Malaysian Orthopaedic Journal最新文献

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.

The Achilles tendon rupture often present as a significant clinical challenge. We present a complex case of chronic Achilles tendon rupture complicated by infection and segmental loss after failed primary repair. The patient underwent meticulous debridement, reconstruction using Baker's U-lengthening technique with augmentation using plantaris tendon. Tension-relieving sutures and a biosynthetic graft [Artelon® Flexband] were used for enhanced support. Post-operatively, a structured rehabilitation program was implemented, leading to successful healing with full weight-bearing capability at 12 weeks, with improved ankle function and no evidence of contracture. The utilisation of Baker's U-lengthening, along with adjunctive measures, proved effective in managing this challenging case. This report highlights the importance of a multidisciplinary approach, incorporating orthopaedic, infectious disease, and rehabilitation specialists in the comprehensive management of complex Achilles tendon injuries.

Restoring bone loss in revision Total Hip Arthroplasty (THA) surgery is challenging. Acetabular impaction bone grafting (AIBG) allows the restoration of bone stock and normal hip biomechanics. AIBG is usually performed as a single-stage surgery with hip component implantation, as it is traditionally believed that adequate loading of the impacted graft is necessary for integration with the host bone thus preventing bone resorption. We present a case of a 73-year-old gentleman who presented with bilateral hip pain and reduced mobility. He was diagnosed with left THA aseptic loosening with acetabular protrusion and subsequently underwent a two-stage AIBG using irradiated femoral head allografts. The first stage was performed without acetabular loading, yet the allograft successfully integrated with the host bone. This is the first reported case of a two-stage AIBG demonstrating that acetabular loading may not be required for allograft integration to host bone. Therefore, AIBG may be performed as a two-stage procedure, when necessary, especially in the setting of complex revision hip surgeries and patients with poor bone stock.

Introduction: Bone loss is a serious complication following an open fracture or fracture-related infection in the tibia. Treatment with Ilizarov bone transport in this condition is preferred because it minimises additional soft tissue injury and is able to close the bone and soft tissue defects through distraction osteogenesis. The objective of this study is to evaluate the relationship between functional outcomes of patients with tibial bone loss treated with Ilizarov bone transport and return to work.

Materials and methods: A cross-sectional study among 40 patients was carried out in 2 public hospitals. Patient records and radiographs were reviewed for information on the initial injuries, treatment, union of bone, and complications while on treatment. The clinical outcomes were evaluated with ASAMI Bone grading system while the functional outcome of the affected limb was assessed using Lower Extremity Score (LEFS) and ASAMI Functional grading system at least 10 months after the removal of the Ilizarov external fixator.

Results: Thirty-eight (95%) achieved union. Thirty-six (90.0%) patients had excellent and good scores for clinical and functional results, respectively using the ASAMI grading system. The mean LEFS is 80.1% (range 58 to 91%). Thirty-three (82.5%) patients were able to return to work. The clinical outcome has a strong and positive correlation with functional outcome both on ASAMI functional score and LEFS (p<0.001). Patients with good and excellent ASAMI functional scores significantly correlate with higher odds to return to work (p<0.001). Return to work was also associated with a higher LEFS score (p=0.006).

Conclusion: Most patients with tibial non-union treated with Ilizarov bone transport have good and excellent clinical and functional outcomes and are able to return to work. Return to work significantly correlates with good functional outcomes.

Introduction: Surgeons performing periacetabular osteotomy (PAO) should account for proximal femoral morphology to prevent secondary femoroacetabular impingement. Herein, we aimed to clarify proximal femoral morphology in patients with developmental dysplasia of the hip (DDH).

Materials and methods: This retrospective study included 57 patients with DDH (77 hips) who underwent PAO (DDH group). The control group comprised 30 patients (30 hips) with unilateral femoral head necrosis and contralateral unaffected hips (healthy hips). Coronal planes were created parallel to the femoral neck axis based on three-dimensional image analysis of hip computed tomography images. Coronal slices were obtained using clockwise rotation around the femoral neck axis in 15° increments, creating seven positions for measuring alpha (α)-angles. The superior and anterior directions were defined as 12 o'clock and 3 o'clock, respectively. Cam deformity was defined as an α-angle ≥60°. Outcome measurements were the α-angles of seven slices, cam deformity, and correlations between the maximum value of the α-angles and related factors.

Results: α-Angles were greater in the superior direction in the control than in the DDH group; conversely, they were greater in the anterior direction in the DDH than in the control group. The DDH group had more cam deformities than the control group. Cam deformities were more superior (12:30 to 1:00) in the control group, and more anterior (2:00 to 3:00) in the DDH group. Maximum α-angles in the DDH group correlated with superior acetabular coverage.

Conclusion: Surgeons should carefully consider acetabular version during PAO and avoid acetabular retroversion in cases with cam deformities.

Introduction: Articular cartilage has limited healing potential as it is a hypocellular and avascular structure, hence it is to manage articular cartilage defects. The arthroscopic osteochondral autograft transplantation procedure is minimally invasive and cosmetically acceptable procedure to manage cartilage defects.

Materials and methods: This is a prospective study extending from 2018 to 2023 done at Sports Injury Center, New Delhi involving 36 patients with focal full-thickness chondral/osteochondral defect, age <45 were included. Global Chondral change, Multi ligamentous injuries, varus or valgus malalignment, kissing lesion and defect > 20mm were excluded. The osteochondral lesion was debrided down till healthy cartilage margins, donor graft was harvested from the non-weight-bearing area of the MFC. Lysholm score was used to assess functional outcome.

Results: Median age 35 years (range 20 - 44 years). A total of 51% of the patients were aged between 31 and 40 years (n=18). Male to female ratio was 3.37:1. The median defect size was 8mm (range 7-10mm). There was a gradual improvement in knee-specific symptoms with time. There was a significant increase in Lysholm score with time (p<0.0001).

Conclusion: The OATS procedure is a reliable, reproducible method and its results are encouraging with early mid-term follow-up; however, a long-term follow-up study is required to ascertain the validation of OATS procedure for preventing degenerative arthritis in patients with osteochondral injuries of the knee.

Introduction: Anterior cruciate ligament (ACL) surgeries are among the most common orthopaedic surgeries performed globally. The quoted failure rates of ACL surgery are approximately 10-15%, which is unacceptably high. The likely cause of failure is multi-factorial and the ability to predict a high-risk patient pre-operatively will allow surgeons to be better decision makers. The aim of the present study was to assess risk factors for failure and develop a score to help predict failure in ACLR.

Materials and methods: A retrospective case-control study (n=112 patients) was carried out over a period of two years at a tertiary referral centre. Patients with ACLR failure were grouped into Group 1 (n=56) and patients with a successful ACLR at one year follow-up with no objective or subjective instability AND return to sport were age matched to group 2 (n=56). Risk factor regression analysis was carried out to develop a scoring system (MATS score) and ROC curve analysis was used to generate a cut-off score to predict failure risk.

Results: The frequency mapping data showed a high level of prevalence of risk factors in the test group versus the control group. We found an average MATS score of 4.1 in the control group versus 5.9 in the test group. ROC curve analysis showed that a cut off value of 5.5 may be taken with a good sensitivity and specificity, and good inter-observer reliability.

Conclusion: Based on our assessment of risk factors in the study population we developed the MATS score to aid in clinical decision making. Patients with a score of less than or equal to 5 can be classified as low risk of failure. Patients with a score of 6 or more are considered high risk for ACLR failure.

Introduction: Recurrent anterior shoulder dislocation is particularly more common among occupations involving the frequent use of the upper limb above shoulder height such as manual labour. The present study aims to investigate outcomes of arthroscopic Bankart repair and Remplissage in manual workers as few studies have been undertaken in this specific subgroup. The arthroscopic Bankart repair and Remplissage in treatment of recurrent anterior shoulder dislocation in manual workers has reduced recurrence rates and improved patient satisfaction.

Materials and methods: A total of 36 patients underwent arthroscopic Bankart with Remplissage for recurrent anterior shoulder dislocation, enrolled between February 2022 to December 2023 considering various inclusion and exclusion criteria. Patients were evaluated in post op period for range of motion, oxford shoulder instability score and visual analogue score for pain at intervals of 6 and 12 months.

Results: All patients enrolled had soft tissue with bony Bankart lesion with mean of glenoid bone loss (%) was 11.75% (±3.15%) and all participants had engaging Hill-Sachs lesion. The mean pre-operative OSIS was 19.56 (±2.17) and mean VAS was 5.53 (±0.56). In the post op evaluation, there was no clinically significant decrease in range of motion with mean loss of external rotation of 3.86 (±1.44) at 12 months. The mean OSIS increased to 41.0 and mean VAS decreased to 2.36 at 12 months follow-up which was statistically significant. There was no incidence of dislocation in post op period of 12 months.

Conclusion: Arthroscopic Bankart repair and Remplissage in recurrent anterior shoulder dislocation in manual workers demonstrates significant improvements in functional outcomes, minimal post-operative range of motion restrictions, and stable shoulders at the 12-month follow-up, highlighting the efficacy and safety of the procedure.

Different surgical techniques are used to preserve knee articular cartilage deterioration; however, combining these techniques can be challenging. This case study describes a 35-year-old man with bilateral genu varum malalignment and left knee pain, diagnosed with a grade IV chondral lesion in the lateral femur, a complex lateral meniscus lesion, and a radial tear in the medial meniscus. The patient underwent a valgus-producing tibial osteotomy, lateral osteochondral allograft transplantation, and lateral meniscal allograft transplantation using a 3D model of the proximal tibia. Seventeen months post-operatively, he experienced torsional trauma, leading to a tear of the transplanted meniscus posterior root and an anterior cruciate ligament injury. Subsequent surgical exploration revealed evidence of chondroprotective changes, including femoral osteochondral allograft healing and biomechanical integration of the transplanted meniscus, as indicated by the lateral meniscus root tear development. This case highlights the potential of combining these surgical procedures to achieve biomechanical integration of the transplanted meniscus, contributing to cumulative chondroprotective effects.