Percutaneous endoscopic spinal surgery performed in the awake state offers a new paradigm for treatment of symptomatic lumbar disc prolapse. We report the outcome of 23 patients who underwent this procedure. Visual analogue scale for pain improved from 7.3 to 2.1; 19 of the 23 patients achieved good to excellent results according to the MacNab criteria. Patient acceptance of the procedure was 91.3%. All but one patient were discharged from hospital within 24 hours. One patient developed foot drop post-operatively. There was no incidence of dural tear, post-operative infection or worsening of symptoms. We conclude that this is a safe, effective, and well-tolerated procedure.
We report the outcome of 32 patients who underwent total hip replacement (THR) augmented with morsellized fresh frozen femoral head allografts and acetabular reconstruction cages. Nine patients underwent primary THR and 23 patients underwent revision THR. Follow-up ranged from two to 9 years. Two most common indications for the procedures as reported in literature were rheumatoid arthritis and aseptic loosening of the hip. All but one patient achieved good outcome with radiographs showing full incorporation of bone grafts and no evidence of loosening of the implants. Morsellized bone grafting used with acetabular reinforcement devices is valuable for addressing severe acetabular deficiencies.
A study to determine average knee laxity in the Malaysian population and how it affects daily living was conducted at the University Malaya Medical Centre between January and April 2004. Fifty two male and 76 female subjects were recruited for this study, all of whom were healthy volunteers with no ambulatory problems. Side to side knee laxity testing was performed using a KT-1000 arthrometer. Significant differences in knee laxity were noted among different races and between sexes. For instance, overall, Chinese and female study participants had higher knee laxity: (left knee, 2.17 mm (SD=1.30) and right knee was 2.88 mm (SD= 1.51)). On average, the difference between knees was 0.70 ± 1.26 mm (less than 1 mm) which is a smaller variation than reported in previous studies which suggested 3 mm. Despite finding knee laxity ranging from 0 to 8mm, no correlations were found between Lysholm, IKDC and Tegner knee outcome scores and the degree of knee laxity. No other predictors such as height, weight and age correlated with levels of knee laxity. We therefore conclude that knee laxity is a common occurrence in the normal population and is therefore not suitable as a sole predictor of knee function and should not be used as the only criteria for surgical intervention.
Study site: Orthopedic clinic, Universiti Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
Traumatic hip dislocation in children is uncommon; when this condition is diagnosed in paediatric patients, it is most frequently seen as a unilateral posterior dislocation and is rarely associated with fracture. We report here a case involving a young girl who dislocated both hips in two separate incidents.
Reduction of a malunited femoral diaphyseal fracture can be achieved by osteotomy and immediate internal fixation or gradual skeletal traction followed by delayed internal fixation. We retrospectively reviewed 27 patients with malunited and shortened femur. Nine patients with mean shortening of 4.7 cm (2.5-10.0) underwent acute one-stage reduction and gained 2.5 to 5.0 cm length. Eighteen patients with mean shortening of 5.3 cm (3.5 to 9.0) underwent twostage reduction and gained 2.0 to 5.0 cm length. There was no paralysis in either group. No infection occurred in the one-stage procedure. Intramedullary fixation demonstrated superior results compares to plate fixation.
Domestic paediatric hand injuries make up the bulk of overall paediatric hand injuries. This is a retrospective study of domestic paediatric hand injuries admitted into an urban hospital that required surgical intervention. The most common injuries sustained were tendon injuries (24%), total amputations (20%) and lacerations wounds (16%). Accordingly the most common surgical interventions were tendon repairs (28%), toilet suturing (24%) and refashioning (20%). Parents and care providers need to be more vigilant and careful when supervising children including ensuring the safe storage of dangerous items. Sharp items may require additional safety features and warning labels.
We report on the medium term outcome of five patients (ten hips) who underwent one stage bilateral total hip arthroplasty. Both Harris Hip Scores and Oxford Hip Scores improved postoperatively as did range of motion. There was no radiographic evidence of loosening in any hip arthroplasty involved in this study, however one revision surgery was needed due to periprosthetic fracture. There were no increased medical complications. Based on our limited experience, we believe that one stage bilateral total hip arthroplasty is safe in selected patients.
A 27-year-old patient with ameloblastoma of the mandible
underwent anterior mandibulectomy and reconstruction with
left fibula osteocutaneous flap. The bone was shaped at the
lower limb before cutting the pedicle. Vascularised free fibula flap provides a good alternative to other bone grafts in mandible reconstruction as it is relatively easy to perform, carries a low complication rate, and mandibular shaping with intact pedicle cuts down on ischaemic as well as total operative time.
The incidence of pseudoaneurysm after total hip arthroplasty is extremely rare. The most common mechanism of vascular injury is due to direct trauma during the operative procedure and most reported cases are acute in a presentation. We report an unusual case of pseudoaneurysm of the external iliac artery, presenting 6 years after initial surgery, and occurring following septic loosening of total hip arthroplasty. This case highlights the importance of prompt recognition of infection of total hip arthroplasty, and also indicates the need for prompt and appropriate treatment for these infections.
We report a case of a broken K-wire migrating to the cervical spine from the right clavicle in a 9-year-old child. The initial diagnosis, fracture of the clavicle with an acromioclavicular joint dislocation, was treated by open reduction and K-wiring. One K-wire broke and migrated to the neck, posterolateral to the C6 vertebra. The K-wire was removed percutaneously under image intensification. Acromioclavicular joint dislocation in children is rare since the distal clavicle does not ossify until the age of 18 or 19 years meaning that almost all closed fractures of the clavicle in children can be treated nonoperatively.
Musculoskeletal tumour is much less common compared to tumours of epithelial origin. Most of these tumours are benign, with only about 1% malignant in nature. A general orthopaedic surgeon may only come across a malignant primary bone or soft tissue tumour a few times in his entire medical career. The current recommendation is for these conditions to be investigated and treated in centres with musculoskeletal oncology service. Careful clinical evaluation with appropriate plain radiography can provide adequate information for definitive diagnosis and treatment for most cases, especially the benign tumours. For some other cases, further investigations will be necessary. Magnetic resonance imaging (MRI) can provide excellent details on anatomical location of a tumour and delineate vital structures that may have been distorted by the lesion. For primary malignant tumours, computerized tomography scanning is still the gold standard for evaluation of pulmonary metastasis, and bone scan can allow early detection of distant metastasis to other bones. Whole body MRI has recently been recommended for tumour staging but the potential benefit for musculoskeletal tumour is not that convincing. PET may be very helpful for follow up detection of tumour recurrence but its role in diagnosis and staging of musculoskeletal tumours is still being evaluated...
Biopsy is a crucial step in the management of musculoskeletal sarcoma. The surgical approach to the biopsy site is important, as the tract must be removed en bloc with the tumour during limb sparing surgery so as to reduce the risk of local recurrence. The biopsy tracts of 26 osteosarcoma patients were evaluated histologically for tumour infiltration. Horizontal sections of 1 mm thickness with 2 cm radius from were evaluated from each excised biopsy tract. Five out of 26 cases (19.2%) showed positive tumour infiltration. One case (3.85%) had tumour infiltration in the pseudocapsule, two cases (7.69%) had tumour infiltration into the muscle and two other cases (7.69%) had tumour infiltration into the subcutaneous tissue. None had skin infiltration. We conclude that resection of the entire biopsy tract is indeed mandatory for surgical treatment of osteosarcoma.
Congenital partial aplasia of the atlas with a posterior arch remnant is rare. It may be found as an incidental radiological finding or patients can present with neurological signs and symptoms after head or neck trauma. A 36-year-old female presented with a 3-day history of right sided neck pain radiating down the right arm. Radiographs of the cervical spine showed a radiolucent area in the region of the posterior arch of the atlas. Computed tomography subsequently revealed partial absence of the posterior arch of the atlas with a defect at the anterior ring. Her clinical condition subsequently improved with rest, analgesia and physiotherapy. This case report illustrates a situation where congenital defect of the posterior arch of the atlas was revealed in a patient with neck pain. Awareness of the existence of this condition will help clinicians avoid misdiagnosis and excessive investigations.
In 1977, a female patient, aged 31y, presented with histiocytosis X in the right pelvis and was treated with radiotherapy. She presented again in 1999 at the age of 53y with a similar problem at the same location this time also involving the acetabulum. The affected right hip was treated with cemented total hip replacement. Two years postoperatively, the patient was pain free with no evidence of local recurrence or loosening of implant, thus demonstrating that total hip replacement is a viable treatment option for histiocytosis involving the hip.
Although lipoma is common in the upper limbs, it rarely occurs in the palm, and usually does not compress the surrounding structures. Here, we report a patient presenting with compressive neuropathy of the ulna and median nerves secondary to a palmar lipoma. Surgical excision led to full neurological recovery.
Palmaris longus is a dispensable muscle with a long tendon which is very useful in reconstructive surgery. It is absent 2.8 to 24% of the population depending on the race/ethnicity studied. Four hundred and fifty healthy subjects (equally distributed among Malaysia's 3 major ethnic groups) were clinically examined for the presence or absence of palmaris longus. This tendon was found to be absent unilaterally in 6.4% of study subjects, and bilaterally in 2.9% of study participants. Malays have a high prevalence of palmaris longus absence at 11.3% followed closely by Indians at 10.7% whilst Chinese had a low absence rate of 6.0%.
This study involved evaluation of the elbows of 50 children between 4 to 14 years of age. Clinical examination for elbow flexion, extension, range of motion and carrying angle were performed, followed by ultrasonographic examination to determine position of the ulnar nerve in relation to the medial epicondyle upon elbow flexion and extension. Thirty-one elbows showed anterior displacement of the ulnar nerve, of which 14 were due to subluxation and 17 to dislocation. We found that anterior translation of ulnar nerve is present in the elbows up to 31% of children, especially those with increased range of elbow motion.
Forty children treated non-operatively for fractures of the femoral shaft were reviewed with regard to differences in limb length after treatment. Follow up duration ranged from two to seven years. The average femoral overgrowth was 0.85cm (range 0 - 2.5cm) and was influenced by age at the time of fracture. We were not able to find any association between the quantity of overgrowth and race, gender, level or configuration of the fracture.
We conducted a retrospective review on eleven patients who were treated for Type A and C distal femoral fractures (based on AO classification) between January 2004 and December 2004. All fractures were fixed with titanium distal femoral locking compression plate. The patient’s ages ranged from 15 to 85 with a mean of 44. Clinical assessment was conducted at least 6 months post-operatively using the Schatzker scoring system. Results showed that four patients had excellent results, four good, two fair and one failure.
We report a case of 29-year-old female who presented with right heel pain that worsened over a period of two years. The onset of pain was followed by swelling at the medial aspect of right ankle. She was initially treated for plantar fasciitis with multiple steroid injections over the heel. Subsequent MRI revealed a well-defined heterogeneous lesion in continuity with the medial plantar nerve. Excision biopsy was performed and histopathological evaluation revealed monophasic synovial sarcoma. The patient subsequently underwent wide resection and free tissue transfer followed by radiotherapy and chemotherapy. This case highlights an unusual site and presentation of synovial sarcoma which led to delayed diagnosis and treatment.