Malaysian Orthopaedic Journal最新文献

A 31-year-old man presented with abscesses of the left iliacus muscle, adductor muscles and left hip septic arthritis. Following surgical debridement and antibiotics, he remained infection free at 3 years. We present the radiographic evolution of the changes in his left hip . Despite destruction of the hip during initial follow-up, there was remoulding of the proximal femur with changes of avascular necrosis over a 3-year period with good hip function. Hip septic arthritis may result alarming radiographic changes during initial follow-up. Some patients may continue to improve clinically and radiographically in the short term.

Introduction: Knee osteoarthritis is a degenerative joint disease attributed to failure in joint repair process. Key aspect of the diagnosis relies on thorough history, along with physical examination and radiology findings. The conventional weight-bearing plain radiograph remains the key modality to determine the severity of the condition and helps to plan the surgery. Nevertheless, not all patients can undergo weight-bearing plain radiographs, especially those who are wheelchair-bound or have severe deformities. The purpose of this study is to investigate whether a weight-bearing plain radiograph of the knee is essential in all patients with knee osteoarthritis.

Materials and methods: A prospective cohort study on patients with knee osteoarthritis receiving treatment in a single tertiary hospital was conducted. All patients consented to participate in this study. Patients were assessed functionally with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and radiologically with plain radiographs. Patients were subjected to undergo both supine and standing plain radiographs of the knee in the same setting for comparison purposes where measurement is done following patient functional outcome and radiological measurement for the patient.

Results: Our study shows that reduction in joint space is more obvious in weight-bearing radiographs, however in severe or higher-grade osteoarthritis, a supine radiograph is adequate to diagnose knee osteoarthritis.

Conclusion: Standing radiograph of the knee is preferred to a supine knee radiograph wherever possible due to the additional value it brings, however, in certain patient conditions, a supine radiograph is still acceptable.

Introduction: Proximal humerus fractures (PHFs) are associated with morbidity/functional impairment. Rehabilitation adherence is crucial to regain independent function yet is often hindered by pain. This pilot study aims to analyse the safety and efficacy of ambulatory catheter-based interscalene blocks (CISBs) as analgesia in post-surgical PHF patients and summarise learning points to guide further implementation/study of ambulatory CISB.

Materials and methods: This pilot study selected PHF patients who were >18yo, surgically treated and received ambulatory CISB (CISB ≥72 hours). Data was derived from clinical documentation (anaesthetist/surgeon/therapist reviews). Clinical outcomes (e.g. range of motion, Quick Disability of Arm/Shoulder/Hand (qDASH) scores), dynamic/resting pain scores and incidence of CISB-related complications were collected.

Results: Twelve patients were selected with mean ambulatory CISB duration of 9.5 days. All patients improved clinically, with means improvements of +64.6° and +61.9° for passive flexion and abduction, and reduction of 29.8 in qDASH after 3 months. Two patients experienced neurological complications (phrenic nerve palsy; medial forearm numbness) while six patients experienced catheter-based complications (dislodgment, erythema). All complications were self-limiting, resolving with removal of catheter.

Conclusion: Ambulatory CISB can minimise pain and facilitate rehabilitation for PHF patients. Learning points include (1) complications are predictable and incidence/physiological impact on patients can be minimised via appropriate patient selection, (2) standardised protocols (e.g. tunnelling of catheters) help maximise utility of ambulatory CISB while minimising complications, (3) regular monitoring/anticipation of complications facilitate early detection and prompt management. These learning points, combined with existing literature, can be adapted to future applications of ambulatory CISB to better study its safety and efficacy.

Introduction: Congenital pseudarthrosis of the tibia (CPT) is challenging to treat. The main issues following surgery are non-union, refracture, limb deformity and length discrepancy. We evaluated the surgical outcome of children operated in our centre.

Materials and methods: A retrospective study of the outcome of primary bone union, refracture and success rate. Patients who had reached skeletal maturity were further evaluated for Johnston grading, residual limb deformity and limb length discrepancy (LLD).

Results: Twelve patients (13 tibiae) were reviewed with an average follow-up of 14.5 years (range 3.1-24.0 years). Nine (69.2%) tibiae underwent intramedullary (IM) rodding; two (15.4%) were stabilised with the Ilizarov external fixator (IEF) + IM rod; and two other (15.4%) tibiae with the IEF only. Primary union was achieved in 5 (38.5%) tibiae, but refractures occurred in two tibiae (40%), lowering the overall success rate to 23.1%. Fixation with IM rodding alone led to a low primary union rate (22.2%) but combining it with IEF avoided refracture. Seven (53.8%) tibiae reached skeletal maturity and had a union at 12.6 years (7.5-17.4 years), after an average of 3 surgical procedures. Four (57.1%) were Johnston Grade I, and 3 (42.9%) were Grade II. Four (57.1%) tibiae had residual tibial valgus, two (28.6%) tibial varus, four (57.1%) procurvatum and one (14.3%) recurvatum. The average LLD was 3.9cm (2-10cm).

Conclusion: Intramedullary rodding alone is ineffective for producing a bony union but combining it with IEF minimise the refracture rate. The chances of union increased with age, but residual deformity and shortening are an ongoing challenge.

Introduction: This study aimed to study the usefulness of CTX II levels to identify normal population with patients of knee osteoarthritis, and its utility in identifying the severity of disease in primary knee osteoarthritis (KOA).

Materials and methods: This research recruited 80 cases of KOA and 80 healthy adults (160 subjects). Patients with primary knee osteoarthritis were graded according to the KL grading system, and serum CTX II (sCTX II) value were analysed. The age, gender, and BMI of the subjects were recorded.

Results: The sCTX-II value in cases (719.87 ± 256.1pg/ml) was more than in controls (419.26 ± 208.18pg/ml, p<0.001). The sCTX-II value in case group was significantly higher in males (812.67 ± 289.24) than in females (680.11 ± 236.59, p=0.03). In the control group, males (426.13 ± 221.06) and females (398.66 ± 166.92) had similar values (p=0.60). sCTX II level was higher with higher age, but this difference is significant in the case group only (p=0.003). Multivariate analysis revealed that the sCTX II level was only dependent on the severity of the disease. Analysis of the ROC curve reveals a cut-off value of sCTX II as 557.5pg/ml among cases and controls, 407.5pg/ml between KL grade 0-I, as 528.5pg/ml between KL grade I-II, as 681.1pg/ml between KL grade II-III, and as 866.4pg/ml between KL grade III-IV.

Conclusion: sCTX II values are dependent only on the severity of the disease. sCTX II level estimation is an excellent diagnostic tool for identifying the normal population with knee osteoarthritis patients and has a clinical significance in identifying KOA cases of KL grade I and II.

Hamartomas are benign masses of disorganised tissue native to specific anatomical sites, with a potential for malignant transformation. While they can manifest in various organs, cases involving the hands are exceptionally rare. Hamartomas in the hand have been documented sparingly. To date, there have been no cases of hamartomas in the fingers, hence contributing to the limited body of literature. This case report discusses a hamartoma in the right little finger of an 80-year-old male with a history of a slowly growing painless mass over the course of 5 years. Examination revealed a 1x1 mass with benign features over the proximal interphalangeal joint (PIPJ). A plain radiograph was unremarkable. An excision biopsy was done, and histopathological examination (HPE) revealed a diagnosis of hamartoma. Post-operatively, his wound healed accordingly, and normal function of the finger was achieved.

Introduction: Recent advances in orthopaedic research focus on improving bone healing and grafting. Osteopaste, a synthetic bone cement made from tetra-calcium phosphate (TTCP) and tri-calcium phosphate (TCP) has been developed to overcome limitations of traditional bone grafts. This study evaluates the radiographic density and new bone formation to bridge the critical size defect of Osteopaste compared to two other synthetic grafts, JectOS (calcium phosphate) and MIIG-X3 (calcium sulfate) at 6, 12, and 24 weeks.

Materials and methods: A critical size defect measuring approximately 4.5mm (width) x 9.0mm (length) was surgically created at the proximal tibial metaphysis and implanted with Osteopaste, JectOS, or MIIG-X3. Following cement implantation, surrounding soft tissues were repositioned and sutured with bioabsorbable surgical suture. Bone defect healing and cement density were qualitatively and quantitatively evaluated using plain radiographs and computed tomography (CT) scans at 6, 12, and 24 weeks.

Results: The Osteopaste group showed radiographic density levels between those of JectOS and MIIG-X3. JectOS had the highest density, while Osteopaste was higher than MIIG-X3. In the Osteopaste group, new bone formation bridged the critical size defect by 12 weeks, but no bridging occurred in the other two groups at any time point. Statistical analysis showed significant differences in mean density among the groups at 6, 12, and 24 weeks (P<0.0001).

Conclusion: Osteopaste effectively promotes new bone formation. Its performance falls between that of JectOS, which has the highest density, and MIIG-X3. These results suggest that Osteopaste could be a useful alternative for bone grafting.

Introduction: We have devised an algorithm to assist classifying acetabulum fractures using plain radiographs. This study aimed to test if the accuracy and reliability of fracture classification increases using our algorithm in resident doctors.

Materials and methods: Seventy-two residents of eight tertiary care institutes took part in our survey. These residents were divided into three groups, Groups A, B, and C, with 31, 20, and 21 residents, respectively. Two different Collections (1 and 2) containing radiographs of twenty patients each, with known classification from CT and intra-operative findings, were prepared. Collection 1 radiographs were given to Group A and B, and Collection 2 radiographs were given to Group C. Group A residents were asked to classify the fractures using our algorithm, and Group B and C residents were asked to classify the fractures according to their understanding. Intra-observer and interobserver reliability were estimated.

Results: A total of 1411 unique responses were made. The accuracy of group A, B, and C residents was 53.8%, 34.9% and 28.3%, respectively (p-value 0.001). The interobserver reliability for fracture classification was fair with an algorithm (κ = 0.32) and slight without an algorithm. The intra-observer reliability among five observers was moderate (κ = 0.43).

Conclusion: Our algorithm improves the accuracy and reliability for classifying acetabular fractures according to the Judet-Letournel classification for resident doctors with two to four years of experience.

Introduction: Anterior cruciate ligament (ACL) tears are a common musculoskeletal injury often requiring anterior cruciate ligament reconstruction (ACLR). Many factors are thought to influence patient outcome and determining the extent can allow for optimisation of patient care. One of these factors is graft tunnel placement, both femoral and tibial. The aim of this study was to investigate whether graft tunnel placement influences clinical outcome following ACLR.

Materials and methods: The patient responses from six patient-reported outcome measures (PROM) at initial presentation and one year following ACLR, as well as demographic data at presentation, were collected. Graft tunnel placement was evaluated using 10 validated radiological measurements on antero-posterior and lateral radiographs following surgery.

Results: A total of 45 patients were included in the study. There was a significant longitudinal improvement (p<0.001) for almost all PROM scores when comparing pre-operative to post-operative results. Overall, no significant correlation was demonstrated between graft tunnel placement and PROM scores, except for a weak association between femoral tunnel positioning on lateral view radiographs and the overall Knee injury and Osteoarthritis Outcome Score (rho=0.37, p=0.038) and the Lysholm score (rho=0.36, p=0.034) and also tibial tunnel placement on lateral view radiographs and the EQ-5D VAS score (rho=0.37, p=0.037).

Conclusion: ACLR is a clinically successful treatment strategy for patients with symptomatic ACL tears. Graft tunnel positioning does not generally affect clinical outcomes, although there may be a weak association with femoral tunnel positioning on lateral radiographs.

Introduction: There are various methods used to repair lacerated tendons. The minimum requirement for the best results and lowest rupture rate is the four-strand repair technique. The cruciate type of repair is among the most popular methods available but is very technical and requires expertise. An easier two-double-loop method for tendon healing is suggested in this study. This study assessed the biomechanical properties of two well-known tendon repair techniques-the modified Kessler and cruciate approaches-and two lesser-known double-loop techniques for tensile strength, stiffness, and failure mode.

Materials and methods: Twenty-four adult chickens' Achilles tendons were randomly divided into three groups and sutured with a four-strand core suture using the four-strand modified Kessler technique, the four-strand cruciate technique, and the two-double-loop approach. Twenty-four more adult chicken Achilles tendons were acquired, and they were randomly assigned to the same three groups along with an extra running epitendinous repair. A synthetic, non-absorbable monofilament polypropylene suture was used for all repairs.

Results: The four-strand modified Kessler, and the four-strand cruciate procedures had the lowest mean ultimate tensile strength, whereas the two double-loop techniques had the strongest. The results were dramatically impacted by using an epitendinous suture during test analysis.

Conclusion: The strongest and comparatively less technically complex technique used in this investigation was the two-double-loop, four-strand core suture method. The significance of the extra strength that the epitendinous suture gave was clear. Using this in a clinical setting is recommended for hand flexor tendon injuries.