Neurological deficit after surgery for spinal deformity is a rare but devastating complication. Factors that have been associated with a post surgical deficit are congenital curves, large curves, kyphotic deformities, anterior and posterior surgery, ligation of multiple anterior vessels and hypotension; controlled or otherwise. Intra operative wake up tests have been used alone or in combination with spinal cord monitoring: to detect evolving neurological deficit in spinal deformity surgery. Despite these checks, major neurological deficits still occur post surgery. This is a report of two cases with normal intra operative wake up tests, but developed neurological deficit twelve hours after the end of surgery.
Sixty-five patients with congenital kyphosis and kyphoscoliosis who underwent spinal arthrodesis are reviewed to determine the factors that influenced the outcome of arthrodesis. Mean follow up after surgery was 6 years and 6 months with all patients having a minimum of 2 years follow up. A satisfactory outcome, or a stable arthrodesis was defined as a loss of correction of less than 10 degrees from the time of surgery till review. An unsatisfactory outcome, or unstable arthrodesis was considered when there was more than 10 degree loss. Type of vertebral anomaly and type of arthrodesis procedure were significantly influenced stability of arthrodesis, whereas age when arthrodesis was performed and size of curve at surgery were not significantly related to stability of arthrodesis.
Non-traumatic, progressing sagittal plane deformities are uncommon, but can lead to neurological deficit if untreated. The currently used Cobb method in assessing sagittal spinal curves is based on measuring the tilt of the end vertebrae. This study describes a method which quantifies the apex of the sagittal curve based on the apical quality as measured by the radius of curvature. Both this and the Cobb methods are compared to determine which has relevance in determining neurological deficit. Radiographs of 36 consecutive patients diagnosed with congenital kyphosis were reviewed. Twenty-four had normal neurology and 12 had neurological deficit as a result of sagittal curve progression. Both groups of patients had their weight bearing lateral radiographs analysed to measure the sagittal curve by the usual Cobb method and the Radius of Curvature method. There was no difference for the Cobb values for negative neurology and patients with positive neurological deficit (p = 0.3). There was a difference in these two groups when the radius of curvature method was used (p < 0.0005). The Radius of Curvature method has more relevance than Cobb method in quantifying sagittal plane deformity in congenital kyphosis when assessing neurological deficit.
156 consecutive children with supracondylar fracture humerus were reviewed. Of these, 56 children with severely displaced fractures were treated with side arm traction. A retrospective review revealed that a mean post-reduction Baumann angle of 74.2 degrees for boys and 75.9 degrees for girls; and mean post-reduction humero-ulna angle of 11.6 degrees for boys and 12.7 degrees for girls was achieved. A linear correlation was noted between the duration of traction and the age of the patient, older patients requiring longer traction. The region below the line in the graph, plotting the duration of traction (y-axis) versus the age of the patient (x-axis) shows when the fracture is unstable; and the region above the line shows when the fracture is stable and can only be reduced by surgery. 10 children presented late; 6 presented within the unstable period and were successfully reduced with traction; while 4 presented stable and required open reduction. We conclude that traction is an acceptable and safe method for reduction of this fracture, and can be used to reduce late presentations while their fractures are still unstable.
A case report of a missed appendicitis presenting with abdominal wall necrotising fasciitis which extended up to the right knee. This subcutaneous collection in the prepatella region of the right knee presented as a crepitus and mimicked an intraarticular pathology.
Diabetic foot lesions may arise from frictional trauma due to tight or inappropriate footwear, repetitive stresses on parts of the foot, overlying bony prominence generated by walking and accidental trauma to the neuropathic foot. Many diabetics have been found to be unaware of their foot lesion, or know what the precipitating cause was. Based on the assumption that accidental trauma would affect the foot in a random fashion and result in lesions distributed evenly throughout the foot, a study was performed to determine whether foot lesions were distributed evenly or concentrated to certain areas of predilection. It was found that foot lesions were not evenly distributed but concentrated to certain areas of predilection. Even though relatively high proportion of the study population walked about in open slippers and barefeet, the study showed that accidental trauma was not a predominant precipitant of diabetic foot lesions. Diabetic foot lesions tend to occur as a result of cumulative, repetitive trauma to areas of prediliection rather than accidental trauma.
Conflicting recommendations exist on the issue of scoliosis screening in the general population. Worldwide, opponents cite the relative inaccuracy of screening tests, cost-ineffectiveness and psychosocial effect of 'labelled' patients but advocates quote the successes in many centres and the advantages of timely intervention. We studied 205 patients with idiopathic scoliosis and found they presented at relatively later ages and with curves that showed rapid annual progression. We suggest that screening in Malaysia may identify patients early for treatment besides promoting health awareness.
An epidemiological study of 101 consecutive musculoskeletal sarcomas seen at the Institute of Radiotherapy and Oncology between 1995 and 1999 inclusive was carried out. The commonest sarcomas seen were osteosarcoma, rhabdomyosarcoma, Ewing's Sarcoma, liposarcoma, leimyosarcoma, malignant fibrous histiocytoma and chondrosarcoma; which collectively accounted for 84.2% of the group. Thirty patients (29.7%) presented with metastases. The commonest site of occurrence was lower extremity with 47.5%, followed by 34.7% in the trunk and peritoneum/axial skeleton, 9.9% in the head and neck region; and 7.90 in the upper extremity. We found no apparent relationship between race and incidence osteosarcoma and Ewing's sarcoma, as was reported by previous workers.
This study was conducted to determine the factors involved in predicting the onset of paraplegia in tuberculosis of the spine. A cross-sectional, case control review of 85 cases of spinal tuberculosis was conducted at the National Tuberculosis Centre in Kuala Lumpur. Sixty-nine of these cases were normal neurologically, whilst 16 cases experienced neural deficit. The data was analysed using backward logistic regression and Fishers exact probability test. The factors studied included symptoms and signs of spinal tuberculosis, common investigations for tuberculosis, and physical factors of the disease. Only the erythrocyte sedimentation rate (ESR) showed a significant difference between the neural deficit and neurologically normal groups. This suggests that the ESR may be a factor in predicting evolution of paraplegia in spinal tuberculosis. In addition, it was noted that a low proportion of patients had positive sputum smear results and bacterial culture growth for mycobacterium tuberculosis suggesting these tests are of limited value for tuberculosis of the spine.
Sixty inpatients with diabetic foot were studied prospectively at the Orthopaedic wards of Hospital Kuala Lumpur. Data was evaluated to document the patient profile and the factors that were associated with a major amputation (either above knee or below knee) of the lower limb. Factors that were associated with increased risk of amputation were a low education level, manual occupation, poor foot care, peripheral vascular insufficiency of the lower limb, insulin dependence, anaemia and leucocytosis. However only anaemia, leucocytosis and hyperglycaemia were statistically significant in predicting a more adverse surgical procedure. This study recommends that foot care awareness and practice is important. This can be effectively dealt with at specially organised, multi disciplinary Diabetic Foot Clinics.
Motorcyclists form the highest group of fatalities on Malaysian roads. This is a prospective study conducted at 3 major hospitals for a period of 12 months to determine the type of motorcyclist injuries that usually required hospitalization. Four hundred and twelve consecutively injured motorcyclists were available for study. One hundred and eighty six (45.15%) were fatally injured and 226 (54.85%) were seriously injured and surviving. The main cause of fatalities was head injury, while lower limb injuries accounted for majority of hospitalizations. This study highlights the vulnerability of the motorcyclist to lower limb injuries.
One hundred primary TKR surgeries done between January 1994 and December 1999 were reviewed after a mean follow-up of 37.4 months. The rate of superficial and deep wound infection were 2% and 9% respectively. The most common organism in wound infection was Staphylococcus aureus. The factors that were significantly associated with superficial wound infection were diabetes mellitus (p = 0.005) and rheumatoid arthritis (p = 0.0000). The factors that were significantly associated with deep wound infection were diabetes mellitus (p = 0.000). There was no significant difference between duration of surgery, and the mean age among patients with and without wound infections.
Motorcyclists make up the largest group of fatalities on Malaysian roads, majority succumbing to head injuries despite the compulsory safety helmet laws in the country. One possible reason for this high fatality is improper usage of safety helmets. This study examines the compliance of proper safety helmet use in motorcyclists in a typical Malaysian town. Five hundred motorcyclists were studied. Only 54.4% of motorcyclists used helmets properly, 21.4% used them improperly; and 24.2% did not wear helmets. Six variables were found to be significant in improper safety helmet use. They were age, gender, race, formal education level, prior accident experience and type of license held. Marital status and riding experience were not significant. Efforts promoting proper use of safety helmets should focus on the young, male, less formally educated, unlicensed rider, who has had a prior accident.
SCIWORA or Spinal Cord Injury Without Radiological Abnormality; is a pre-MRI term that includes injuries to the spinal cord in the absence of radiological (plain radiographs, tomographs and CT scans) evidence of injury to the spinal column or cord. It occurs in skeletally immature spines because of the inherent plasticity of the bony structures in this age group. The prognosis is dependent on the extent of cord damage, and the role of active management is limited. A high index of suspicion is needed to establish a diagnosis. This diagnostic accuracy can be improved with the free availability of MRI scanning for the spines. We describe three cases of SCIWORA with a minimum follow-up of three years and a review of current literature.
The functional outcome of 27 patients (16 males, 11 females) with a proximal humeral fracture was evaluated using the Simple Shoulder Test. Fifteen patients were also assessed using the Constant system. The mean age of the patients was 46.3 years (range 16-90 years) and the mean follow-up was 14 months (range 6-29 months). There were ten 2-part fractures, eight minimally displaced fractures, two 3-part fractures, three 4-part fractures, three 1-part fracture-dislocations and one 3 parts fracture-dislocation. Twenty-four fractures were treated conservatively and 3 surgically. Thirteen patients (48%) regained full function on the simple shoulder test and almost all regained range of movement sufficient for activities of daily living. Six patients were not able to return to their previous job. All patients were pain free at rest and were able to sleep on the affected side comfortably, although 9 patients had pain with activity, even though most pain were mild in nature. The mean Constant scores for the fractured arm and the normal arm were 72.5 points and 91 points respectively. The strength of shoulder abduction was reduced by a mean of 34%. Although the outcome was generally satisfactory, there was nevertheless a statistically significant deterioration of function following the fracture.