율을낮출수있다고보고하였다. 35-38) Zeegen 등 24) 은근위경골대치물을사용한 8명의환자중한예에서슬개건의파열을보고하였는데이들은슬개건의고정을위한 tube 를사용하지않았다. 본연구에서는 Trevira tube 를이용하여슬개건을치환물에부착하였으며그결과기능적인결과가양호한것으로나타났다. Kabukcuoglu 등 16) 은근위대퇴골종양대치물의평균기능적점수는 83% 로보고하였고, 원위대퇴골에서는여러저자들이 80-83% 의기능적점수를보고하였으며, 17,39) Grimer 등 19) 은근위경골종양대치물의평균 MSTS 기능적점수는 77% 이었다고보고하였다. 본연구에서는평균기능점수는근위대퇴골에서 81.2%, 원위대퇴골에서 77.4%, 근위경골에서 78.1%, 근위상완골에서 80.2% 로양호이상의결과를얻었으며특히 Trevira tube 를이용한군에서더욱좋은기능적결과를보였다. 결론 사지에서발생한골종양의치료에서종양대치물을사용한골종양의치료는만족할만한방법으로생각된다. 이러한대치물중 MUTARS system (Impantcast) 은다른 system 에비해많은장점을가진다. 먼저 Trevira tube (impalantcast) 는근육과건의재부착이더쉽도록하여고관절및견관절의탈구을낮추고근위대퇴및경골치환술시좋은기능적인결과를나타낸다. 두번째육각형모양으로단조된스템과골수강내의특별한전처지기법으로인해무균성이완을낮출수있다. 하지만감염등의합병증에주의를해야할것으로생각되며보다많은증례를분석하여예후인자를파악해야하며장기적인추적조사가필요할것으로사료된다. 참고문헌 1. Mittermayer F, Krepler P, Dominkus M, et al. Long-term follow up of uncemented tumor endoprostheses for the lower extremity. Clin Orthop Relat Res. 2001;388:167-77. 2. Sluga M, Windhager R, Lang S, Heinzl H, Bielack S, Kotz R. Local and systemic control after ablative and limb sparing surgery in patients with osteosarcoma. Clin Orthop Relat Res. 1999;358:120-7. 3. Eckardt JJ, Kabo MK, Kelly CM, et al. Expandable endoprosthesis reconstruction in skeletally immature patients with tumors. Clin Orthop Relat Res. 2000;373:51-61. 4. Hornicek FJ, Gebhardt MC, Sorger JI, Mankin HJ. Tumor reconstruction. Orthop Clin N Am. 1999;30:673-84. 5. Kneisl JS, Finn HA, Simon MA. Mobile knee reconstructions after resection of maligant tumors of the distal femur. Orthop Clin N Am. 1991;22:105-19. 6. Lindner NJ, Ramm O, Hillmann A, et al. Limb salvage and outcome of osteosarcoma. Clin Orthop Relat Res. 1999;358:83-9. 7. Rougraft RT, Simon MA, Kneisl JS, Greenberg DB, Mankin HJ. Limb salvage compared with amputation for osteosarcoma of the distal end of the femur. J Bone Joint Surg Am. 1994;76:649-56. 8. Sanjay BK, Moreau PG. Limb salvage surgery in bone tumor with modular endoprosthesis. Int Orthop. 1999;23:41-6. 9. Donati D, Zavatta M, Gozzi E, Giacomini S, Campanacci L, Mercuri M. Modular prosthetic replacement of the proximal femur after resection of a bone tumour. J Bone Joint Surg Br. 2001;83:1156-60. 10. Eckardt JJ, Eilber FR, Dorey FJ, Mirra JM. The UCLA experience in limb salvage surgery for malignant tumors. Orthopedics. 1985;8:612-21. 11. Safran MR, Kody MH, Namba RS, et al. 151 endoprosthetic reconstructions for patients with primary tumors involving bone. Contemp Orthop. 1994;29:15-25. 12. Enneking WF, Dunham W, Gebhardt MC, Malawar M, Pritchard DJ. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res. 1993;286:241-6. 13. Capanna R, Morris HG, Campanacci D, Del Ben M, Campanacci M. Modular uncemented prosthetic reconstruction after resection of tumours of the distal femur. J Bone Joint Surg Br. 1994;76:178-86. 14. Mittermayer F, Windhager R, Dominkus M, et al. Revision of the Kotz type of tumour endoprosthesis for the lower limb. J Bone Joint Surg Br. 2002;84:401-6. 15. Georg Gosheger, Carsten Gebert, Helmut Ahrens, Arne Streitbuerger, Winfried Winkelmann, Jendrik Hardes. Endoprosthetic Reconstruction in 250 Patients with Sarcoma. Clin Orthop Relat Res. 2006;450:164-71.
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43 Functional and Radiological Results of Intermediate-term Follow Up in MUTARS Tumor Endoprostheses Dong Joon Kang, M.D., Jeung Il Kim, M.D., Jong Seok Oh, M.D., Tae Yong Moon, M.D.*, and In Sook Lee, M.D.* Departments of Orthopaedic Surgery, *Radiology, College of Medicine, Pusan National University, Busan, Korea Purpose: This study was designed to verify intermediate-term functional and radiological results of limb salvage operation using endoprosthetic replacement system (MUTARS ) used in patients with a malignant bone tumor. Materials and Methods: Thirty one cases which used MUTARS tumor prosthesis were reviewed. The mean age of the patients was 49.2 years and the mean follow up was 39.8 months. We retrospectively reviewed complications, and evaluated functionally and radiologically by Enneking functional score, ISOLS radiological implants evaluation system at last follow-up. Results: 3 patients had died of disease, distant metastasis was seen in 4 patients and local recurrence was seen in 1 patients. Complications were developed in 12 patients. (infection 6, leg length discrepancy 2, aseptic loosening 2, periprosthetic femoral fracture 1, screw loosening 1) Mean value of total functional scores were 81.2% in proximal femur, 77.4% in distal femur, 78.1% in proximal tibia, and 80.2% in proximal humerus. The overall radiological result was relatively satisfactory. Conclusion: Our results suggest limb salvage with the MUTARS endoprosthesis is successful with good functional and radiological results. But we should be careful with complications such as infection. Key words: extremities, bone tumor, prosthetic reconstruction, functional and radiologic evalutation Received March 21, 2011 Revised May 3, 2011 Accepted May 30, 2011 Correspondence to: Jeung Il Kim, M.D. Department of Orthopaedic Surgery, Pusan National University Hospital, 10, Ami-dong 1-ga, Seo-gu, Busan 602-739, Korea TEL: +82-51-240-7248 FAX: +82-51-247-8395 E-mail: Osteokim@yahoo.co.kr