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Fulltext Outcome of Islanded Gastrocnemius Musculocutaneous Flap in Orthopaedic Practice

Yusof MN, Ahmad-Alwi AA

Malays Orthop J, 2019 Mar;13(1):25-29.
PMID: 31001380 DOI: 10.5704/MOJ.1903.004

Introduction: Large wounds in the leg require combination of local flaps or free flap for wound coverage. Gastrocnemius musculocutaneous flap (GMCF) allows a large wound to be covered by a single local flap. However, the conventional GMCF is often associated with donor site morbidity where the exposed soleus raphe causes poor uptake of the skin graft. Islanding the skin on the muscles allows the donor site to be closed primarily, thus avoiding the donor site morbidity. Materials and Methods: Medical records of twelve patients who underwent islanded GMCF surgery from 2004 till 2018 were reviewed retrospectively. Results: The mean age was 31 years old. Eight cases were with open fracture of the tibia, two degloving injury exposing the patella, one open fracture of patella and necrotising soft tissue infection. The wound size ranged from 12cm2 to 120cm2. All flaps survived. Three patients required skin grafting at the donor site while in the rest the donor sites were able to be closed primarily. Four patients developed deep infection, one healed after vacuum dressing, one after bone transport and one after split thickness skin graft. One patient ended up with below knee amputation after developing chronic osteomyelitis of the tibia. Conclusion: Islanded gastrocnemius musculocutaneous flap is an effective simple alternative for coverage of large soft tissue defects from the knee to half of the leg distally with minimal donor site morbidity. Aggressive debridement of unhealthy tissue is necessary to prevent infection following wound coverage with this flap.
Fulltext Highly Crosslinked Polyethylene Tibial Post Fracture in the Unafflicted Limb of a Patient with Unilateral Lower Limb Poliomyelitis: A Case Report

Lee WC, Wee L

Malays Orthop J, 2019 Mar;13(1):42-44.
PMID: 31001383 DOI: 10.5704/MOJ.1903.008

We present a unique case of tibial post fracture of a posterior-stabilised total knee arthroplasty (PS-TKA) using highly crosslinked polyethylene (HXLPE) in the unafflicted limb of a patient who had poliomyelitis. The tibial post is an upright structure perpendicular to the PE insert articular surface which articulates with the cam of the femoral component to prevent excessive posterior translation of the tibia. We explore the choice of PS polyethylene (PE) inserts in patients with neuromuscular disorders (NMD). A 74-year old gentleman presented with recurrent knee pain seven years after the index PS-TKA with HXLPE. The TKA was performed on the unafflicted left limb (contralateral to the weak side affected by poliomyelitis). The posterior drawer test was positive. During the single-stage revision surgery, the HXLPE tibial post was noted to be broken. The liner was replaced with a thicker non-HXLPE. The patient achieved an excellent outcome at one-year post-surgery. This is the first report of HXLPE tibial post fracture in the unaffected knee of a patient with NMD affecting the lower limb. The HXLPE's reduced resistance to fatigue crack propagation might not be suitable in PS-TKA where there might be focal stress points on the tibial post, which was amplified in this case as it was the limb that the patient most depended on. When managing end-stage osteoarthritis with TKA in the unafflicted knee of a patient with NMD causing lower limb weakness, the selection of polyethylene material in PS-TKA may need more consideration than previously thought.
Fulltext Infected Non-union of Tibia Treated with Ilizarov External Fixator: Our Experience

Fahad S, Habib AA, Awais MB, Umer M, Rashid HU

Malays Orthop J, 2019 Mar;13(1):36-41.
PMID: 31001382 DOI: 10.5704/MOJ.1903.006

Introduction: Tibia is the most common long bone fractured due its vulnerable subcutaneous location and most often associated with acquired complications of delayed union or non-union due to infection. Amongst the various treatment options to treat them, the Ilizarov external fixator application is considered superior due to its multiple advantages. The objective of this study was to analyse the role of Ilizarov fixation in infected tibial non-union, as well as to assess bony union and associated functional outcomes. Materials and Methods: A retrospective review was conducted for the duration between 1st January 2005 to 31st December 2016. Total of fifty-one patients with tibial non-union associated with infection who treated with the Ilizarov fixator were included in the study. Patient records were reviewed for union of bone, bone and functional outcomes and complications. Results: The most common organism for infection was identified to be Staphylococcus Aureus. At the time of final follow-up all patients had achieved union except two, one of whom had to undergo amputation due to non-union and sepsis. Majority of the patients had an excellent score as per ASAMI grading system for bone and function results. The most common complication noted was pin track infections. Conclusion: In our experience, Ilizarov external fixator is better suited for infected non-union of tibia because it can provide a stable mechanical environment, bone transport, correct deformities, and enable weight bearing and hence we recommend its use for the same.
Fulltext Intra- and Inter-observer Variability in Different Methods of Measuring Carpal Collapse

Agrawal S, Chabra T, Pandey S, Bhardwaj P

Malays Orthop J, 2019 Mar;13(1):20-24.
PMID: 31001379 DOI: 10.5704/MOJ.1903.003

Introduction: Carpal collapse of wrist occurs in disorders like rheumatoid arthritis and Kienbock's disease. Three techniques have been described to measure carpal collapse. First, the carpal height ratio (CHR), measured by dividing carpal height by 3rd metacarpal length. Second, the revised carpal height ratio (RCH ratio), measured by dividing carpal height by length of capitate. Third, capitate radius distance (CR index), measured by shortest distance between distal edge of radius and the proximal edge of capitate. The index publications describe good reliability of all these but which method out of the three is best in terms of intra- and inter-observer variability is not known. The purpose of this study was to find out which method had the least inter- and intra-observer variability for determining carpal collapse. Materials and Methods: Fifty normal wrist postero-anterior radiographs were studied by three assessors who measured CHR, RCH ratio and CR index separately. The measurements were repeated after one month by all the three observers. The results were then statistically analysed. Results: The p-value was <0.001 in all the three assessors in CR index meaning that the intra-observer variability was least in CR index. For the inter-observer variability intra class coefficient of 0.9 indicated that the CR index has the least variability. Conclusion: CR index is the most reproducible method to measure carpal collapse. The method which provides accurate measurement of carpal collapse will allow better staging of carpal disorders.

Study site: Grande Hospital, Nepal
Fulltext Post-implantation Deformation of Titanium Rod and Cobalt Chrome Rod in Adolescent Idiopathic Scoliosis

Sia U, Tan BB, Teo YY, Wong CC

Malays Orthop J, 2019 Mar;13(1):14-19.
PMID: 31001378 DOI: 10.5704/MOJ.1903.002

Introduction: Post-implantation rod deformation is anticipated in scoliosis surgery but the difference in rod deformation between titanium and cobalt chrome rod has not been elucidated. This study aims to compare the difference in rod deformation between two groups. Materials and Methods: Twenty-one adolescent idiopathic scoliosis (AIS) patients were recruited from a single center. The over-contoured concave rods were traced prior to insertion. Post-operative sagittal rod shape was determined from lateral radiographs. Rod deformation was determined using maximal rod deflection and angle of the tangents to rod end points. The differences between pre- and post-operative rod contour were analysed statistically. Rod deformation and thoracic kyphosis between two types of implants were analysed. Results: Both rods exhibited significant change of rod angle and deflection post-operatively. Curvature of the titanium rod and cobalt chrome rod decreased from 60.5° to 37°, and 51° to 28° respectively. Deflection of titanium rod and cobalt chrome rod reduced from 28mm to 23.5mm and 30mm to 17mm respectively. There was no significant difference between titanium and cobalt chrome groups with regard to rod angle (p=0.173) and deflection (p=0.654). Thoracic kyphosis was increased from 20° to 26° in titanium group but a reduction from 25° to 23° was noticed in cobalt chrome group, but these findings were not statistically significant. Conclusion: There was no statistical difference in rod deformation between the two groups. Thus, the use of titanium rod in correction of sagittal profile is not inferior in outcome compared with cobalt chrome but with lower cost.
Fulltext Relative Telomere Length in Blood Leukocytes of Patients with Anterior Cruciate Ligament Injury: A Pilot Study

Daechavijit P, Siridonthanakasem J, Wongsupha P, Yuktanandana P, Honsawek S

Malays Orthop J, 2019 Mar;13(1):8-13.
PMID: 31001377 DOI: 10.5704/MOJ.1903.001

Introduction: Anterior cruciate ligament (ACL) tear is the most common knee ligament injury, especially in athletes. The objective of this study was to investigate relative telomere length (RTL) in blood leukocytes of patients with ACL injury compared with that of controls. Materials and Methods: A total of 187 subjects were invited to participate in this study. Ninety-two patients with clinically diagnosed ACL rupture were enrolled. Ninety-five age and gender-matched healthy controls were also recruited. Blood leukocyte RTL were analysed using quantitative real-time polymerase chain reaction. Results: Patients with ACL rupture had significantly longer relative telomere length than healthy controls (P=0.002). The patients with ACL rupture were classified into two groups according to the sport history of patients which are contact sports and non-contact sports. RTL in patients with non-contact sports was significantly greater than those with contact sports (P=0.006). Moreover, RTL was inversely correlated with body mass index of patients with ACL injury (r=-0.34, P=0.001). Logistic regression analysis indicated that long RTL was associated with a higher risk of ACL rupture. Conclusion: The present study showed that subjects with ACL rupture had significantly greater telomere length compared with their age and gender-matched controls. This finding may result from the increases in physical activity and overexpression of telomerase which acts as a protective mechanism against ACL injury. RTL in blood leukocytes is associated with a risk of ACL rupture.
Fulltext Extracellular Vesicles in the Synovial Joint: Is there a Role in the Pathophysiology of Osteoarthritis?

Esa A, Connolly KD, Williams R, Archer CW

Malays Orthop J, 2019 Mar;13(1):1-7.
PMID: 31001376 DOI: 10.5704/MOJ.1903.012

The role of extracellular vesicles (EV) in osteoarthritis has become the focus of much research. These vesicles were isolated from several cell types found in synovial joint including chondrocytes and synovium. As articular cartilage is an avascular tissue surrounded by synovial fluid, it is believed that EV might play a crucial role in the homeostasis of cartilage and also could hold key information in the pathogenesis of osteoarthritis. This is thought to be due to activation of pro-inflammatory factors leading to a catabolic state and degradation of cartilage. In addition, due to the nature of articular cartilage lacking neuronal innervation, knowledge of EV can contribute to identification of novel biomarkers in this debilitating condition. This can be either directly isolated from aspirate of synovial fluid or from peripheral blood. Finally, EVs are known to shuttle important signalling molecules which can be utilised as unique modality in transferring therapeutic compounds in a cell free manner.
Fulltext Correction using Halo Gravity Traction for Severe Rigid Neuromuscular Scoliosis: A Report of Three Cases

Mejabi JO, Sergeenko OM, Ryabykh SO

Malays Orthop J, 2019 Mar;13(1):49-53.
PMID: 31001385 DOI: 10.5704/MOJ.1903.010

Severe rigid neuromuscular scoliosis is a major challenge to the spine surgeon due to the possibilities of neurological sequelae from acute correction of the deformity. Halo gravity traction has been considered as a way of reducing the deformity before correction to prevent neurological complications. Three female patients with severe neuromuscular scoliosis aged seven to 13 years with main coronal Cobb angle of 95°-128° and Kyphotic Cobb of 47°-118° having ≤35% flexibility on traction, had between 18 to 23 days of 16 hour/day of halo gravity traction and night time supine traction with 4kg weight for 7-8 hours. They had 28.9% and 18.5% of main coronal and kyphotic Cobb angle correction post-traction respectively. All had posterior instrumentation and post-operatively, they had correction of main coronal Cobb angle of 29°-58° and kyphotic Cobb angle of 30°-77° with no neurological complication. Halo gravity traction is therefore a viable option for reducing post-operative neurological complication in rigid severe scoliosis.
Fulltext Aneurysmal Bone Cyst after Femoral Derotational Osteotomy: A Case Report

Sahin K, Demirel M, Turgut N, Arzu U, Polat G

Malays Orthop J, 2019 Mar;13(1):45-48.
PMID: 31001384 DOI: 10.5704/MOJ.1903.009

Aneurysmal bone cysts rather than local aggressive lesions of the bone which may arise in any part of the axial or appendicular skeleton. Although several theories are available in the literature, the pathogenesis is still conflicting. We report an exceptional case of an aneurysmal bone cyst in the distal femur of a female cerebral palsy patient who underwent bilateral distal femoral derotational osteotomy and plate-screw fixation operations when she was 11 years old. Twenty-four months after the operation, radiographs showed a cystic lesion in the distal portion of the right femur around the osteotomy site. The diagnosis of Aneurysmal Bone Cyst (ABC) was made and the lesion was treated by curettage with cement application. After 36 months of follow-up, there was no recurrence. This is the first case reported in literature which raises the possibility that an osteotomy could be a cause in the development of an aneurysmal bone cyst.
Fulltext Modified One-third Tubular Plate with Hook for Distal Lateral Malleolus Fracture Fixation

Kow RY, Low CL

Malays Orthop J, 2019 Mar;13(1):60-61.
PMID: 31001388 DOI: 10.5704/MOJ.1903.013
Fulltext In Situ Fixation of Symptomatic Fibrous Non-union Hoffa Fracture: A Case Report

Soni A, Kansay R, Gupta S, Malhotra A

Malays Orthop J, 2019 Mar;13(1):57-59.
PMID: 31001387 DOI: 10.5704/MOJ.1903.014

Femoral condyle fracture in coronal plane, also known as Hoffa fracture, is a rare fracture. Non-union of Hoffa fracture is even rarer. We present a case of fibrous nonunion of a Hoffa fracture in which the fractured fragment, though not freely movable, led to painful walking. Since the fragment was un-displaced and non-movable we fixed the fractured fragment in situ. Patient regained full range of motion of the knee and was asymptomatic on follow-up.
Fulltext Lessons Learned: Patient Communication During the Pandemic

Wang E, Real I, David-Wang A, Rubio DA, Gaston CL, Quintos AJ, et al.

Malays Orthop J, 2021 Mar;15(1):12-15.
PMID: 33880142 DOI: 10.5704/MOJ.2103.002

A series of mortalities among musculoskeletal tumour patients secondary to medical illnesses during the first few months of the pandemic highlighted the need to review our methods of communication with patients. Prominent among patients' concerns had been a fear of consulting at hospitals and a lack of ready access to health care. Recommendations are made for proactive consultation and patient education, identifying at-risk patients for follow-up and probing for possible co-morbidities. Telemedicine use is encouraged bearing in mind its inherent limitations. A network of physicians and pharmaceutical representatives is an added help we can offer our patients who may be isolated by community quarantine.
Fulltext Prevalence and Pattern of Musculoskeletal Injuries Among Malaysian Hockey League Players

Manaf H, Justine M, Hassan N

Malays Orthop J, 2021 Mar;15(1):21-26.
PMID: 33880144 DOI: 10.5704/MOJ.2103.004

Introduction: Hockey is a team sport that involves running, sprinting, and making sudden changes in directions of movement to control a ball against the opposing team. Therefore, due to its nature of fast movement, hockey players may be at risk of various musculoskeletal injuries. This study aimed to identify the prevalence and pattern of musculoskeletal injuries sustained among Malaysian Hockey League players.
Materials and Method: Data were collected from 84 field hockey players that participated in the Malaysian Hockey League competition from June 2016 until December 2016. All injuries were recorded by the participating medical team using a structured questionnaire. A descriptive statistical analysis and Chi-Square test were used to explore the prevalence of the injury.
Result: More than half of the players were reported to have lower limb injuries (51.6%). Sprain and strain were the most prevalent injuries (63%) and mostly affected the ankle (29%). Male players sustained more injuries (50.8%) compared to female players (49.2%).
Conclusion: This study suggests that a guideline is needed for injury prevention strategies that will benefit the hockey players in preventing injuries.
Fulltext Fat Embolism Syndrome - A Qualitative Review of its Incidence, Presentation, Pathogenesis and Management

Timon C, Keady C, Murphy CG

Malays Orthop J, 2021 Mar;15(1):1-11.
PMID: 33880141 DOI: 10.5704/MOJ.2103.001

Fat Embolism Syndrome (FES) is a poorly defined clinical phenomenon which has been attributed to fat emboli entering the circulation. It is common, and its clinical presentation may be either subtle or dramatic and life threatening. This is a review of the history, causes, pathophysiology, presentation, diagnosis and management of FES. FES mostly occurs secondary to orthopaedic trauma; it is less frequently associated with other traumatic and atraumatic conditions. There is no single test for diagnosing FES. Diagnosis of FES is often missed due to its subclinical presentation and/or confounding injuries in more severely injured patients. FES is most frequently diagnosed using the Gurd and Wilson criteria, like its rivals it is not clinically validated. Although FES is a multi-system condition, its effects in the lung, brain, cardiovascular system and skin cause most morbidity. FES is mostly a self-limiting condition and treatment is supportive in nature. Many treatments have been trialled, most notably corticosteroids and heparin, however no validated treatment has been established.
Fulltext Coordinating a Postgraduate Orthopaedic Exam During the COVID-19 Pandemic

Mohamed-Haflah NH, Abdullah S, Abdul-Rani R

Malays Orthop J, 2021 Mar;15(1):16-20.
PMID: 33880143 DOI: 10.5704/MOJ.2103.003

The Coronavirus (COVID-19) pandemic and institution of the Movement Control Order (MCO) had resulted in the cancellation of a major orthopaedic exam in April 2020. The exam is known as the Malaysian Orthopaedic Specialist Committee (OSC) Part I Examinations. It is similar to the British Royal Colleges of Surgeons Membership (MRCS) exams and held twice annually in April and October. There are up to 200 candidates involved. With implementation of new guidelines and standard operating procedures (SOP), the OSC Part I exam was successfully held by Universiti Kebangsaan Malaysia (UKM) from 5th-9th October 2020. Here we highlight the challenges we faced whilst coordinating a major exam at a national level during the COVID-19 pandemic with recommendations for future exams.
Fulltext Use of Digital Technology for Education: The Future of Collaborative Learning

Lai S, Tang C

Malays Orthop J, 2021 Mar;15(1):142-143.
PMID: 33880165 DOI: 10.5704/MOJ.2103.025
Fulltext CT-guided Percutaneous Drainage of Intra-spinal Haematoma as an Alternative to Surgical Evacuation

Wcg P

Malays Orthop J, 2021 Mar;15(1):141.
PMID: 33880164 DOI: 10.5704/MOJ.2103.024
Fulltext Osteomyelitis: An Uncommon Complication of BCG Vaccination

Pancharatnam D, Yong SM, Tan SC

Malays Orthop J, 2021 Mar;15(1):144-145.
PMID: 33880166 DOI: 10.5704/MOJ.2103.026
Fulltext Predictors of Functional Outcome in Unstable Ankle Fractures Treated Surgically - A Prospective Cohort Study

Balaji G, Bhukya S, Nema S, Rajeswari M, Vellaipandi V

Malays Orthop J, 2021 Mar;15(1):85-92.
PMID: 33880153 DOI: 10.5704/MOJ.2103.013

Introduction: Unstable ankle injuries require anatomical reduction and stabilisation for optimal outcome. In spite of adequate care, a few patients have poor outcome. In this study, we assessed the risk factors that predict the clinical outcomes in surgically treated unstable ankle fractures.
Material and methods: This prospective cohort study was conducted on 68 patients who underwent surgical management for an unstable ankle injury. Demographic details, fracture type and associated medical comorbidities were recorded. Pre-operative radiographic assessment was done for all patients. At the end of one year follow-up, clinical (American Orthopaedic foot and ankle society-AOFAS and Olerud-Molander ankle - OMAS) scores and radiological parameters were assessed and analysed.
Results: Fracture dislocation (0.008), diabetes mellitus (0.017), level of alchohol consumption (0.008) and pre-operative talocrural angle (TCA) > 100° (0.03) were significant predictors of poor outcomes as per AOFAS. Fracture dislocation (0.029), diabetes mellitus (0.004), pre-operative TCA > 100° (0.009), female gender (0.001), age more than 60 years (0.002) and open injuries (0.034) had significantly poor outcome as per OMAS. Other parameters (smoking, hypertension, classification, syndesmotic injury, medial clear space and tibiofibular overlap) did not affect the outcome significantly.
Conclusion: Our study showed that poor outcome predictors in unstable ankle fractures are age >60 years, female gender, diabetes mellitus, alcohol consumption, fracture dislocation, open fractures and pre-op TCA >100°.
Fulltext Femoral Stem Subsidence and its Associated Factors after Cementless Bipolar Hemiarthroplasty in Geriatric Patients

Gema A, Irianto KA, Setiawati R

Malays Orthop J, 2021 Mar;15(1):63-71.
PMID: 33880150 DOI: 10.5704/MOJ.2103.010

Introduction: Early femoral stem subsidence has been a concern as a predictor of the beginning of implant loosening, especially on cementless hip arthroplasty implants. This study aimed to determine the factors that affect femoral stem subsidence and outcome following hemiarthroplasty in the geriatric population.
Materials and Methods: This is a retrospective study of 179 patients who underwent cementless bipolar hemiarthroplasty during the 2011-2019 period at an orthopaedic and traumatology hospital. Data on the patient's demography, pre-operative American Society Anaesthesiologist (ASA) score, body mass index (BMI), canal flare index (CFI), Dorr classification, and stem alignment were obtained. The primary outcomes were post-operative femoral stem subsidence, post-operative pain, and functional outcome using Harris Hip Score (HHS). Statistical analysis was conducted to identify risk factors associated with the primary outcome.
Results: The mean femoral stem subsidence was 2.16 ±3.4 mm. The mean post-operative Visual Analog Score (VAS) on follow-up was 1.38 ± 1. Mean HHS on follow-up was 85.28±10.3. American Society Anaesthesiologist score 3 (p = 0.011, OR = 2.77) and varus alignment (p=0.039, OR = 6.963) were related to worse stem subsidence. Otherwise, neutral alignment (p = 0.045 and OR = 0.405) gave protection against femoral stem subsidence. The female gender (p = 0.014, OR 2.53) was associated with postoperative pain onset. Neutral alignment had significant relationship with functional outcomes (p = 0.01; OR 0.33).
Conclusion: A higher ASA score and varus stem alignment were related to a higher risk of femoral stem subsidence. Meanwhile, neutral stem alignment had a protective effect on the femoral stem subsidence and outcome.

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