Malaysian Orthopaedic Journal最新文献

Introduction: There is no consensus yet whether delayed limb salvage procedures with an "ischemic time" of more than 6 hours are worthwhile, as these repairs are often complicated by reperfusion injury. Our study aims to determine the outcomes of delayed revascularization to validate our current treatment approach and assess areas for future improvement.

Material and methods: We performed a retrospective cohort study on a highly selected group of patients who underwent delayed revascularization surgery for lower extremity traumatic vascular injuries in our institution from January 2008 to June 2018. Exclusion criteria include the presence of a terminal non-salvageable ischemic limb; defined as a gangrenous extremity evident by non-blanchable, mottled skin with complete limb paralysis, renal trauma, known renal impairment, and those with an ischemic time less than 6 hours. The demographic data, type and level of vascular, type of injuries, duration of ischemia, MESS score, and the need for secondary amputation were assessed. Result: Fifty-nine patients were identified and included in the analysis. Fifty patients (84.7%) were male, while 9 patients (15.3%) were female. The mean age was 28.1 years. The most injured vessel was the popliteal artery (n=41, 69.5%). The commonest injury pattern was contusion with thrombosis (n=31, 52.5%). Revascularizations were mainly achieved by interposition saphenous vein graft (n=40, 67.8%). The mean duration of delayed was 14.1 hours. A total of 83.1% of patients (n=49) had a Mangled Extremity Severity Scoring (MESS) of 7 and above. The limb salvage rate in this study was 89.8%, with only 6 patients (12.2%) requiring secondary amputations. Thirty-one patients developed rhabdomyolysis, with 6 cases (19.4%) requiring temporary inpatient renal replacement therapy (RRT). Out of the six, only one patient required lifelong RRT.

Conclusion: Limb salvage in those with the duration of delayed of more than 6 hours should be attempted after careful assessment and a high rate of limb salvage, minimal renal complication and acceptable functional (mobility) outcomes can be achieved, despite the reperfusion injury that accompanies.

Introduction: Anterior cruciate ligament (ACL) reconstruction is a commonly performed surgical procedure. The objectives of this retrospective comparative study are (1) to evaluate the obliquity, size and the intra-articular aperture shape of the tibial tunnel in patients operated with an anteromedial portal technique, and (2) to determine their possible relation with revision surgery.

Material and methods: Patients operated for a primary ACL reconstruction between 2014 and 2018 were eligible. All patients of primary and revision ACL fulfilling the inclusion criteria were assessed for presence of a knee CT scan within one month of surgery and at least three years of follow-up. Several radiological parameters were measured for the study, among which: Tunnel height, Coronal tunnel angle, Maximal tunnel width and Sagittal tunnel inclination. Multivariate analyses were performed to identify parameters correlated with revision.

Results: Mean age of the primary group was 30.5±8.4 versus 29.4±8.0 of the revision group. The majority of patients were males in both groups (n=33, 76.7% and n=38, 95.0%, respectively). A longer diameter of the intra-articular ellipse (p=0.005) and an increased mid-tunnel to TT distance on the axial plane (p=0.006) were significantly correlated with revision. A ROC curve analysis determined a cut-off value of 27.9mm from the tubercle was an optimal entry point.

Conclusion: A greater distance between the mid-point of the tibial tunnel entrance and the centre of the tibial tubercle is linked to a higher risk of revision. An elongated elliptic shape in the antero-posterior plane also correlates with revision risk.

Surgical management of femur osteomyelitis remains challenging. The burden of this chronic disease invariably results in composite bony and soft tissue defects that can interfere with bony stability. Therefore, reconstructive surgery is integral to functional limb salvage and limb preservatives. To the best of our knowledge, we are the first to report the limb salvaging method and important planning considerations for a case of chronic refractory osteomyelitis. We presented a case of a 31-year-old female with chronic post-traumatic osteomyelitis of the right femur. This intractable disease results in frequent remission of infection and non-union of the midshaft fracture. Surgical management with the implant, external fixation, and cement spacer failed due to infection. This rendered vascularised bone graft with massive allograft the only option. We described the anatomical aberrant during the harvest of free fibula flap and modified chimeric fibula flap to overcome the soft tissue defect complicated with severe fibrotic tissue with a background of an obese patient. She had undergone emergency hematoma evacuation 20 hours after the surgery. Otherwise, the flap survived well, and the patient started to have partial weight bearing. Chimeric fibula osteocutaneous free flap is a useful armament to provide a complex 3-dimensional spatial arrangement in a case of chronic osteomyelitis with huge bony and soft tissue defects.

Introduction: Intramedullary nailing in the management of hip fractures is gaining in popularity. Our study aims to determine if there are any clinical and radiological differences between the Proximal Femoral Nail Antirotation II (PFNA II) and the Dynamic Hip Screw (DHS) in the management of stable intertrochanteric (IT) femur fractures. Materials and methods: This is a single blinded prospective randomised controlled trial of 33 patients, aged above 60, comparing the use of the PFNA II and the DHS for the treatment of stable IT femur fractures in a single tertiary centre with an established ortho-geriatric co-managed hip fracture care pathway.

Results: Of the 33 patients enrolled, 18 patients were treated with the DHS and the rest with the PFNA II. The two groups had similar demographic profiles and pre-operative radiological parameters. There was no statistical difference between the two groups in terms of intra-operative bleeding, post-operative pain score and total surgical time. The median Harris Hip and Parker Mobility Scores for the DHS group were non-inferior compared to the PFNA II group. Surgical time, blood loss, post-op radiological parameters and functional outcomes including time to ambulation were similar in both groups.

Conclusion: We recommend the use of the DHS for stable IT fracture patterns in view of its cost savings and equivalent functional and radiological outcomes.

Introduction: Unicompartmental knee arthroplasty (UKA) has significant advantages over total knee arthroplasty (TKA). However, due to its need for precise positioning and soft tissue balancing, UKA failures and revision rates may be higher than that of TKA. Robotic-assisted UKA offers more accurate implant positioning, soft tissue balancing, improved lower limb alignment, and a reduction in surgical error. There are few studies studying functional outcomes post robotic-assisted UKA. The aim of this study was to compare the functional outcomes between robotic-assisted and conventional medial UKA.

Material and methods: A retrospective review was done of 159 patients; 110 patients underwent conventional UKA while 49 patients underwent robotic-assisted UKA. Outcome measures included the Oxford Knee Score (OKS), Knee Society Score (KSS), Visual Analogue Score (VAS) for pain, and range of motion (ROM) at three months, one-year and two years post-UKA.

Results: Pre-operative patient demographics and outcome scores were not significantly different between both groups. ROM was significantly greater in the MAKO compared to the Oxford group at 3 months (p=0.039), 1 year (0.053) and 2 years (0.001) post-operation. While OKS, KSS and VAS scores improved for both groups, there were no significant differences in the final outcome measures. None of the patients experienced a mechanical failure, infection, or revision post-surgery. One patient each in the Oxford and MAKO group suffered a periprosthetic fracture.

Conclusion: Both robotic-assisted MAKO UKA and conventional Oxford UKA showed good clinical outcomes. Robotic-assisted MAKO UKA had superior ROM outcomes compared to conventional Oxford UKA up to two years post-surgery.

Introduction: The proximal femur is the most common long bone affected by metastatic disease. Pathologic fractures in this area are frequent, secondary to weight-bearing and deforming forces. Long-stem endoprosthetic replacement is often used to replace and bypass segments affected by metastases. However, implant cost remains prohibitive for patients in low-resource settings. An improvised megaprosthesis using a hip implant combined with Kuntscher nail provides an economic option.

Material and methods: This is a case series of three patients diagnosed with pathologic fracture of the hip secondary to metastatic bone disease who underwent proximal femoral resection with reconstruction using an improvised endoprosthesis in a single tertiary hospital. Outcomes determined include total blood loss, total surgical time, length of hospital stay, latest functional score using the Musculoskeletal Tumour Society (MSTS) score, and pain scale using the numerical rating scale (NRS).

Results: For case 1, a 42-year-old female with metastatic breast carcinoma, currently alive with disease and able to perform activities of daily living (ADLs) with minimal assistance; for case 2, a 77-year-old male diagnosed with prostatic carcinoma, able to ambulate with assistive device before expiring 2 years post-surgery; and for case 3, a 57-year-old female with metastatic breast carcinoma, able to resume unassisted ADLs at 3 months post-surgery before refusing systemic treatment in her second year of surveillance monitoring.

Conclusion: An improvised megaprosthesis is a cost-effective implant option in low-resource settings, which may help decrease complications related to immobilisation for patients undergoing palliative surgery for metastatic bone disease.

Introduction: Simulation-based surgical skills workshops using 'Silent Mentors' are employed in numerous surgical training programs worldwide, yet empirical evidence on their effectiveness remains limited. The objective of this study was to investigate whether participation in the surgical skills workshop within the Silent Mentor Program (SMP) resulted in an improvement in the surgical skills of the workshop attendees.

Material and methods: Participants in the SMP at Universiti Malaya during the period from May 15, 2022, to September 24, 2023, were included in the study. Participants self-evaluated their surgical skill confidence levels in four fundamental surgical skills (chest tube insertion, central venous line insertion, endotracheal intubation, and skin suturing). The pre-workshop confidence scores were assessed and compared with immediate post-workshop scores.

Results: The findings demonstrated that after the training, participants exhibited higher confidence in all four fundamental surgical skills. Skin suturing demonstrated the highest total confidence score post-workshop, with a median of 21 and an interquartile range (IQR) of 18-24. Endotracheal intubation and chest tube insertion followed closely, both with a median of 19. Conversely, central line insertion displayed the lowest total confidence score, registering a median of 18 (IQR=16-21). No statistically significant differences were observed in the confidence level scores for chest tube insertion, central line insertion, and endotracheal intubation between pre- and post-workshop assessments across all demographic characteristics.

Conclusion: In conclusion, utilizing silent mentors in surgical skills training enhances proficiency in all four fundamental surgical skills, with skin suturing demonstrating particularly noteworthy improvements. The consistent confidence levels across demographic factors suggest the workshop's effectiveness across a broad spectrum of participants.

Introduction: The incidence of femoral neck fractures (FNFs) in elderly patients is increasing as average lifespans and the prevalence of osteoporosis increase. The optimal treatment strategy remains unclear. We compared the outcomes of cephalomedullary nail (CMN) and cannulated screw (CTS) fixations used to treat stable FNFs in patients over 65 years of age.

Material and methods: Among elderly patients with Garden type 1 and 2 FNFs treated between January 2010 and May 2018, 44 who were followed-up for more than 1 year were included. There were 28 cases in the CTS group and 16 cases in the CMN group, and the average age at the time of surgery was 76.3 years (range, 65-88 years). Radiological and functional variables were analysed to compare the results by fixation device.

Results: There were no significant differences between the groups in terms of functional outcomes or bone union times. However, operation and fluoroscopy times were significantly shorter in the CMN group. The neck shaft varus angulation and the extent of device sliding were greater in the CTS group. Multivariate analysis showed that CTS use was independently associated with major complications.

Conclusion: The CMN is a useful tool for treating stable FNFs in the elderly. It is simpler to use than conventional CTS fixation and is associated with fewer complications.

In this case report, we present a 13-years-old patient who sustained a Monteggia equivalent fracture along with an ipsilateral distal radius fracture following a fall on the elbow. Comminuted ulnar fracture was treated with open reduction and internal fixation with a bridging plate. After restoring the ulnar length, the radial neck fracture was successfully reduced. The distal radius fracture was managed conservatively. Our literature review shows that, the patient is one of the comparatively older patients treated with open reduction and internal fixation in this area and that a successful outcome was achieved with early mobilisation. This case underscores the need for further studies to determine the optimal treatment strategy in such cases.