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  1. Soh EZF
    Cureus, 2021 Sep;13(9):e18068.
    PMID: 34692290 DOI: 10.7759/cureus.18068
    Necrotizing soft tissue infection (NSTI) is a rapidly spreading and fulminant infection that may occur within any layer of skin and soft tissue and may result in sepsis and multiorgan failure. Cases of intravenous injection of drugs causing NSTIs have been reported, especially involving injection of illicit drugs or insulin. NSTI can be due to polymicrobial or monomicrobial infection and infection involving Klebsiella species has been rising, especially in patients with diabetes mellitus. This is a case of an extensive upper limb and shoulder Klebsiella pneumoniae NSTI following an injection of a non-steroidal anti-inflammatory drug in a diabetic patient. NSTI diagnosis is based on history and clinical examination, supplemented with imaging and laboratory investigations. Early recognition, extensive and serial debridement, antibiotics, and wound management are crucial for the better outcome of the disease. This patient underwent emergent debridement with antibiotics coverage, followed by serial debridement and wound care. The wound healed within the stipulated time, with good function of the affected limb following the rehabilitation program.
  2. Soh E, Muhamad-Ariffin MH, Baharudin A
    Malays Orthop J, 2020 Mar;14(1):88-91.
    PMID: 32296489 DOI: 10.5704/MOJ.2003.015
    Treatment of severe spinal deformities associated with neurofibromatosis has proven to be challenging. An 11-year-old girl, with neurofibromatosis and severe cervicothoracic kyphoscoliosis, was initially treated with posterior instrumentation and fusion. Implant failure developed within a year, requiring an anterior stabilisation and fusion with a non-vascularised fibular strut graft for better stability and increased likelihood of achieving union. The posterior instrumentation was removed due to its prominence and wound breakdown. Following the removal of the posterior implant, the fibular graft fractured. The patient was maintained on a cervical collar until union was achieved. Posterior spinal fusion alone in severe spinal deformities in neurofibromatosis has a high risk of failure. A combined anterior and posterior fusion may increase the chance of success, with better stability and union rate.
  3. Wan Ali WAA, Soh EZF, Abdullah S, Narin Singh PSG, Ahmad AA, Sapuan J
    Cureus, 2021 Jan 13;13(1):e12691.
    PMID: 33604222 DOI: 10.7759/cureus.12691
    Introduction Closed reduction is an effective method of treatment for distal end radius fractures. We present a case series of patients with distal end radius fractures who underwent closed manipulative reduction using the periosteal block. We describe the technique in detail and examine its efficacy in pain lowering effect during closed reduction. Methods Nineteen patients with distal end radial and ulnar fractures were included and grouped based on the Frykman classification. The reduction was performed using a periosteal block of 10 ml of 2% lignocaine injection. The severity of pain was recorded by utilizing the visual analog scale (VAS) in five phases: 1) before injection, 2) after 15 minutes of analgesia in a resting position, 3) during minimal motion, 4) during full manipulation and reduction, and 5) post-procedure. The VAS scoring was classified as painless (VAS score of 0), mild pain (VAS score between 1-3), and painful (VAS score of 4 and above). Results The study included 19 patients [median age of 53 years (range: 18-88 years)]; there were 11 (58%) males and eight (42%) females. The mechanism of injury was a fall (n=12, 63%) or a motor vehicle accident (n=7, 37%). There was a statistically significant reduction of pain between phase one and all the other phases. Between the different fracture configurations, there was no significant difference in pain reduction. The most painful phase was expected to be phase four, ie, during full manipulation, in which four (21%) patients had a VAS score of 0, 12 (63%) patients had a VAS score between 1-3, and three (16%) patients had a VAS score of 4. Thus, 16 out of 19 patients (84%) had no or minimal pain during the most painful phase. There were no complications from the periosteal blocks. Conclusions The periosteal nerve block is an effective procedure providing satisfactory analgesia during the reduction of distal radial and ulnar fractures. It has no side effects and is free from complications associated with conventional sedation.
  4. Kesu Belani L, Abdullah S, Soh EZF, Abd Jabar F, Nasseri Z
    Cureus, 2021 Apr 11;13(4):e14417.
    PMID: 33987066 DOI: 10.7759/cureus.14417
    A snapping tendon on the dorsal aspect of the thumb is a rare condition as opposed to the common triggering on the volar aspect of the thumb. This condition is known as triggering of the extensor pollicis longus (EPL). A 21-year-old female presented with a clicking or snapping sensation that was felt on the dorsum of her thumb when it is extended. There was no history of trauma. She worked in an ice-cream parlor with repetitive scooping ice-cream motions. Her triggering immediately resolved on releasing the EPL fascia ulnar to Lister's tubercle. Upon wake-up surgery, we could immediately confirm this. We recommend dynamic ultrasound as an investigation and do not recommend MRI. The surgical method of choice is either wake-up surgery or wide-awake local anesthesia no tourniquet (WALANT) surgery.
  5. Abdullah S, Tokiran MF, Ahmad AA, Soh EZF, Makpol S, Sapuan J
    J Hand Surg Glob Online, 2023 Mar;5(2):196-200.
    PMID: 36974291 DOI: 10.1016/j.jhsg.2022.12.003
    PURPOSE: This study evaluated the clinical and biochemical safety profile of infiltration of lidocaine with adrenaline in wide-awake local anesthesia no tourniquet for distal radius plating.

    METHODS: Twenty-four participants were randomly assigned to the therapeutic group (n = 19) (1% lidocaine in 1:100,000 adrenaline) and control group (n = 5) (2% lidocaine alone). Clinical parameters, including skin necrosis, duration of recovery of sensation, and lidocaine toxicity, were monitored. The serum lidocaine level was measured at different time intervals using a high-performance liquid chromatography reagent.

    RESULTS: No lidocaine toxicity was recorded in any participant. The therapeutic group had a longer time for recovery of sensation. There was a significant difference in the serum lidocaine levels between both the groups at all time intervals up to 6 hours, with all participants exhibiting serum lidocaine levels below the mild toxicity level of 6.0 μg/mL.

    CONCLUSIONS: Lidocaine used within a safe recommended dose in wide-awake local anesthesia no tourniquet for distal radius plating is clinically and biochemically safe.

    CLINICAL RELEVANCE: Determining the clinical and biochemical safety profile of lidocaine with adrenaline in wide-awake local anesthesia no tourniquet can promote wider use of this technique.

  6. Abdullah S, Ghazali KAB, Soh EZF, Sapuan J, Gill PS, Lim CH
    J Hand Surg Glob Online, 2024 Nov;6(6):814-817.
    PMID: 39703592 DOI: 10.1016/j.jhsg.2024.06.008
    PURPOSE: Fixation of metacarpal or phalanx bone fractures is usually performed under general anesthesia (GA) or regional anesthesia and with the use of a tourniquet to minimize bleeding. However, the use of tourniquet causes pain and discomfort after surgery. Wide-awake local anesthesia no tourniquet (WALANT) enables the surgery to be performed with the patient fully awake and without a tourniquet, which allows intraoperative assessment of function during surgery. This study aims to compare the perioperative parameters and clinical outcomes between GA versus WALANT in hand fracture fixations.

    METHODS: Forty-eight patients with hand fractures were recruited over a period of 15 months. Twenty-one patients had undergone fracture fixation under GA, whereas another 27 patients had the surgery under WALANT. Parameters including vital signs (heart rate and systolic blood pressure), surgery duration, estimated blood loss, visual analog scale, and quick disabilities of the arm, shoulder, and hand (QuickDASH) questionnaire were evaluated.

    RESULTS: Wide-awake local anesthesia no tourniquet group had significantly higher systolic blood pressure values and higher estimated blood less than GA group. Wide-awake local anesthesia no tourniquet group also documented shorter surgical time compared with GA group, but the difference was not significant. In terms of clinical outcomes, WALANT group recorded significantly lower visual analog scale score at 2 hours and 2 weeks postsurgery. However, WALANT has a comparable QuickDASH score with GA group except at 3 months postsurgery.

    CONCLUSIONS: Wide-awake local anesthesia no tourniquet surgery for hand fracture fixation provides a similar analgesic effect and comparable QuickDASH score except at 3 months postsurgery compared with GA.

    TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IIb.

  7. Soh EZF, Htwe O, Naicker AS, Nasirabadi AR, Ghazali MJ, Mohd Mustafah N, et al.
    J Tissue Viability, 2020 May;29(2):104-109.
    PMID: 32014382 DOI: 10.1016/j.jtv.2020.01.005
    BACKGROUND: Diabetic foot ulcer is commonly seen in people with diabetes mellitus. Inadequate plantar pressure offloading has been identified as a contributing factor to development of diabetic foot ulcers. Various pressure off-loading footwear are widely available in the market but poor compliance has been reported especially for indoor usage. StepEase™ diabetic socks have been designed using Ethylene Vinyl Acetate (EVA) microspheres for better redistribution of plantar pressure. The objective of this study was to determine the efficacy of StepEase™ in redistributing the foot plantar pressure and to assess patients' satisfaction on the usage of the socks.

    METHODS: This was a prospective non randomized clinical trial conducted on 31 patients with diabetes mellitus with high risk foot (King's classification stage II) over a 12 weeks period. Dynamic foot plantar pressure reading was recorded at day 0, 6 weeks and 12 weeks intervals, both barefoot and with StepEase™, using Novel Pedar-X system (Novel GmbH, Munich, Germany). Patients' satisfaction and usage practice were assessed by a questionnaire.

    RESULTS: The mean age of subjects was 57.9 years with mean body mass index (BMI) of 26 kg/m2. The mean duration of diagnosis with diabetes mellitus was 10.2 years. The mean peak plantar pressure was found to be highest at the right forefoot and left heel region, 267.6 kPa (SD113.5 kPa) and 266.3 kPa (SD 94.6 kPa) respectively. There was a statistically significant reduction of mean peak pressure (P 

  8. Abd Hamid MH, Abdullah S, Ahmad AA, Narin Singh PSG, Soh EZF, Liu CY, et al.
    Cureus, 2021 Jan 23;13(1):e12876.
    PMID: 33633905 DOI: 10.7759/cureus.12876
    INTRODUCTION: Distal end radius fractures are common fractures commonly treated with an option of open reduction and plating. Traditionally, plating is performed under general anesthesia (GA) or regional block. Recently, a new technique of plating under wide-awake local anesthesia with no tourniquet (WALANT) has been introduced. We aim to compare the preoperative anxiety level, intraoperative pain scores, post-operative pain scores, operating time, blood loss and clinical outcome of distal end radius plating with WALANT versus GA with tourniquet.

    METHODS: We conducted a randomized controlled study on patients with closed fracture of the distal end of the radius requiring open reduction and plating from January 2019 till April 2020. We recruited 65 patients (33 patients in the WALANT group and 32 patients in the GA group). Randomization was done via block randomization. Data were collected to evaluate preoperative anxiety using the Amsterdam Preoperative Anxiety and Information Scale (APAIS) score, intraoperative pain score during injection (baseline) (V1), 10 minutes after injection (V2), during incision (V3), during gentle manipulation (V4), during aggressive manipulation (V5) and during first drilling of screw (V6), blood loss, duration of surgery and post-operative pain score. Additionally, intraoperative visual analog scale (VAS) score was obtained in the WALANT group. At three weeks, six weeks, three months and six months after operation, the Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) scores and range of motion (ROM) of the wrists were obtained.

    RESULTS: The average age in the WALANT group was 47.19 (range, 36-64) years and GA group was 49.48 (range, 38-60) years. The mean APAIS score obtained was 7.78 (WALANT group) and 7.36 (GA group) with no statistical difference. For intraoperative VAS, only during V4 and V5 were the scores 1/10; otherwise at all other phases, the VAS score was 0. The average time for surgery was statistically longer in the WALANT group (61.22 minutes) compared to the GA group (55.33 minutes) (p = 0.003). There was no statistical difference in mean blood loss in both groups. The average post-operative VAS showed statistical significance only at 1 hour and 12 hours post-operation with no statistical difference at 2 and 24 hours post-operation. There was no difference in the post-operative ROM including wrist flexion, extension, supination and pronation for both groups up to six months' follow-up.

    CONCLUSION: There was no statistically significant difference in terms of preoperative anxiety level, intraoperative and post-operative VAS score, amount of blood loss and clinical outcome in both groups for plating of the distal end radius. However, the operating time was slightly longer in the WALANT group. We conclude that distal radius plating under WALANT has similar outcomes to GA. In centres with limited resources, WALANT offers a safe, reliable and cheaper option, reserving GA time for head, abdominal and thoracic surgery.

  9. Gsangaya MR, Htwe O, Selvi Naicker A, Md Yusoff BAH, Mohammad N, Soh EZF, et al.
    PMID: 37841643 DOI: 10.1016/j.asmart.2023.09.002
    PURPOSE: Anterior cruciate ligament injury (ACL) commonly occurs during sporting events. It causes pain, instability and reduction in range of movement of the knee which results in altered balance, reduced strength as well as loading to the involved knee. The challenge to get the patient back to competitive sports level much depends on the rehabilitation process. Post ACLR rehabilitation is challenging due to the long rehabilitation time as well as boring repetitive exercises. The aim of this study is to compare between the effectiveness of using immersive virtual reality (PlayStation VR) in addition to the conventional rehabilitation as an aid in rehabilitation of patients after ACLR in terms of objective functional assessment and pain and subjective knee function scoring.

    METHODS: This randomised controlled trial was undertaken in a tertiary hospital in Malaysia from July 2019 until July 2020. Thirty patients were randomised into a group undergoing purely conventional rehabilitation (Group 1) and a group undergoing both conventional rehabilitation and immersive virtual reality assisted rehabilitation (Group 2). The immersive virtual reality assisted rehabilitation was started at 3 months post operatively for 3 months duration. Limb loading, balance, range of motion, functional hop tests of the knee, pain and subjective scoring of the knee with the International Knee Documentation Committee (IKDC) Scores were measured preoperatively and at 6 months.

    RESULTS: There were significant differences in terms of improvement of pain scores (p = 0.012) as well as IKDC Scores (p = 0.024) in Group 2 as compared to Group 1. However, there were no significant differences with regards to limb loading, balance, range of motion and functional hop tests of the knee (p > 0.05). No adverse events were observed during the study period.

    CONCLUSION: Immersive virtual reality can be used as an adjunct in rehabilitation of patients after ACL reconstruction in terms of improving their pain as well as their subjective knee evaluation. Large randomised control trial is recommended to further investigate the efficacy.

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