Gentamicin, whether administered either intravenously, incorporated into bone cement or for local intra-operative irrigation, is a commonly used antibiotic in orthopaedic practice. The former two have been well studied, however the literature on the therapeutic efficacy and safety of gentamicin irrigation is sparse. The objective of this study was to assess systemic absorption of gentamicin irrigation in joint replacement surgery. This was a non-randomised, prospective study. Ninety-eight patients (group A) who underwent total joint replacement and 40 patients (group B) who underwent hemi-arthroplasty were treated traoperatively with gentamicin irrigation. Serum gentamicin levels were assayed at 4 hours and 24 hours post-surgery. Sixteen of 98 patients in group A (16%) and 12 out of 40 patients in group B (30%) were found to have serum gentamicin level above 2mcg/ml at 4 hours post-surgery. We conclude that intra-articular gentamicin irrigation is systemically absorbed at substantial levels.
This study was conducted to assess the optimum period for Kirschner wire fixation and cast immobilization for displaced lateral condylar fracture of the humerus in children. We retrospectively reviewed 12 patients with displaced lateral condyle humerus fracture, ranging in age from 3-9 y, with injuries that occurred between Jan 2005 and Dec 2006. All patients were treated with two Kirschner wire fixation and elbow immobilization. In all except 2 patients, the Kirschner wires were maintained for 3 to 4 weeks. Mean time for union was 3.78 weeks and mean humeroulnar arch motion at last review was 138.7 degrees. Only one patient had a 5 degree increased carrying angle in valgus as compared to the non-injured side, and 50% had prominent scars > 4mm. We conclude that fracture union can be expected within three to four weeks for most children after open reduction and fixation with 2 Kirschner wires.
We describe herein a modified technique for reconstruction of chronic rupture of the quadriceps tendon in a patient with bilateral total knee replacement and distal realignment of the patella. The surgery involved the application of a Dacron graft and the ‘double eights’ technique. The patient achieved satisfactory results after surgery and we believe that this technique of reconstruction offers advantages over other methods.
In comminuted patellar fractures, a combination of cerclage wiring and tension band fixation is said to provide good mechanical stability. This is a retrospective review of four patients treated with this method. All fractures described herein were classified as 45-C3 (based on Orthopaedic Trauma Association classification) and were fixed with a 1.25mm cerclage wire and tension band wire proximally looped through the quadriceps tendon and distally through the patellar ligament in a figure-of-eight configuration. The average follow-up period was 10 months. The Activity of Daily Living Scale (ADLS) of the Knee Outcome Survey was used to assess symptoms and functional capability of the knee. In all the cases, fracture union was achieved at an average of 11 weeks. The average ADLS score was good (92.5 %). Full range of knee motion was achieved by end of the third postoperative month. None of the patients had complications, such as infection and implant failure.
The safety of simultaneous bilateral total knee arthroplasty (TKA) remains controversial. The objective of the current study was to investigate perioperative morbidity and mortality rates within 30 days of simultaneous bilateral TKA. A detailed analysis of medical, surgical and anaesthesia records of 183 consecutive patients who underwent total knee arthroplasty between 2002 and 2006 was performed. The mean age of the patients was 67.6 years old. More than 80% had one or more co-morbidities, but none of them had ASA score greater than class 2. The mean hospital stay was 10 days, and the mean surgical time 156 minutes. Less than half of the patients (42.6%) required blood transfusion. The rate of perimorbidity was 15.3 % and there was no mortality in this series. We believe that simultaneous bilateral total knee arthroplasty is a safe and cost effective option for our patients, provided that patients are selected and informed appropriately.
Bone lengthening with distraction osteogenesis involves prolonged application of an external fixator frame. Qualitative and quantitative evaluation of callus has been described using various imaging modalities but there is no simple reliable and readily available method. This study aims to investigate the use of a densitometer to analyze plain radiographic images and correlate them with the rate of new bone formation as represented by the bone healing index. A total of 34 bone lengthening procedures in 29 patients were retrospectively reviewed. We used an X-Rite 301 densitometer to measure densities of new callus on plain radiographs taken at 4 and 8 weeks after surgery. Patients aged below 16y had significantly lower BHIs indicating faster bone healing and shorter duration of treatment. The ratio of radiographic densities between centre and edge of the new bone measured from plain radiographs taken at 8 weeks correlated positively with the eventual BHI of the patient. This method provides a simple and easy way to predict the rate of bone healing at an early stage of treatment and may also allow remedial action to be taken for those with poor progress in bone formation.
We report here a rare presentation of an extra-nodal non-Hodgkin's lymphoma. Both clinical presentation radiological findings were suggestive of psoas abscess. Surgical debridement was performed and histopathological examination of the tissue sample revealed the diagnosis of non-Hodgkin's lymphoma. It is therefore important to note that non-Hodgkin's lymphoma can mimic psoas abscess and that psoas lesion with vertebral involvement does not necessarily indicate infection. It is always advisable to obtain needle biopsy to establish diagnosis before embarking on surgical intervention. The practice to send any suspicious tissue obtained intra-operatively for histopathological examination is also warranted.
This is a prospective randomized clinical trial to compare use of a combination of periarticular drug injection with patientcontrolled analgesia (PCA) to PCA alone in post-total knee arthroplasty (TKA). Thirty patients who were admitted for unilateral total knee arthroplasty were selected randomly into an Injection group or a Standard group. The periarticular injection contained Ropivacaine, Ketorolac and Adrenaline, given intra-operatively. The mean amount of opioid used was 22.87 mmol/L in the Injection group as compared to 39.78 mmol/L in the Standard group (p = 0.026). The Injection group had lower pain score at rest and during exercise (p=0.021, p=0.041, respectively), as well as better return to function (p=0.026) and shorter hospital stay (6.1 days, Injection; 7.5 days, Standard, p=0.027). Overall, the group receiving periarticular drugs injection had less pain, less narcotic usage, earlier return to function, similar experience of adverse effects and shorter hospital stays.
The goal of treatment in distal radius fracture is to restore the anatomy of the distal radius, however the criteria currently used to evaluate the quality of eduction are based on Western based published figures. This goal of this study was to investigate whether there are variations in the morphology of the distal radius among the multiracial population of Malaysia. Consecutive normal wrist radiographs of patients who presented to the accident and emergency unit in three major hospitals in Malaysia were measured. The palmar tilt of the distal radius averaged 12.6o ± 3.55o, and the radial inclination averaged 25.1o ± 3.42o. The ulnar variance averaged – 0.1 ± 1.31mm, 38.4% of the patients had neutral ulnar variance, 28.8% have negative ulnar variance and 32.9% have positive ulnar variance. Our results indicate that distal radius morphometric parameters in the Malaysian population are comparable to Western figures.
A rare case of spontaneous bilateral stress fractures of femoral neck leading to coxa vara in a young female with history of chronic renal disease and secondary osteomalacia is described. Once the underlying disease was controlled, the fracture was treated by valgus osteotomy with good result.
Infection after joint replacement surgery is problematic and difficult to treat. The utility of antibiotic laden bone cement for reduction of risk of infection in primary and revision joint replacement surgery has already been established in many studies. In this study, we examined the efficacy of bone cement containing cefuroxime, employing a modified in vitro Kirby-Bauer susceptibility model for investigation of 13 strains of organisms that are found in orthopaedic infections. Organisms investigated were broad spectrum and effective for Gram-positive, Gram-negative, aerobic organisms and anaerobes. Simplex P with added cefuroxime was effective against 8 out of 13 strains. Cefuroxime is stable during exothermic polymerisation of the cement, and is released from the cement at concentrations high enough to inhibit the growth of most organisms encountered after joint arthroplasty.
Dupuytren contracture is commonly seen in northern European populations but not in Asians. Even more rare is a presentation of flexion deformity of fingers involving two different pathologies with incidental carpal tunnel syndrome in the same patient. We report herein a case of Dupuytren contracture with congenital camptodactyly and unilateral carpal tunnel syndrome.
Splinter or foreign body removal from the hand and foot is a common occurrence. Usually only the deep seated, broken or missed splinters are referred to the surgeon for removal. Unless the object is radio-opaque, plain radiograph will not give any useful information, hence removal can sometimes be very difficult and traumatic. We are reporting a case where a radiolucent splinter was removed with the aid of ultrasonography. This modality can help to localize a splinter at the pre and intra-operative period, minimizing amount of exploration and time of operation.
Int roduction: Treatment of calcaneal fracture is still controversial and indication for surgery is not well
established. We are reporting the mid term outcome of calcanel fractures treated conservatively. Material and Methods: Patients admitted with calcaneal fractures from 1st November 2002 till 31st December 2004 and were treated conservatively were included in this study. The fractures were grouped according to Essex-Lopresti classification and their outcomes were assessed with the Maryland foot score. We also looked at time to weight bearing and returning to occupational activity. Results: Forty-four patients were included for evaluation. Patients with extraarticular calcaneal fractures had significantly higher rating scores compared to those with intraarticular fractures (98.2 and 88.8 respectively, with a p value = 0.0001). Generally, both group of patients had a good clinical outcome. 18 of the 44 patients (41%) started partial weight bearing before or at 6 weeks and 31 patients (72%) were able to start full weight bearing by 12 weeks. 31 patients (72%) were back to work 12 weeks after the injury. Conclusion: Conservative management for calcaneal fractures is an acceptable mode of treatment with satisfactory.
Aim: This study was designed to evaluate the use of ultrasound in diagnosis of infection and tumour of long bones. Methodology: Patients referred from the orthopaedic unit with doubt regarding long bone clinical and/or radiological signs which could be tumour or infection were enrolled in this study. Analysis of ultrasound characteristics included presence of pericortical fluid over normal cortex well away from the primary lesion, wavy contour sign (fluid tracking in and out muscle planes), subperiosteal fluid and soft tissue mass displacing adjacent muscle planes. Results: Fourteen out of 15 patients with confirmed osteomyelitis were diagnosed by ultrasound examination. Ultrasound as a diagnostic tool has a sensitivity of 93% and specificity of 100%. The most accurate indicator was pericortical fluid noted up to several centimetres from the long bone abnormality seen on plain x-rays. Conclusion: Ultrasound is a safe, fast, cost-effective imaging modality that can play an important role in diagnosis of osteomyelitis as it then serves as a tool for ultrasound guided aspiration.
Purpose: To evaluate the usefulness of ultrasound guidance in percutaneous needle biopsy for musculoskeletal tumours.
Methods: Forty-five consecutive patients underwent ultrasound-guided needle biopsy. An additional group of 50 patients who underwent needle biopsy without ultrasound guidance was retrospectively selected as historical control. The sample was considered adequate when a diagnosis can be made, and diagnostic when the diagnosis is similar to the final report based on the excised tumour.
Results: Adequacy of the biopsy samples was 84% in ultrasound-guided group as compared 76% in the group with no ultrasound guidance. Diagnostic accuracy was 64% in the ultrasound-guided group and 52% in the group without ultrasound guidance. Both of these differences were not statistically significant.
Conclusions: Ultrasound guidance did not provide a significant advantage in the biopsy of musculoskeletal tumours. Diagnostic accuracy seems to improve with the use of larger 14 gauge biopsy needle but further evaluation is necessary.
Interlocked intramedullary nailing is accepted as the gold standard for femoral shaft fractures. However for Winquist type I and II femoral fractures at the isthmus region, unlocked intramedullary nailing (Küntscher nailing) is still a good option. We performed a retrospective study on 86 patients with a total of 88 femoral shaft fractures around the isthmus that presented at our institution between 1 January 1988 and 31 August 2003. All patients (84.1% Winquist type I and 15.9% Winquist Type II fractures) were treated with unlocked intramedullary nail. The average time to union was 16 weeks with 97.7% rate of union. There were two cases (2.3%) of infection and non-union each. Overall results were comparable to standard interlocking intramedullary nailing. We conclude that unlocked intramedullary nailing is a good treatment option for Winquist Type I and II femoral fracture around the isthmus with its good union rate and minimal complications.
Interlocking intramedullary nailing is suitable for comminuted femoral isthmus fractures, but for noncomminuted fractures its benefit over unlocked nailing is debatable. This study was undertaken to compare outcomes of interlocking nailing versus unlocked intramedullary nailing in such fractures. Ninety-three cases of noncomminuted femoral isthmus fractures (Winquist I and II) treated with interlocking nailing and unlocked nailing from 1 June 2004 to 1 June 2005 were reviewed; radiological and clinical union rates, bony alignment, complication and knee function were investigated. There was no statistical significant difference with regard to union rate, implant failure, infection and fracture alignment in both study groups. Open fixation with unlocked femoral nailing is technically less demanding and requires less operating time; additionally, there is no exposure to radiation and cost of the implant is cheaper. We therefore conclude that unlocked nailing is still useful for the management of non-comminute isthmus fractures of the femur.
This study evaluates the outcome of anterior cruciate ligament (ACL) reconstruction with arthroscopy using the bone–patella tendon-bone method. We performed this procedure in 24 patients with the average age of 33.1 years (range: 17-51 years ) between 2004 and 2006. Sixteen of the 24 patients were available for evaluation using the Lysholm Knee Score and International Knee Documentation Committee (IKDC) system. Based on the Lysholm score, there was a statistically significant improvement in knee function when comparing pre- and post-surgical scores (p
We are reporting a case of post-traumatic chronic osteomyelitis of the tibia with an open wound exposing an intra medullar nail implant for 13 years. The patient presented with fresh ipsilateral tibia plateau fracture. He was treated by removal of the implant, debridement and local placement of Gentamicin-impregnated PMMA beads according to guidelines of two-stage Belfast technique . After five months of wound treatment, the exposed bone was covered by healthy granulation tissue and the patient was able to fully bear weight.