Malaysian Orthopaedic Journal最新文献

Introduction: Distal radius fractures are among the most common orthopaedic injuries, and volar locking plate fixation is a widely used surgical method. The restoration of radiological parameters post-operatively is believed to be associated with reliable functional recovery. This study aims to evaluate the correlation between radiological parameters and functional outcomes following distal radius fracture fixation.

Materials and methods: This prospective cohort study included patients with distal radius fractures treated with volar locking plates. Radiological parameters, including volar tilt, radial inclination, radial height, and ulnar variance, were assessed post-operatively. Functional outcomes were measured using the Patient Rated Wrist Evaluation score at predefined follow-up intervals. Correlation analyses were conducted to assess the relationship between radiological restoration and clinical outcomes. Pearson correlation coefficient was applied to assess the relationship between the outcome variable and predictor variables. Simple linear regression was initially performed with a significance threshold of 25%, followed by stepwise multiple linear regression using a 5% significance level.

Results: A total of 78 patients (56.4% male, 43.6% female) with a mean age of 50.3 ± 14.7 years were included. Most patients sustained partial or complete intra-articular distal radius fractures. The mean cumulative PRWE score at 3 months was 42.4 ± 6.6, with mean pain and function sub-scores of 21.24 and 21.34, respectively. The study findings showed that increased age and ulnar variance were significantly associated with worse PRWE scores while greater palmar tilt was associated with better outcomes. Radial height and radial inclination were not significantly correlated with functional scores.

Conclusion: Understanding the relationship between radiological alignment and functional outcomes can aid in optimising surgical techniques and improving patient recovery.

Introduction: Posterior malleolus (PM) fractures are frequently caused by pronation or supination injuries with an external rotation component to the ankle. Historically, fixation of the PM was not considered essential if it involved less than 25% of the tibial articular surface. However, studies have now shown that trimalleolar fractures fare worse than bimalleolar fractures. This study primarily aims to evaluate the clinical outcomes of trimalleolar fractures, focusing on posterior malleolus fixation regardless of the fragment size.

Materials and methods: A prospective observational study was undertaken to investigate the efficacy of PM fixation at a tertiary care centre from October 2020 to December 2022. All participants underwent pre-operative radiographs and were classified according to the Lauge-Hansen system. Sixteen consecutive patients underwent the posterolateral approach to reduce and stabilise the PM, utilising either a buttress/antiglide plate or a posterior-to-anterior (PA) screw, in conjunction with fixation of the medial and lateral malleoli. Patient characteristics, injury specifics, surgical details, and complications were documented. Clinical outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system.

Results: The study cohort included 16 patients with an average follow-up of 18 months. The AOFAS scores indicated excellent outcomes in six cases, good outcomes in eight cases, and a fair outcome in two cases. PA lag screw fixation was used in seven patients when the fracture fragment was large enough with three excellent, three good and one fair outcome. While buttress/antiglide plate fixation was employed in nine patients when the fracture fragment was small or comminuted with three excellent, five good and one fair outcome. One patient developed a superficial infection, which was managed with debridement, and another patient experienced malunion. Both of these patients had a fair outcome.

Conclusion: A posterolateral approach allows fixation of the posterior malleolus and fibula through a single incision, ensuring anatomical reduction and stable fixation. This method yields excellent outcomes with minimal complications, though further research with larger studies is needed.

Introduction: Conservative treatment in flexible flat foot (FFF) is preferred in most cases; only in symptomatic and conservative-refractory cases is surgical treatment proposed. Subtalar arthroereisis (STA) is a well-established technique, but there remains a paucity of information surrounding the effectiveness and outcome. The aim of this study was to evaluate radiological and functional outcome of STA in FFF.

Material and methods: This study is a case series of 15ft with symptomatic FFF treated by STA from a period of 2018-2024. Mean age at the time of surgery was 10.1±0.83 years. There was a significant increase in both American Orthopaedic Foot and Ankle Society score (AOFAS) and The Oxford Ankle Foot Questionnaire for Children (OxAFQ-C) subjective scoring with p-value of <0.001. Degree of valgus correction was statistically significant (p=0.001). There were significant differences between pre-and post-operative lateral radiographic measurements with p-value of <0.005. One patient with the lowest radiological angle of correction and increased femoral anteversion had loosened implant in two years follow-up.

Results: Despite results in earlier studies, recent evidence, including randomised control trials, supports the reliability of STA in managing FFF, advocating its use over traditional osteotomies due to fewer complications and quicker rehabilitation periods. In our study, all subjects had significant improvement in lateral radiographic measurements and subjective scoring evaluation during follow-up.

Conclusion: STA is an option for surgical treatment in symptomatic FFF patients. In this study, all presented subjects showed overall satisfying functional and radiological outcome.

Introduction: While pedobarography is emerging in Malaysia for foot-related clinical and research use, there are no published normative foot plantar pressure values. This study aimed to identify pressure values and areas of distribution in the normal foot of the multiracial population in Pahang, Malaysia. The differences by ethnic groups, gender, and BMI levels were also investigated.

Material and methods: In this cross-sectional study, 600 normal feet without pre-existing diabetes mellitus and any lower limb and spine pain were assessed using Emed-q100 pedobarography platform device and EMED/E (Expert) software from January 2018 to December 2018. The data were analysed using SPSS, with descriptive statistics for demographics and foot pressure, Pearson Chi-Square for associations, t-tests for gender differences, and one-way ANOVA for comparisons across ethnicity and BMI groups.

Results: The mean maximum peak pressure (MPP) was measured at 508.98 kPa (SD 164.06) with significant differences by BMI whereby the score was highest in the obese (p<0.001). No significant differences by gender and ethnicity were reported. In terms of peak pressure area (PPA), most (42.2%) were observed in the first metatarsal head and big toe region (1MH&T), followed by second metatarsal head (2MH) (31.5%). For overweight and obese, PPA mostly distributed in 2MH (34.8% and 50%, respectively). Significant differences in PPA were also seen between races. There was no significant difference in the pressure area distribution by gender.

Conclusion: The MPP is affected by BMI while PPA distribution is affected by BMI and ethnicity. These findings can be used as an initial reference for further studies related to orthopaedic clinical applications, particularly involving the Malaysian population with various ethnicities and cultural backgrounds.

Introduction: Giant cell tumours (GCT) of the distal tibia are uncommon, locally aggressive lesions that are frequently difficult to manage due to the anatomical and functional intricacies of the region. This case study seeks to elucidate the clinical presentation, surgical procedures, and results in three individuals with distal tibial giant cell tumours, highlighting management and reconstructive techniques in this uncommon location with higher risk of morbidity compared to other locations and to achieve pain free ambulation.

Materials and methods: Three cases presenting with localised pain and swelling with painful weight-bearing in the distal tibia, were included in the study. Two patients had primary GCT whereas one had recurrence of the tumour after being managed elsewhere. All patients had biopsy and radiologically proven GCT with differing degrees of local aggressiveness. The management strategy involved wide-margin tumour resection followed by reconstruction techniques including contralateral fibular strut grafting and ankle arthrodesis with cementation and bone graft to restore structural integrity and functionality.

Results: All three patients underwent successful tumour resection and reconstruction without major intra-operative complications. Radiological assessments confirmed adequate union of grafts and no signs of recurrence during follow-up.

Conclusion: This series highlights the efficacy of various modalities for the treatment of GCT of distal tibia. While these methods demonstrate promising results in terms of stability and patient satisfaction, vigilance for recurrence and long-term complications remains critical.

Introduction: For extensive osseous involvement of primary tumours in the distal femur and proximal tibia, knee resection arthrodesis (KRA) is an economic alternative to endoprosthetic reconstruction in developing countries. Enneking (1977) described the use of an intramedullary (IM) nail for KRA and is still regarded as the most reliable method for fusion. We sought to determine if dual plating or IM nailing for KRA would produce comparable outcomes.

Material and methods: This is a cross-sectional study of 30 patients who underwent KRA with either IM nail or dual plates for tumours about the knee. Demographic and surgical profile, functional scores using the Musculoskeletal Tumour Society (MSTS) score, and incidence of complications were determined.

Results: Mean follow-up was 2.28 years (SD 20.4). IM nail was utilised in 12 (40%) and dual plating in 18 (60%). 21 complications occurred, with 11 (52.38%) and 10 (47.62%) occurring in the IM nail and dual plating group respectively. MSTS score was higher with the IM nail (23.5 vs 22.5). Mean operative time was longer with the IM nail compared to dual plating (8.29 vs 7.80 hours). Blood loss was higher with the IM nail (1309.09 vs 1138.89mL).

Conclusion: Outcomes of IM nailing and dual plating KRA are comparable, including the incidence of complications. While blood loss and operative time were noted to be longer in the IM nailing group, and hospital admission was longer in the dual plating group, the difference was not significant. Larger, prospective studies are recommended to report outcomes for fusion done following tumour resection.

Introduction: Fast-setting high viscosity cement was introduced in the last decade, offering arthroplasty surgeons the benefit of shortened setting time. This could reduce the operating time, which may reduce the risk of infection and improve theatre efficiency. PALACOS® Fast R+G high viscosity cement has an average setting time of less than 6 minutes (30% faster than regular PALACOS® R+G) due to the lack of a waiting phase. The aim of this study was to investigate the safety of total knee arthroplasty performed using this fast-setting, high viscosity cement and short-term radiological outcomes.

Material and methods: This single surgeon case series looked at 344 primary TKAs performed using PALACOS® fast R+G cement from January 2016 to March 2020. Data were collected on patient demographics, perioperative events, and complications. Radiographs taken immediately post-operatively and at the one-year follow-up were analysed using the Knee Society Roentgenographic Evaluation and Scoring System (KSRESS).

Results: This case series included 313 consecutive patients (31 bilateral) with a mean age of 70 years (range 44-93). A total of 237 patients (76%, 262 TKA patients) had a minimum one-year follow-up. No adverse events were noted perioperatively; ten patients had superficial wound issues and were managed successfully with wound care and/or oral antibiotics. Six (1.7%) patients underwent re-operation in the study period. These included one DAIR, one staged revision for deep infection, two revisions for instability, one manipulation under anaesthetic for stiffness, and one patella internal fixation for fracture. The mean combined valgus angle for the prosthesis was 183.1° (range 177.7° to 187.8°), indicating adequate alignment. At one-year follow-up, no radiographs demonstrated any new loosening or worsening of any previously noted radiolucent lines.

Conclusion: This study reports the largest case series that looks at the use of fast-setting bone cement in primary TKA. It demonstrates good safety, as evidenced by a low re-operation rate, deep infection rate, and no adverse events during implantation. Fast-setting cement offers the promise of improving theatre efficiency and decreasing total running costs. Further studies are needed to provide data on improved theatre efficiency, cost savings and the longevity of implanted knees utilising this cement.

Bilateral patella tendon (BPT) rupture is a rare cause of extensor mechanism failure. It is extremely rare when a young patient without any systemic disease or risk factors, presents with bilateral patella tendon rupture simultaneously. We describe a case of a young lady without predisposing risk factors who sustained a BPT rupture following trauma from jumping on a trampoline. She was admitted inpatient and evaluated with imaging, before eventually undergoing surgical repair of bilateral knee extensor mechanism. Different surgical techniques were employed in both knees with equally excellent outcomes.

Introduction: Triple Arthrodesis is the preferred surgical treatment of stage III Adult Acquired Flatfoot Deformity. However, studies have reported subsequent midfoot degenerative arthrosis, with medial column instability.

Material and methods: This is a retrospective study using prospectively collected registry data from a single tertiary institution. Between 2007 to 2014, all patients who had undergone Triple Arthrodesis with concomitant percutaneous Tendo-Achilles lengthening were included. Patients with previous foot surgery, revision surgeries, and concomitant surgical procedures were excluded. We aim to report on our two years outcomes using the hindfoot and midfoot AOFAS and VAS scores, as well as radiographic parameters such as first-metatarsal declination angle, medial cuneiform calcaneal angle, navicular height, medial cuneiform - first metatarsal cuneiform angle, calcaneal pitch and medial longitudinal arch.

Results: There were 22 feet from 21 patients that met the criteria of having undergone Triple Arthrodesis with concomitant percutaneous Tendo-Achilles lengthening. Hindfoot and midfoot American Orthopaedic Foot and Ankle Society (AOFAS) scores improved by an average of 34.6 and 36.7 points at 24-months post-surgery (p<0.001). Between six months to two years post-operatively, there was evidence of mid-foot sagging as shown with an increase in Calcaneal-First metatarsal angle by a mean of 5.1° (p=0.001). Additionally, a decrease in the Calcaneal Pitch Angle by 2.9° (p=0.003) and Cuneiform-Calcaneal angle by 5.5° (p=0.000). Navicular Height also decreased significantly by 2.8mm (p=0.001) over this period. A total of 18 (85.6%) reported overall satisfaction being met at the time of a phone survey, at an average of 8.3 years (range 5.8 to 12.4) post-surgery. One patient required an ankle replacement, and another had removal of hardware done.

Conclusion: Triple arthrodesis with concomitant Tendo-Achilles lengthening results in significant improvement in AOFAS mid-foot and hindfoot scores at two years. At two years mark, there was features of mid-foot sagging postoperatively, despite continued improvement in AOFAS scores. Eighteen of the 21 patients were satisfied with the outcomes, on a phone survey, at an average of 8.3 years post-surgery.

This case report describes the use of a human acellular dermal matrix (ADM) as an interpositional allograft to stabilise and maintain the lesser metatarsophalangeal joint (MTPJ) pseudoarthrosis, and to prevent recurrent deformities, following arthrodesis of the first MTPJ and excision arthroplasty of the lesser metatarsals (MTs) for an elderly lady with severe rheumatoid forefoot deformities (RFDs). At six-month follow-up, the patient was recovering well with a clinically stable and radiographically well aligned foot, with no pain at the resection sites. She was also able to wear commercially available footwear.