A Rare Case of Salter-Harris Type I Growth Plate Injury in a Patient Undergoing Limb-Lengthening Procedure

Growth plate injuries over the distal femur typically occur due to high-energy trauma. It is commonly associated with serious complications such as growth disturbance. Its occurrence in children undergoing limb-lengthening procedures is uncommon. We report a case of distal femur growth plate injury in a 13-year-old boy undergoing a limb-lengthening procedure for femoral hypoplasia. Conservative treatment yielded a good functional outcome in this patient.

Functional outcome and quality of life following treatment for post-traumatic osteomyelitis of long bones

INTRODUCTION

The clinical outcomes and factors associated with treatment failure of post-traumatic osteomyelitis have been investigated in many studies. However, limb functionality and quality of life following treatment for this condition have not been thoroughly studied.

METHODS

This cross-sectional study included 47 patients with post-traumatic osteomyelitis of the lower limb. Functional outcome was assessed using the Lower Extremity Functional Score (LEFS), and quality of life was assessed using the validated Malay version of the Short Form-36 questionnaire version 2.

RESULTS

The mean follow-up period was 4.6 (range 2.3-9.5) years, and the median age of the patients was 44 years. Osteomyelitis was located in the tibia for 26 patients and in the femur for 21 patients. Osteomyelitis was consequent to internal infection in 38 patients and due to infected open fractures in nine patients. 42 (89.4%) patients had fracture union and control of infection. Bone defect was found to be a significant contributing factor for treatment failure (p = 0.008). The median LEFS for the success group was 65, compared to 49 for the failure group. Although the success group showed better scores with regard to quality of life, the difference between the two groups was not statistically significant.

CONCLUSION

Treatment of post-traumatic osteomyelitis of the lower limb had a high success rate. The presence of a bone defect was associated with treatment failure. Successfully treated patients had significantly better functional outcomes than in those in whom treatment failed.

Revisiting the Pedicled Gastrocnemius Flap for Orthoplastic Limb Reconstruction

INTRODUCTION: Gastrocnemius muscle flap is performed in a combined approach of the orthopaedic and plastic team for limb reconstruction in the developed countries. However, this practice is not readily available in Malaysia because of the smaller numbers of plastic surgery services in government hospitals. This study reviews the outcome of the gastrocnemius flap performed by the orthopaedic team. MATERIALS AND METHODS: Thirty-two patients underwent gastrocnemius flap surgery with a mean age of 35.3 years (range 13-82). The flaps were done to cover the upper third (22), upper half (4), knee (2), distal femur (2) and the popliteal fossa (1). The initial problems were open fracture (21), infection following plating (5), necrotising fasciitis (3), degloving injury (1), pin site infection (1) and melioidosis (1). Five patients were having underlying Diabetes mellitus, 3 Hepatitis B, 2 HIV and 1 Hepatitis C infections. RESULTS: There was no flap necrosis. Complications include persistence infection in 3 patients which required advancement of the flap (1) and additional fasciocutaneous flap (2) to cover the wound breakdown. All fractures achieved union but one patient with infection following double plating for tibial plateau fracture developed chronic osteomyelitis. One patient develops transient peroneal nerve palsy following the lateral gastrocnemius transfer. Both patients who had patella ligament reconstruction with gastrocnemius flap develop knee stiffness. CONCLUSIONS: Gastrocnemius flap is a reliable and safe procedure in salvaging the leg from amputation related to open fractures and infections in orthopaedic surgery. It should be one of the options for the operative procedure thought during the orthopaedic training.

Early Experience with Local Custom Made Synthetic Bone Construct for the Treatment of Bone Defect

Introduction: Segmental bone defect can be treated with autologous bone graft and bone transport. Synthetic bone graft has successfully been used for the treatment of metaphyseal fracture or bone cyst. However, their use for the treatment of segmental bone defect has not been establish. Recently, a local company has produced a biodegradable custom made synthetic bone construct phosphate-based materials that is used to treat fractures and bone defect. Materials and Methods: After getting approval from Medical Device Agency, we used SBC to treat segmental bone defect in our patients. A case series review was conducted in these cases. Results: Three patients underwent surgery using SBC as a spacer to fill the defect at the docking site to prevent soft tissue collapse in one patient and as a replacement for bone autologous bone grafting in two patients. In our observation granules resorbtion ranged from 40-80% by 6 months with no radiological evidence of new bone formation. SBC mixed with bone marrow aspirate failed to harden into a palette. Although no new bone formation was seen at the docking site, insertion of SBC prevents soft tissue invagination and reduced the need of a second surgery to remove other conventional spacers. Conclusion: SBC may be used as a spacer to prevent soft tissue interposition and skin invagination in bone transport. However mixing it with bone marrow aspirate resulted in failure to form beads and does not form bone.

Integration and Islamisation Program for Clinical Post Graduate Students in International Islamic University of Malaysia (IIUM)

Integration and islamisation (INI) programmes for undergraduate medical students have been practiced, reviewed and published in many journals. However, there is only a dearth of study on the implementation of such a programme for postgraduate clinical students. Hence, there is a need to examine such a programme because of the different learning environment and characteristic of the students. The aim of this paper is to examine the existing clinical postgraduate programme at IIUM and attempts to improve the INI curriculum. Method: The study employs an analytical method and important factors for the development of the curriculum are analysed to come out with the objective, content, teaching methodology and assessment method suitable for the program. Result: The study identified the important factors that determine the curriculum to be the needs of National Health Service, the mission of the university, the requirement of the professional body and characteristic of the students. The study proposes that the objective of the program is to produce holistic orthopaedic surgeons who understand the belief of Muslim patients and is able to facilitate them in their ibadah and daily life as a Muslims. This is achieved through offering a course which consists of 4 main subjects on the principles of shariah which include the element of Islamic worldview, fiqh ibadah, fiqh muamalah and Islamic moral values with emphasis on issues related to medicine. The teaching method proposed is having regular seminars which consist of presentations and discussion of important concept in Islamic fiqh and followed by case study on fiqh issues related to Medicine. Finally, the students should be assessed from the case write up which they are required to submit before they can sit for the final professional exam. Conclusion: This improved program enables students to complete their study without compromising their duties to provide services at their respective hospitals.

Model of A Critical Size Defect in the New Zealand White Rabbit’s Tibia

Introduction: Critical size defects (CSD) in the long bones of New Zealand White rabbits (Oryctolagus cuniculus) have been used for years as an experimental model for investigation of the effectiveness of a new bone substitute material. There are varieties of protocols available in the literature. This technical note attempts to present an alternative surgical technique of a CSD in the New Zealand white rabbit tibia. Methods: Thirty-nine New Zealand White rabbits were used in this study. A CSD of approximately 4.5 mm (width) X 9.0 mm (length) was surgically drilled at the proximal tibial metaphysis, approximately 1 cm from the knee joint. The surrounding of soft tissue was repositioned and sutured layer by layer with bioabsorbable surgical suture. Two x-rays of anteroposterior and lateral were taken before assessed under computed tomography scan at 6, 12 and 24 weeks. Results: This alternative method created CSD with less bleeding from the muscle observed. No mortality or other surgical complications observed within 6 weeks, 12 weeks and 24 weeks following surgery. Conclusion: A simple and safe method for performing CSD was demonstrated and recommended as an alternative approach for surgery on New Zealand White rabbits.

Predictors of major lower limb amputation among type II diabetic patients admitted for diabetic foot problems

INTRODUCTION

Diabetes mellitus (DM) is the most common cause of amputations in Malaysia. This study aimed to identify the predictive factors for major lower limb amputation among patients with type 2 DM (T2DM) who were admitted to a hospital, in order to reduce its likelihood.

METHODS

This cross-sectional study involved 218 patients with T2DM who were admitted to Hospital Tengku Ampuan Afzan, Kuantan, Malaysia, for diabetic foot problems from June 2011 to July 2012. A form was developed to document the patients' profiles, comorbidities, complications, investigations, treatment and clinical outcomes. The predictors for major lower limb amputations were determined using univariate and stepwise logistic regression analysis.

RESULTS

A total of 31 patients underwent major lower limb amputations (25 transtibial, 6 transfemoral). The following factors were found to be associated with the incidence of major lower limb amputations: T2DM duration ≥ 10 years, diabetic neuropathy, diabetic nephropathy, presentation with gangrene, diabetic foot conditions of Wagner grade 4 or 5, and necrotising fasciitis. Patients who underwent major amputations had significantly lower haemoglobin and albumin levels, and higher total white blood cell counts, erythrocyte sedimentation rates, and C-reactive protein, urea and creatinine levels. However, only T2DM duration ≥ 10 years, positive bacterial culture and albumin levels were significant on stepwise logistic regression analysis.

CONCLUSION

T2DM duration ≥ 10 years, positive bacterial culture and low albumin levels were found to be significant predictive factors for major lower limb amputation among patients with T2DM admitted for diabetic foot problems.

The functional outcome and quality of life following open diaphyseal tibial fractures

Introduction: The clinical outcome of open tibia fracture been extensively studied in many institutions. However, the functional outcome and quality of life has not been widely studied. The aim of this study is to evaluate the functional outcome and quality of life for patients with open tibia fracture that were treated in Hospital Tengku Ampuan Afzan. Methods: Between 2009 and 2010, we treated 33 patients with open diaphyseal tibial fractures with a minimum period of one year follow up. There were 31 males and 2 females; the mean age of 29 years old (range: 10 to 60). Four patients sustained open fracture grade I, 13 grade II, 12 grade IIIA and 4 with grade IIIB. All patients who fulfill the inclusion criteria were called for interview in the clinic by the investigator. The outcome that were analyzed include health related quality of life (SF36) and Lower Extremity Functional Score (LEFS). Results: All except one fracture achieve union. One patient with grade IIIB open fracture developed infected non union. Quality of life is satisfactory in all domains. The functional outcome score was significantly reduced in grade IIIB (48.5) as compare to other grade (grade I 74.2, grade II 70.4, grade IIIA 74.1). Conclusions: The quality of life and the functional outcome worsened with increasing severity of fracture.

Model of a critical size defect in the New Zealand White rabbit’s tibia

Introduction: Critical size defects (CSD) in the long bones of New Zealand White rabbit (Oryctolagus cuniculus) have been used for years as an experimental model for investigation of the effectiveness of a new bone substitute materials. There are varieties of protocols available in the literature. This technical note attempts to present an alternative surgical technique of a CSD in the New Zealand white rabbit tibia. Methods: Thirty-nine New Zealand White rabbits were used in this study. A CSD of approximately 4.5 mm (width) X 9.0 mm (length) was surgically drilled at the proximal tibial metaphysis, approximately 1 cm from the knee joint. The surrounding of soft tissue was repositioned and sutured layer by layer with bio absorbable surgical suture. Povidone soaked gauze and bandage were used as a dressing. There is no control group used in this study. Results: This alternative method created good CSD with less bleeding from the muscle observed. No mortality on other surgical complications were observed within 6 weeks, 12 weeks and 24 weeks following surgery. Conclusions: A simple and safe method for performing critical size defect was demonstrated and recommended as an approach for surgery on New Zealand White rabbits.

10 years review of endowment fund for research in IIUM Kuantan

Introduction: IIUM Research Endowment Fund was initiated to encourage research activities, but was withdrawn in 2015 due to financial constraint. The discontinuity was additionally justified as Endowment Funds being an internal fund, does not contribute to MyRA, an instrument used to gauge research activities in Malaysian Universities. It is divided into Endowment A (Non-S&T) and B (S&T) which funds RM5,000.00 and RM20,000.00 accordingly. This study aims to analyze the output of IIUM Kuantan lecturers from the fund from 2005- 2015. Methods: Data were obtained from IIUM Kuantan Research Management Center filing system, which include End of Project Forms and Research Reports among others. The outcome measured includes publication, human capital and seminar presentation. Each outcome was given scores to indicate its importance. Results: A total number of 349 grants, which consisted of 117 grants for Endowment A (RM585,000) and 232 grants for Endowment B (RM4,640,000) were approved since 2006 until 2015. The total amount of grant given was RM5,225,000. Endowment A and B produced 76 and 242 publications, 34 and 121 students’ project and 74 and 299 conference presentations accordingly. Endowment A and B utilized RM2839.81 and RM10,108.93 for 1 score accordingly. Conclusions: Although Endowment Grants were not considered in MyRA markings for research grants received, it has contributed significantly to other MyRA scores such as publication, presentation and students’ development with a relatively small amount of money.

Acute vascular complications (flap necrosis and congestion) with one stage and two stage distally based sural flap for wound coverage around the ankle

INTRODUCTION

The understanding of the skin's vascular anatomy has improved in the last decade. It has lead to technique modification such as the staged procedure in performing sural flaps and improvement in the flap survival rate. The aim of this study was to evaluate the acute vascular complications (flap necrosis or congestion) of 29 patients who underwent distal base sural flap for coverage of wound around the ankle.

METHODS

Twenty-four males and five females with a mean age of 37.1 years old underwent sural flap surgery to cover wounds at around the ankle. There were 12 cases of open fracture, five infected fractures, four spoke injuries, four degloving injuries and four diabetic foot ulcers. Twentythree cases were done as a single stage procedure while six as a two-stage procedure. The flaps were tunnelled under the skin in three cases.

RESULTS

Twenty one flaps healed uneventfully, seven acute vascular complications occur in a single stage group: five developed partial necrosis, one had congestion with epidermolysis, and one had complete flap necrosis. Complications were treated by dressing or skin grafting and only one required a repeat flap surgery.

CONCLUSIONS

Acute vascular complications may be minimised when sural flap is done in stages for elderly, diabetic, smokers and/or patients with large wound around the ankle. Even if the flap appears necrotic, the underlying structure may still be covered as the fasciosubcutaneous layer of the flap may still survive.

Outcomes of infected grade IIIB open tibial fractures

INTRODUCTION

Infection following grade IIIB open tibial fracture is common. The primary aim of managing this condition is to achieve control of infection before the bone reconstruction procedure is performed. The outcomes for such patients have not been evaluated in the literature. This study was conducted to examine the outcome of a multi-stage procedure for the treatment of infected grade IIIB open tibial fractures.

METHODS

Between 2004 and 2008, we treated 11 patients with infected grade IIIB open tibial fractures in our unit. The management of infected grade IIIB open tibial fracture comprised three stages, which included serial debridement, wound closure by local flap surgery and bone reconstruction. The margin of resection and the type of bone reconstruction depended on the anatomical location of the disease, the extent of osteomyelitis and patient preference regarding treatment options. Bone reconstruction procedures included bone grafting, plating, interlocking nail, hybrid and monolateral external fixator, and Ilizarov bone transport.

RESULTS

Gram-negative organisms were isolated from all patients. Pseudomonas aeruginosa (P. aeruginosa) (44%) was the most common organism cultured. Infection was resolved in all patients. Nine fractures achieved union, with a mean union time of 15 months. Two patients with P. aeruginosa infection developed non-union of the fracture and refused additional surgery after three years of treatment.

CONCLUSION

The multi-stage management approach is well-accepted and effective in controlling infection in infected grade IIIB open tibial fractures.

Percutaneous plating in paediatric tibial fractures

BACKGROUND

Although non-operative treatment is a mainstay of tibial fracture management in children, certain fractures require a surgical approach. However, choices concerning optimal methods and implants are difficult. The purpose of this study was to determine the effectiveness of percutaneous plating of tibial fractures in children.

MATERIALS AND METHODS

Sixteen tibial fractures treated using the percutaneous plating technique between 2000 and 2007 were reviewed. The mean age at operation was 10 years 9 months (range: 6-16 years). There were eight open and closed fractures each. Operative indications were acute fractures with associated injuries or fractures, open fractures and compartment syndrome. Nonunions or failures following other treatments were also indicated. Without exposing the fracture sites, the plates were fixed through a subcutaneous tunnel from remote incisions.

RESULTS

All fractures healed without a bone graft. The mean time required for union was 13 weeks (range: 8-24 weeks). No major complications such as malunion, implant failure or deep infection occurred. With the exception of one case with a 15-mm overgrowth, no discrepancy in leg length over 10mm was encountered. Other minor complications included one case each of transient superficial infection and skin irritation caused by the plate. All patients achieved an excellent or satisfactory clinical outcome with no limping.

SUMMARY

Percutaneous plating technique is a safe alternative treatment for paediatric tibial fractures that are difficult to manage using other methods.

Distal tibial reconstruction with use of a circular external fixator and an intramedullary nail. The combined technique

BACKGROUND

Distal tibial reconstruction with use of an external fixator when there is bone loss, limb-length discrepancy, and/or ankle instability is associated with many problems. The technique of limb-lengthening, ankle arthrodesis, and segmental transfer over an intramedullary nail has been introduced to overcome these problems. The present study investigates this combined technique.

METHODS

Between 2002 and 2005, six patients, who ranged from seventeen to seventy years old, underwent distal tibial reconstruction and ankle arthrodesis with use of a circular external fixator and an intramedullary nail to treat a distal tibial defect following resection for chronic osteomyelitis or tumor or to treat a limb-length discrepancy combined with ankle instability. Functional and radiographic results were evaluated, with use of the criteria described by Paley et al., at an average follow-up of thirty-four months.

RESULTS

The mean size of the bone defects in three patients was 5.3 cm (2, 7, and 7 cm), and the mean amount of the limb-shortening in four patients was 5.25 cm (range, 4 to 6 cm). The mean external fixation time was 3.5 months, and the mean external fixator index was 0.57 mo/cm. There was no recurrence of infection in the two patients with osteomyelitis. All six patients had excellent bone results, and the functional results were excellent for two patients and good for four patients. There were four complications, three of which were categorized, according to Paley, as a problem (a difficulty that occurs during lengthening and is resolved without operative intervention) and one that was categorized as an obstacle (a difficulty that occurs during lengthening and needs operative treatment).

CONCLUSIONS

The combined technique is an improvement over the classic external fixation techniques of distal tibial reconstruction with ankle arthrodesis. It reduces the duration of external fixation, thus increasing patient acceptance, and it is associated with a low complication rate facilitating more rapid rehabilitation.