Total femur endoprothesis is an alternative replacement for massive malignant bone tumor with intramedullary extension or skip lesion. Four patients underwent total femoral resection and replacement with megaprosthesis: three had primary malignant bone tumor and one had salvage procedure for aseptic loosening of the distal femoral replacement. Tumor-free margins were achieved in all patients with two patients required vascularized latissimus dorsi free flap cover for reconstruction of soft tissue defects. The average follow-up was 24 months (range 16 - 60 months). All four patients were still alive with three of them being disease-free and one survived even with the presence of lung metastasis. The functional results obtained were either excellent or good in all patients in accordance to the Musculoskeletal Tumors Society grading system.
Patellar thickness is an important consideration for resurfacing in total knee arthroplasty. A patella of 25 mm in thickness is not suitable for resurfacing using the currently available total knee systems. A cross sectional study on patellar thickness using plain radiographs was undertaken on 56 patients. It was observed that the average thickness of the bony part of the patella was 20.05 mm (range 17-23 mm). The actual thickness of cartilage varies from 2.0 to 5.5 mm (mean 3.2 mm). Thus the mean thickness of the patella was 23.2 mm (range 20.2-26.2 mm). The majority of our patients (73%) had patellar thickness of 24 mm or less. The patellar thickness had a significant correlation with the patient's height (R=0.5). Since the majority of our patients have thin patella, we are of the opinion that majority of our patients are not suitable for patellar resurfacing.
Pedicle screw system has increasingly been used for correction of thoracic scoliosis. It offers several biomechanical advantages over hook system as it controls all three-column of the spine with enhanced stability. Of many techniques of pedicle screw placement in the thoracic spine, the funnel technique has been used in Sarawak General Hospital since 2002. This prospective study aims to assess the accuracy of the placement of thoracic pedicle screws using the funnel technique in the corrective surgery of idiopathic scoliosis. A total of 88 thoracic pedicle screws were inserted into the T4 to T12 vertebrae of 11 patients. Post-operative CT-scan was performed to evaluate the position of the pedicle screw. Seventy six (86.4%) screws were noted to be totally within the pedicle. There was no screw with medial violation of the pedicle, 8 (9.1%) screws breeching the lateral wall of the pedicle and 4 (4.5%) screws with anterior and lateral penetration of the vertebral body. No clinical sequel with the mal-positioned screws was noted. In conclusion, the funnel technique enabled simple, accurate and reliable insertion of pedicle screw even in the scoliotic thoracic spine without the need of any imaging guidance. It is however imperative for the surgeon to have a thorough knowledge of the thoracic spine anatomy, and to be familiar with the technique to insert these screws diligently.
Spinal fusion using autologous bone graft is performed in an increasing rate for many spinal disorders. However, graft harvesting procedure is associated with prolonged operation time and potential donor site morbidity. We produced an engineered 'bone graft' substitute by using porous hydroxyapatite (HA) scaffold seeded with autologous bone marrow osteoprogenitor cells (OPCs) and fibrin. This obviates bone graft harvesting, thus eliminates donor site morbidity and shortens the operation time. The aim of this study is to evaluate Hydroxyapatite (HA) ceramics as scaffold for autologous tissue engineered bone construct for spinal fusion in a sheep model. The sheep's marrow was aspirated from iliac crest. The bone marrow mesenchymal stem cells (BMMSCs) were cultured for several passages in the presence of growth and differentiation factors to increase the number of OPCs. After the cultures reached confluence, they were trypsinized and seeded on Hydroxyapatite scaffold (HA). Approximately 5 million cells were generated after 3 weeks of culture. Microscopically, very tight Colony Forming Units (CFU-Fs) were seen on monolayer culture. The Von Kossa and Alizarin Red staining of monolayer culture showed positive mineralization areas; indicating the presence of OPCs. Sheep underwent a posterolateral spinal fusion in which scaffolds with or without OPCs seeded were implanted on both sides of the lumbar spine (L1-L2). Intended fusion segments were immobilized using wires. At the end of third month, the fusion constructs were harvested for histological examination. Fibrous tissue infiltration found in the inter-connecting pores of plain HA ceramics indicates inefficient new bone regeneration. New bone was found surrounding the HA ceramics seeded with autologous cells. The new bone is probably formed by the sheep BMMSCs that were initially encapsulating HA while it remained intact. The new bone is naturally fused with the vertebrae. In conclusion, the incorporation of autologous bone marrow cells improved the effectiveness of HA ceramics as 'bone graft' substitute for spinal fusion.
In view of poor regeneration potential of the articular cartilage, in-vitro engineering of cartilage tissue offers a promising option for progressive joint disease. This study aims to develop a biologically engineered articular cartilage for autologous transplantation. The initial work involved determination of chondrocyte yield and viability, and morphological analysis. Cartilage was harvested from the knee, hip and shoulder joints of adult New Zealand white rabbits and chondrocytes were isolated by enzymatic digestion of the extra-cellular matrix before serial cultivation in DMEM/Ham's F12 media as monolayer cultures. No differences were noted in cell yield. Although chondrocytes viability was optimal (>93%) following harvest from native cartilage, their viability tended to be lowered on passaging. Chondrocytes aggregated in isogenous colonies comprising ovoid cells with intimate intracellular contacts and readily exhibited Safranin-O positive matrix; features typically associated with articular cartilage in-vivo. However, chondrocytes also existed concurrently in scattered bipolar/multipolar forms lacking Safranin-O expression. Therefore, early data demonstrated successful serial culture of adult chondrocytes with differentiated morphology seen in established chondrocyte colonies synthesizing matrix proteoglycans.
Bone defect following en bloc resection of primary bone tumor around the knee can be reconstructed by allograft or prothesis or combination of both. Resection-arthrodesis is an alternative option for young vigorous patients facing circumstances of financial constrain or limited supply of allograft. This study was undertaken to determine the outcome and complications associated with resection-arthrodesis of 22 primary bone tumors (13 giant cell tumors and 9 osteosarcomas) around the knee treated between 1990 and 2003 at the University Malaya Medical Center. The mean follow-up was 6 years (range 1-13 years). hree patients with osteosarcoma died of lung metastasis, 3 required above knee amputation and 2 defaulted follow-up. Local complications of the procedure include infection in 8 cases (36.4%), non-union 7 (31.8%) and mal-union. Of 14 patients who returned for final evaluation, 79.8% had satisfactory outcomes according to the Musculoskeletal Tumor Society grading system. In conclusion, resection-arthrodesis of the knee is a viable treatment option for selected patients with primary bone tumor around the knee, and good functional outcome can be expected in the presence of short-term local complications.
This retrospective study aims to evaluate the effectiveness of the modified regime for rehabilitation of Zone II flexor tendon injuries in Sibu Hospital. From January to December 2003, 8 patients with 15 injured digits were treated by using the combined method of dynamic traction and passive mobilization. According to Strickland's criteria, 14 (93.3%) digits achieved good to excellent outcomes and only 1 (6.7%) was rated as poor. No occurrence of tendon rupture was noted. The overall grip strength of the injured hand was 50.1% of the uninjured hand at 3 months after the repair. Our results compare favorably with the other published studies. We believed that this modified regime is as effective as other established regimes and suitable to be adopted in our setting. Further study with larger sample group will be required to consolidate our findings.
This finite element analysis is aimed at comparing relative stiffness of three different posterior instrumentation constructs: the Hospital Universiti Kebangsaan Malaysia Spinal Instrumentation System (HUKM-SIS), the Cotrell-Dubousset Instrumentation (CDI) and Harrington Instrumentation System (HIS), used in the treatment of adolescent idiopathic scoliosis (AIS). The constructs were tested under various loads using MSC Patran 2001 r2a. Under increasing flexion loads, there was a linearly corresponding increase in deflection magnitudes for all constructs on the load-deflection curve. The CDI was the stiffest construct under axial, forward flexion and extension loads, followed by the HUKM-SIS and HIS. Under lateral bending loads, the HUKM-SIS construct was the stiffest followed by CDI and HIS. The HUKM-SIS construct was stiffer than HIS under torsional loads. We conclude that multiple pedicle screws increase the stiffness of posterior instrumentation constructs under all loads and inter-segmental spinous processes wiring increase the stiffness against lateral bending.
Femoral interlocking nailing requires fluoroscopic assistance for insertion of the nail and distal screws. In this study, scattered radiation to the eye and hand of the operating surgeon was measured during the procedure. Thermo-luminescent dosimeter (TLD) was used to quantify the dose received by the surgeon. The mean radiation exposure time during the procedure was 3.89 minutes. The mean scattered radiation doses to the hand and eye were 0.27 mSv and 0.09 mSv per procedure respectively. These very low doses have made a surgeon very unlikely to receive more than the recommended annual dose limit set by the National Council on Radiological Protection.
The need for perioperative blood transfusion in elderly patients with trochanteric fracture scheduled for elective dynamic hip screw fixation has recently been questioned following reports on the association between allogeneic blood transfusion and post-operative infections. This retrospective study was undertaken to assess the amount of per operative blood loss and transfusion requirement in relation to pre-operative haemoglobin level in 198 patients with trochanteric fractures. The average per operative blood loss was 409 ml and it correlated well with the duration of the operation. More than half of the patients (52.5%) required blood transfusion and nearly three-quarters were anaemic prior to the surgery. Proactive pre-operative measures to optimize the patient's haemoglobin level and intra-operative minimization of blood loss are essential steps to obviate the need for perioperative allogeneic blood transfusion.
Shoulder arthrodesis is a secondary reconstructive option for patients with brachial plexus injuries requiring a stable shoulder. This study was undertaken to evaluate the clinical and radiological outcomes of shoulder fusion in six patients with flail upper limbs following complete brachial plexus injuries. The shoulder was fused in 30 degrees abduction, 30 degrees internal rotation and 30 degrees flexion via a direct lateral approach by using a 4.5 mm reconstruction plate without bone grafting. The average follow-up was 10.3 months. Radiological union was obtained in all patients. Five patients (83%) had relief of pain after the shoulder fusion. Improvement of function was observed in all patients with a mean improvement of 56.6 degrees (range 30 degrees-75 degrees) and 47.5 degrees (range 30 degrees-60 degrees) active flexion and abduction respectively. One patient developed humeral fracture distal to the plate and the fracture eventually healed with a splint. Successful stable fusion of the shoulder in patients with brachial plexus injuries requires rigid fixation with a single 4.5 mm reconstruction plate, protection of bone healing with a triangular abduction brace for 12 weeks and functional trapezius, levator scapulae, serratus anterior and rhomboid muscles for optimizing the functional result.
This retrospective study was conducted in a state hospital set-up and aimed at identifying the incidence of sports-related shoulder dislocations and their characteristics and the sports events involved. All patients with shoulder dislocation related to sporting activities admitted to the hospital from January 1999 to December 2002 were included in the study. There were 18 sports-related shoulder dislocations out of 106 all shoulder dislocations admitted during this 4-year period. The average age of the patients was 25.4 years. All but two were male. All were anterior dislocations. Recurrent dislocation constitutes 78% of the cases with an average of 3 times re-dislocation. Rugby and badminton were the major contributors to the injuries followed by volleyball, soccer and swimming. Conservative treatment was successfully instituted for 88% of the patients and 12% opted for surgical intervention.
This retrospective study was conducted in a state hospital set-up and aimed at identifying the magnitude of shoulder dislocations and their demographic data, characteristics of the injury, mechanism and predisposing factors, and the instituted treatment. Patients with radiographic evidence of shoulder dislocation admitted to the hospital from January 1999 to December 2002 were included. Data were recorded from the case notes. There were 105 shoulder dislocations with male predomination in 77% cases and age ranged between 11 and 90 years (average 30.9 years). The right shoulder was affected in 68% of the cases. The contributing events were fall in 37% of cases, road traffic accident 23%, sports 17% and pathological conditions 13%. Anterior dislocation occurred in 96.2% of the cases. Posterior and inferior dislocations encountered in two patients for each type. Twelve dislocations were associated fracture of the greater tuberosity, two each with humeral neck fracture and cerebral injuries. First time dislocation occurred in 73.6% of the cases. The recurrences ranged between 2 to 6 times (average 3.4 times). Closed manipulative reduction and strapping was the definitive treatment in 92.4% of the cases and the remaining needed surgical reconstruction. Four patients had open reduction and internal fixation of the associated fractures while another four had arthroscopic Bankart's repair. In conclusion, shoulder dislocation represents the most common shoulder problems. It afflicted young adults of reproductive age (21-40 years) and participation in sports was a risk factor in men. Women over 40 years and fall were at risk to develop shoulder dislocation.
The choice between limb salvage and primary amputation in a severely injured limb is at time difficult. A case of severe Gustilo type-IIIB open fracture of the tibia with massive soft tissue loss is presented to highlight the immediate and definitive treatment undertaken to preserve the limb.
Soft tissue loss of the heel is difficult to treat as it may cause significant morbidity particularly recurrent ulceration and subsequent chronic osteomyelitis. Reconstruction of such defect with local flap can provide good result. We report our experience in treating four patients with heel defect using the in-step island flap. The flap, which is based on the medial plantar neurovascular pedicle, provides a sensate durable tissue required for weight-bearing and normal gait.
We report a case of upper cervical instability associated with Down syndrome to highlight its potential progression to inflict cord compression and the rationale for surgical decompression and extended short segment occipito-axial fusion.
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.
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.
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.
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.