Infection plays a pivotal role in enhancing a diabetic foot at risk toward amputation. Effective antibiotic therapy against the offending pathogens is an important component of treatment of diabetic foot infections. Recognition of the pathogen is always difficult as the representative deep tissue sample for culture is surrounded by ulcer surface harbouring colonies of organisms frequently labelled as skin commensals. The emergent of resistant strains represents a compounding problem standing against efforts to prevent amputation. This study was undertaken to identify the pathogens associated with diabetic foot infection in terms of their frequency and sensitivity against certain commonly used antibiotics. Forty-four consecutive patients with open diabetic foot infections had wound swab taken for culture and sensitivity testing. Cultures positive were observed in 89% of the cases with Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeroginosa encountered in 20%, 14% and 14% of cases respectively. Mixed growths were isolated in 6% of cultures. All Staphylcoccus aureus isolates were resistant to Penicillin but 80% were sensitive to Erythromycin and Co-trimoxazole. Klebsiella pneumoniae isolates were sensitive to Methicillin and Gentamycin in 80% and 60% of cases respectively, and resistant to Ampicillin and Ceftazidime in 83% and 50% respectively. All Pseudomonas aeroginosa isolates were sensitive to Amikacin and Ciprofloxacin but 50% were resistant to Gentamycin. There was no single antibiotic possessing good coverage for all common organisms isolated from diabetic foot lesions. Staphylococcus aureus remains the predominant cause of diabetic foot infections followed by Klebsiela pneumonia and Pseudomonas aeroginosa. Most infections are monomicrobial. The emergence of multiresistant organisms is a worrying feature in diabetic foot infections.
Necrotizing fasciitis is a limb- and life-threatening rapidly spreading infection affecting the deep fascia with secondary necrosis of the subcutaneous tissue. It requires immediate medical attention and emergency surgery to prevent morbidity and death. This study was undertaken to determine its co-morbidity and risk factors affecting the outcome of its surgical treatment. This is a retrospective review of 36 cases of necrotizing fasciitis of the lower limb treated in our center between 1998 and 2002. Only 19% of the cases were correctly diagnosed upon admission and 48.6% were initially diagnosed as 'cellulitis'. Diabetes mellitus was the most common co-morbid. Pseudomonas, Staphylococcus, Streptococcus and Enterobactericae were the common pathogens isolated. Ten patients (27.8%) had major amputation as part of radical debridement. The overall mortality rate was 36% with laboratory parameters: high serum urea and creatinine, and low haemoglobin levels were predictors for higher mortality. Poor white cell response which is common in diabetic patients and a delay in surgical debridement were. notable attributes to a higher mortality. Necrotizing fasciitis is a serious infection associated with significant morbidity and mortality. A poor white blood cell response, high serum urea and creatinine, and low haemoglobin level were the predictors for mortality. Early diagnosis and prompt treatment are of paramount importance in the treatment of this infection.
Deep surgical site infection is a devastating consequence of total joint arthroplasty. The use of antibiotic impregnated bone cement is a well-accepted adjunct for treatment of established infection and prevention of deep orthopaedic infection. It allows local delivery of the antibiotic at the cement-bone interface and sustained release of antibiotic provides adequate antibiotic coverage after the wound closure. Preclinical testing, randomised and clinical trials indicate that the use of antibiotic-impregnated bone cement is a potentially effective strategy in reducing the risk of deep surgical site infection following total joint arthroplasty. The purpose of this study was to assess antibacterial activity of erythromycin and colistin impregnated bone cement against strains of organisms' representative of orthopaedic infections including Gram-positive and Gram-negative aerobic organisms: Staphylococcus aureus, coagulase-negative Staphylococci, Enterococcus sp., Proteus sp., Klebsiella sp., Pseudomonas sp., and Escherichia coli. Pre-blended Simplex P bone cement with the addition of erythromycin and colistin (Howemedica Inc) was mixed thoroughly with 20ml liquid under sterile conditions to produce uniform cylindrical discs with a diameter of 14mm and thickness of 2mm. 24-48 hour agar cultures of Staphylococcus aureus, coagulase-negative Staphylococci, Enterococcus sp.,Proteus sp., Klebsiella sp.,Pseudomonas sp., and Escherichia coli were used for the agar diffusion tests. The agar plates were streaked for confluent growth followed by application of erythromycin and colistin impregnated bone cement disc to each agar plate. The plates were incubated at 30 degrees C and examined at 24, 48, 72 hours, and four and five days after the preparation of the impregnated cement. The susceptibility of Staphylococcus aureus to the control discs was most clearly demonstrated showing a distinct zone of inhibition. The zone observed around coagulase-negative Staphylococci, Klebsiella sp., Pseudomonas sp., and Escherichia coli were also significant. However, there was no zone of inhibition or signs of antibacterial activity at the cemented surface were detected around discs with Enterococcus sp. and Proteus sp. The results showed that Simplex P bone cement with the addition of erythromycin and colistin was effective against most of the broad spectrum organisms encountered during total joint arthroplasty. The activity of Simplex P bone cement impregnated with erythromycin and colistin is mainly during the first 72 hours.
Antibiotic-loaded bone cement has been used as prophylaxis against infection in total joint replacement surgery. Its effect on the mechanical strength of cement is a major concern as high dose of antibiotic was associated with a significant reduction in mechanical strength of bone cement. However, the cut-off antibiotic that weakens the mechanical strength of cement remains to be determined. This study was undertaken to observe the changes in the mechanical properties of bone cement with gradual increments of Cefuroxime antibiotic. Cefuroxime at different doses: 0, 1.5, 3.0 and 4.5gm were added to a packet of 40gm bone cement (Simplex P) and study samples were prepared by using third generation cementing technique. Mechanical impact, flexural and tensile strength were tested on each sample. Significant impact and tensile strength reduction were observed after addition of 4.5 gm of Cefuroxime. However, flexural strength was significantly reduced at a lower dose of 3.0 gm. The maximum dose of Cefuroxime to be safely added to 40mg Surgical Simplex P is 1.5gm when third generation cementing technique is used. Further study is needed to determine whether it is an effective dose as regards to microbiological parameters.
The incidence of spinal injuries in Malaysia is on the rise following similar trend of rapid development and increasing number of building constructions sites, and motor vehicles. This epidemiological study was aimed at compiling local data with a view to identifying target areas for preventive measures as well as improvement strategies in the management of these potentially devastating injuries. Seventy eight patients admitted with spine trauma in 1998 in a level-one trauma centre were retrospectively reviewed. All records were traced from the admission and discharge books of the orthopaedic wards, accident and emergency wards, operative registration book, spinal rehabilitation ward and orthopaedic registration data of the Department of Orthopaedics, Hospital Kuala Lumpur. Details on pre-treatment neurological and radiological level of injury and post-treatment outcomes were recorded according to the American Spinal Injury Association (ASIA) impairment scale. Most patients (61.5%) were in the productive ages of less than 34 years with a 4:1 male to female ratio. Majority were due to motor vehicle accidents (57.7%) and fall from a height (28.3%). The thoraco-lumbar junction was the most common site of injury followed by the lower cervical region with 62.5% of which associated with neurological deficit. Neurological deficits: 11 ASIA-A, 1 ASIA-B, 6 ASIA-C, and 3 ASIA-D were detected in 21 (27%) patients with fall from height (50%) particularly landing on the feet (50%) and recreational sports (100%) were the risk factors. Less than 10% of patients were treated surgically and this explains an average 39.4 days of hospitalization (5 times longer in patients treated non-operatively). On discharge, four patients with incomplete neurology recovered to ASIA-E status and the remaining improved to ASIA-C and -D in one and five patients respectively. Only one patient with complete neurology improved to ASIA-B status following surgical treatment. The demographic profiles of our patients were comparable to other series in the literature but still inadequate to provide enough epidemiological data. A multicenter study to provide a larger pool of patients is needed.
Femoral neck fracture non-unions often present with significant difficult treatment decision as regards to surgical options and the risk of complication. We present three cases of femoral neck non-union treated with double screw stabilization technique using sliding compression hip screw and anti-rotational screw. The rationale for opting to these simple implants in our setting is discussed.
Displaced humeral condyle fractures in children are traditionally fixed with smooth Kirschner wire at the expense of a risk of secondary displacement following removal of wire. Screw fixation of such fractures has recently been advocated as it provides stable fixation. We have been using screw osteosynthesis for treatment of displaced lateral humeral condyle fractures in children in our institution since the turn of this century. This study provides a midterm review of treatment of such injuries with special regards to growth disturbances after screw osteosynthesis and to assess rate of union with a view to formulate guidelines for screw removal. We review the outcomes of screw osteosynthesis for displaced lateral condyle fracture of the humerus (19 Milch type-1 and 15 Milch type-II) in 34 children treated in our institution from January 2000 to March 2004. The average age of the patients was 6.1 years. The average follow up was 24.5 months. Screw osteosynthesis led to union (average 6.9 weeks) in all patients with excellent results in 28 patients. Growth disturbances in the form of lateral condyle overgrowth (2 patients), valgus deformity secondary to lateral condyle avascular necrosis (2 patients) and fishtail deformity ((3 patients) were recognized. The implants should not be removed until fracture union is established. Screw osteosynthesis of the lateral humeral condyle fracture prevents secondary fracture redisplacement and lateral condyle overgrowth is probably related to hyperemic response to metaphyseal fixation and early removal of implant before radiological union.
Adequate pain relief is a requisite for a successful closed manipulative reduction (CMR) of fractures and dislocations. This prospective study was undertaken to assess the mode and adequacy of pain relief given to patients undergoing such procedures at Seremban Hospital from the 1st April to the 31st May 2001. All patients with fractures and dislocations scheduled to undergo CMR were included in this study. The type of sedative agents and analgesia administered were recorded. Demographic data and the type of fracture or dislocation of the selected patients were documented. A visual analogue scale (VAS) for pain perception was given to both to the patients and the medical personnel who performed the procedure. All data were collected manually before entered into computerized database for analysis. Of 72 patients included in this study, 47% were Malay, 26% Indian, 21% Chinese and 6% others. There was male predominance and the patients' age ranged between 9 to 79 years (average 27.4 years). Upper limb injuries (79%) were mainly fractures of the radius and ulna (29%) and isolated fracture radius (21%). For the lower limb injuries (21%), combined tibia and fibula fractures constituted 10% of the total cases followed by isolated tibia fractures (10%) and hip dislocation (1%). The most common pain relieving agents given during the CMR were intravenous pethidine alone (43%) followed by combination of intravenous pethidine and valium (36%), intramuscular pethidine (17%) and intramuscular tramal (4%). The Visual Analogue Score (VAS) for pain perception revealed that 61% of the patients had moderate pain while 21% had severe pain during the course of the procedures. Suboptimal pain relief administered during CMR should prompt positive actions to ensure that the patient is not subjected to undue pain just for the sake of an acceptable fracture reduction.
Orthopaedic procedures especially dynamic hip screw (DHS) fixation, interlocking nailing (ILN) of the tibia and femur require fluoroscopic assistance. Frequent exposure to radiation is a major concern to members of the orthopaedic surgical team. This study was undertaken to measure shallow (skin) dose to the operating team personnel and deep (whole body) dose to the surgeon during such procedures in view to provide guidelines to the operating team members regarding the number of procedures allowable for them to perform or assist annually. Skin dose for the operating personnel and whole body dose for the operating surgeon during 25 procedures; ten cases of DHS, seven and six cases of ILN of the tibia and femur respectively, was measured using Thermoluminescent Dosimeter (TLD) chips. The shallow radiation dose for theatre personnel ranged from 0.19 mSy to 0.61 per case while the deep dose for the surgeon was 0.28, 0.55 and 0.81 mSy for seven cases of tibial ILN, ten cases of DHS and six cases of femur ILN respectively. The surgeon has the highest radiation exposure than other theatre personnel and the whole body exposure for DHS was higher than that of for ILN. However, the estimated cumulative dose was still far below the permissible annual dose limit.
Patients with aggressive musculoskeletal tumours often arrive at specialised treatment centres late. Such a delay could mean disfavour for potentially curable or long-term disease-free outcome of limb preserving surgery. This study was undertaken to identify the underlying problem-related delay with a view to propose solution for solving it. We reviewed 30 patients to determine the periods of delay between onset of the first symptom and the definitive treatment. The delays were categorized as 'patient' delay, 'referral' delay and 'treatment' delay. There was 'patient' delay in 57% of patients (n=17), ranging from 1 to 18 months; 'referral' delay in 67% of patients (n=20) ranging from 1 to 19 months and 23% of patients (n=7) had treatment delay (average 23 days) at the treatment centre. The causes of late arrival are not solely patient-related but are multifactorial. Measures to minimize such delays include enhancing awareness only with high index of suspicion among primary care practitioners, creating a special lane specialized imaging studies and establishing a dedicated musculoskeletal tumour unit.
MeSH terms: Adolescent; Adult; Bone Neoplasms/pathology; Bone Neoplasms/surgery*; Female; Hospitals, General; Hospitals, University/utilization; Humans; Health Knowledge, Attitudes, Practice; Malaysia; Male; Middle Aged; Neoplasm Staging; Patient Acceptance of Health Care/statistics & numerical data*; Problem Solving; Prospective Studies; Referral and Consultation/statistics & numerical data*; Time Factors; Muscle Neoplasms/pathology; Muscle Neoplasms/surgery*; Limb Salvage
Forequarter amputation entails surgical removal of entire upper extremity, scapula and clavicle. Several techniques of forequarter amputation have been described. The anterior approach has been the preferred technique of exploration of axillary vessels and brachial plexus. The posterior approach has been condemned to be unreliable and dangerous for most large tumor of the scapula and suprascapular area. We describe a surgical technique using posterior approach of exploration of major vessels for forequarter amputation of upper extremity in eight patients who presented with humeral-scapular tumor. There were six patients with osteosarcoma: three with tumor recurrent and three chemotherapy recalcitrant tumors with vessels involvement. One patient had massive fungating squamous cell carcinoma and another had recurrent rhabdomyosarcoma. Four patients had fungating ulcer and six patients had multiple pulmonary metastases at the time of surgery. The mean estimated blood transfusion was 900 ml (range 0-1600 ml) and two patients did not require transfusion. The duration of surgery ranged 2.5-6.0 hours (mean 3.8 hours). Two patients with known pulmonary metastases required post-operative intensive care monitoring. The mean duration of survival was 5.8 months. The posterior approach of exploring major vessels for forequarter amputation of upper extremity with musculoskeletal tumor is safe and reliable.
Patients treated with external fixation for limb reconsturciton or fracture stabilization equire regular and prolongedperiod of pin-tract care involving frequent visits to clinic and dressing traditionally carried out by trained nurses or medical assistants. A simple method of do-it-yourself dressing was introduced in our institution and this study was undertaken to evaluate the effectiveness of the protocol. Sixty patients (40 trauma-related problems and 20 congenital or developmental disorders) were enrolled into the study. Following application of external fixation, the patients and/or their caretakers were taught on how to do pin-site dressing using normal saline or drinking water as cleansing solution on daily basis. Patients were discharged on the second or third post-operative day and were followed-up every two weeks for an average 182 days (range 66 to 379 days) with special attention on identifying pin-tract infection. A simple grading system for pin-tract infections was proposed. Of 40 patients with trauma-related problems. 65% were post-traumatic infections. There were 788 metal-skin interfaces (239 half-pin fixations and 549 tensioned wire fixations. A total 143 metal-skin interface infections (18.1%) involving half-pin sites (41.3%) and tensioned wire sites (58.7%) was noted. Majority were grade I infections (79.7%), 18.8% grade II and only 1.4% grade III. Most infections (81%)were caused by Staphylococcus aureus. Grade I infections were successfully treated with frequent dressing, grade II by adjunctive oral antibiotic but grade III infections required removal of fixator. All eventually healed. Do yourself non-sterile dressing of metal-skin interfaces is a cost-effective method of pin-site care with a low infection rate. The infections were sucessfully treated using guidelines according to the proposed classification of pin-tract infections.
Post-traumatic chronic osteomyelitis and infected non-unions of the tibia following severe type-III open fracture are difficult to treat Refractoy cases often necessitate amputation despite attempts to salvage the limb. We report our experience in treating such difficult cases with an alternative surgical option using free osteocutaneous fibular graft. Eight consecutive patients with post-traumatic chronic osteomyelitis/infected non-union were treated surgically with free vascularized osteocutaneous fibular graft. Outcomes in term of graft-host union and complication were evaluated. Four patients had anastomotic venous thrombosis requiring anastomotic revision. Five patients developed surgical site infections needing extended antibiotic therapy to achieve resolution at an average of 15.2 weeks. Fibular graft fracture occurred in three patients but all grafts survived and united after a mean time to union of 42.3 weeks (range 31 to 82 weeks). At the final follow-up, union of host-graft junction and control of infection were achieved in all patients except one who required a secondary amputation. Free vascularized osteo-cutaneous fibular graft is a viable limb salvage option for refractory chronic osteomyelitis or infected non-union following treatment of grade-III open tibial fractures.
Slipped capital femoral epiphysis (SCFE) is a relatively uncommon hip disorder in adolescents and its prevalence in Malaysia has not been studied. This retrospective study is undertaken to provide an overview of a 12-year review of SCFE treated in our institution. Fourteen patients (19 hips) with slipped capital femoral epiphysis (SCFE) admitted to Hospital UKM from 1990 to 2002 were reviewed with respect to demographic profile, functional outcome according to the Iowa Hip Score, and complications. There were ten boys (average age, 12.5 years) and four girls (average age, 12 years). Eight were Malays and six were Indians. The average body mass index was 26.1 verweight). The left hips (11 hips) were affected more than the right hips (eight hips). Five patients had bilateral slips. Thirteen hips were considered stable while the other six hips were unstable. The majority of cases were moderate slips (12 hips), four hips had severe slips while three hips had mild slips. Several methods of treatment were instituted. These include in situ cannulated screw fixation (11 hips), Knowles pin fixation (three hips) and gentle closed manipulative reduction with cannulated screw fixation (three hips). One patient with bilateral slips refused surgical treatment. Based on the Iowa Hip Score, most patients (nine) had satisfactory results (excellent or good), three had fair results while one patient had a poor result. Avascular necrosis developed in five hips while chondrolysis occurred in one hip. In situ cannulated screw fixation is the treatment of choice. SCFE is an uncommon condition in Malaysia.
MeSH terms: Adolescent; Child; Epiphyses, Slipped/complications; Epiphyses, Slipped/radiography; Epiphyses, Slipped/surgery*; Female; Femur Head/injuries*; Femur Head/radiography; Femur Head/surgery; Femur Head Necrosis/etiology; Fracture Fixation, Internal; Hospitals, University; Humans; Malaysia; Male; Medical Audit; Retrospective Studies; Time Factors; Treatment Outcome*; Outcome Assessment (Health Care)*; Hip Injuries/complications; Hip Injuries/radiography; Hip Injuries/surgery*
Trend towards changing the face of management for pediatric femoral fractures tends to advocate operative treatment. This study was undertaken to review our current practice in the wake of recent progress in the management of pediatric femoral fractures. Fifty patients with femoral diaphyseal fracture treated in Sarawak General Hospital were reviewed retrospectively after an average follow-up of 2.6 years. There were 36 boys and 14 girls, with a mean age of 6.2 years (range five months to 14 years). Children under six years of age constituted the majority of the patients. Half of the fractures were caused by road traffic accident. Nine patients had associated injuries. The most common site of fracture was at the middle third (N=31). The treatment regimens were delayed hip spica (DHS) in 16, immediate hip spica (IHS) in 24, plate osteosynthesis (PO) in five, titanium elastic nailing (TEN) in five, and external fixation (EF) in one. The minimum hospital stay was two days, and the maximum 33 days (mean, 9.7 days). Malunion was the commonest complication. Conservative treatment is the preferred option for children under six years of age. It is cost-effective with minimal complication. The other treatment options are reserved for specific indication in older children. Diaphyseal fractures of the femur in children can be adequately managed non-operatively.
Total knee arthroplasty is the most preferred option for treatment of severe osteoarthritis of the knee. We report the short-term outcome of 48 total knee replacements in 31 patients utilizing the Apollo Total Knee System after an average follow-up of 48 months (range 15 to 70 months). Records of all patients who underwent TKA using Apollo Total Knee System were retrospectively reviewed. Functional outcome was evaluated using visual analogue scale for pain rating and the Oxford 12-item questionnaire. Postoperative radiographs of the replaced knees were assessed by using the Knee Society Total Knee Arthroplasty Roentgenographic Evaluation and Scoring System. Degenerative osteoarthritis was the commonest indication for TKA. The average patient's age was 63.7 years (range, 30-77 years). The mean visual analogue scale for pre- and post-operative pain was eight and zero respectively. The mean Oxford 12-item questionnaire score pre- and post-operatively was 44.8 and 16.5 respectively. Patient satisfaction was notable in 98% of the cases with an average improvement in arc of flexion of 111 degrees. There were four failures; deep infection (one) and aseptic loosening (three) giving rise to a 94% implant survivor. The short-term results of this series is comparable with or better than a number of outcome studies of the Apollo Knee System or other implants of similar design.
We report a case of a previously healthy 53-year-old man who developed an intra-operative catastrophic event occurring in association with the use of hydrogen peroxide for wound irrigation following surgical debridement of a chronic osteomyelitis lesion of the humerus. It is our intention to highlight this potentially fatal consequence of hydrogen peroxide irrigation as part of bone debridement procedure. This case will serve as a reminder to orthopaedic surgeons who frequently use hydrogen peroxide in their surgical practice.
We report a case of a 55-year-old man who presented with a 6-month history of a fungating ulcer on the right hand at the site of a previously healed ulcer that had been present for 40 years. Histopathological examination of four-quadrant biopsy specimens showed a moderately differentiated squamous cell carcinoma (SCC). A transradiocarpal amputation with stump closure using radial flap was performed as it was not possible to achieve a functionally and cosmetically acceptable hand after a wide excision with 2 cm tumour-free margin. It is our intention to highlight this rare condition as reminder to consider this entity as a differential diagnosis of chronic non-healing skin ulcer.
Acute traumatic transphyseal fracture of the capital femoral epiphysis is a rare but serious injury. The injury is typically inflicted by a severe trauma. Because of the vulnerability and predisposed anatomy of the femoral epiphysis in relation to its blood supply, the fracture has been designated to have poor prognosis with inevitable osteonecrosis and eventual deformity of the hip. We report a case of such fracture in a 13-year-old child in view to highlight some of the anticipated problems in the management of such injury.
MeSH terms: Adolescent; Emergencies; Epiphyses, Slipped/complications; Epiphyses, Slipped/radiography; Epiphyses, Slipped/surgery*; Femur Head/injuries*; Femur Head/radiography; Femur Head/surgery; Femur Head Necrosis/etiology; Femur Head Necrosis/prevention & control; Fracture Fixation, Internal; Hip Fractures/complications; Hip Fractures/radiography; Hip Fractures/surgery*; Humans; Male; Prognosis
We report a case of 20-year-old man who presented with bilateral femoral nerve palsy following resuscitation for traumatic massive blood loss and its consequence. A high suspicious index for this complication may lead to its early recognition. Its related pathoanatomy is discussed based on the described evidences in the literature. Nonoperative treatment remains as a recommended option for coagulopathy-related neuropathy.