This is a cross-sectional study on the use of halovest appliance in the Orthopaedic and Traumatology Department, Kuala Lumpur Hospital from June 1993 to September 1996. Fifty-three patients with cervical spine injuries were treated by halovest stabilization. Majority of cases was caused by motor-vehicle accident; others were fall from height at construction sites, fall at home, hit by falling object and assault. The injuries were Jefferson fracture of C1, odontoid fractures, hangman fractures, open spinous process fracture and fracture body of C2, and fracture, and fracture-dislocation of the lower cervical spines. Majority of patients had hospital stay less than 30 days. The use of the halovest ranges from 4 to 16 weeks and the healing rate was 96%. Two patients of lower cervical spine injury had redislocation and one of them was operated. There was one case of non-union of type II odontoid fracture and treated by posterior fusion. Other complications encountered during halovest treatment were minor. They were pin-site infection, pin-loosening, clamp loosening and neck pain or neck stiffness. This method of treatment enables patient to ambulate early and reduces hospital stay. We found that halovest is easy to apply, safe and tolerable to most of the patients.
This is a retrospective study comprising 45 patients who underwent decompressive laminectomy due to secondary malignancy in the spine. There were 31 males and 14 females. Two of them had no weakness, one was treated for radicular pain and the other for severe intractable back pain. Forty-three patients presented with weakness of the limb of which six patients were able to walk unaided, four with an aid, twenty four were unable to walk of which eleven of them were completely paralysed. Nineteen of the patients had urinary incontinence. Out of 10 patients in Frankel's D, 3 of them regained almost normal power post operatively and were able to walk without any aids at the time of discharge. There were 6 patients in Frankel's C and 2 improved. Of 17 patients in Frankel's B, 6 of them improved and were able to walk with walking aids. Only one out of ten patient from Frankel's A had showed an improvement. A total of three patients deteriorated post operatively and all of them presented with multiple level involvement. There was no change in the post operative status of the two patients who did not have weakness. Overall only 27% of the patient showed improvement following decompressive laminectomy.
A retrospective study was conducted to assess the surgical outcomes of degenerative lumbar spinal stenosis. Twenty-five patients treated with decompressive surgery in Hospital Kuala Lumpur between January 1992 and August 1996 were reviewed. There were seven males and eighteen females. The average age was 51 years old (range 33 to 64 years old). The diagnosis of degenerative spinal stenosis was made based on the clinical features and was confirmed by radiographic findings. Ninety two percent of the patients had moderate to severe symptoms preoperatively. The types of surgery consisted of laminectomy (n = 15), laminotomy (n = 10), and laminoplasty (n = 1). The surgical outcomes were assessed based on patients' own assessment of symptoms relieved and functional returned to daily activities at least six months after the surgery. The average follow-up period was fifteen months (range 6 months to 42 months). Of these twenty-five patients, 4 (16%) claimed to have excellent results, 11 (44%) had good results, 8 (32%) reported fair, and 2 (8%) judged their surgical treatment as poor with little or no use. There was no anaesthetic, cardiovascular, or thromboembolic complications seen in this study. Four patients had recurrent claudication, one demonstrated localised arachnoiditis, and two had lumbar instability which were not documented preoperatively. One patient had L4 nerve root avulsion with dura torn and another patient had superficial wound infection. We concluded in this study that decompressive surgery offers satisfactory results in patients with moderate to severe degenerative spinal stenosis in short term follow-up.
Thirty-two children with femoral shaft fractures were treated conservatively with initial skin traction followed by an additional period in a spica cast. After 12 to 20 months of follow up, none had any pain and all of them were attending school without problems. Shortening of more than 2 cm occurred in 6 (19%) of the 32 patients. The most important factor associated with shortening was an overlap of more than 2 cm of shortening of the fracture ends at the time of cast fitting. The average compensatory overgrowth at final assessment was 7 mm. Angular deformity did not pose a problem. This is a safe, simple and practical method to treat childhood femoral shaft fractures.
Tibial fractures are common and complications occur more frequently than any other long bone fractures. The effect of fibula and location of fracture on union of Tibia fracture remain controversial. A retrospective study of unilateral closed tibial shaft fractures without any associated injury was done. From 1988 to 1992, 74 out of 103 patients were available for the study. There were 60 males and 14 females with the age ranges from 3 to 75 years with an average of 29.7 years. The differences of fractures healing were analyses with respect to the status of the fibula and the location of the tibial fracture. This study concludes that the location of the fracture and the status of the fibula have no significant influence on healing (p > 0.05).
Thirty-eight tibial plateau fractures were treated with open reduction and internal fixation. The fractures were classified into six groups (Hohl's 1991 Classification) and the clinical results were evaluated using the Rasmussen (1973) criteria. The average follow-up period was 2.07 years. Overall there was one excellent, thirty-four (34) good, three fair and no poor results. In three patients with less than a good score there were other associated ipsilateral injuries and delayed mobilisation of the knee joint. There was no direct association between the type of internal fixation and the end result.
Out of 218 fractures of humeral shaft treated in the department, 23 (10.5%) of them developed non-union. 14/23 (60.9%) fracture were located in middle third. Transverse (52.2%), short oblique (17.4%) and comminuted fracture (13.0%) constituted about 82% of all initial fracture pattern. Twelve cases (52.5%) were initially treated with hanging cast. Radial nerve palsy occurred in 4/23 (17.4%) of patient and all of them located at lower third of humerus and only one recovered after eight weeks of injury. Factors such as middle third comminuted opened fractures, soft tissue interposition, improper immobilization and poor patient compliance were found to be directly associated with the non-union. All non-unions healed following plating and bone grafting. Overall 17/23 patient (74%) had good results, 4/23 (17%) fair and 2/23 (9%) with poor functional results.
The displaced supracondylar fracture of the humerus in children (Gartland type 3) is a most challenging injury to treat. There is controversy regarding the initial treatment either closed manipulation and splint immobilization or open reduction and internal fixation. This is a retrospective study comparing two groups of patients with displaced supracondylar fracture of the humerus (Gattland 3) treated in the Orthopaedic Unit, Universiti Kebangsaan Malaysia. The first group, 13 patients treated with closed reduction and splint immobilization and a second group, 15 patients treated with open reduction and internal fixation as initial definitive treatment. The results showed a high failure rate of closed reduction and splint immobilization. This was due to difficulty in reduction, loss of reduction post operatively or during follow-up. Open reduction and internal fixation was more advantages with reduced hospitalization time, fewer complications, more stable fixation and better anatomical reduction with minimal complications for type 3 supracondylar fracture of humerus. We would recommend that all Gartland 3 supracondylar fracture of the humerus be treated with open reduction and two K-wire fixation.
Forty-one patients with 42 elbow dislocations, of which 13 had acute simple dislocations, 21 had fracture-dislocations and 8 had neglected elbow dislocations, were evaluated with regard to limitation of motion, pain, instability and residual neurovascular deficit. All patients with acute simple dislocation were treated with closed reduction, but the duration of immobilization before commencement of active motion varied. Open-reduction was indicated for failed closed reduction and neglected-dislocations. Internal fixation as a primary procedure was only performed for displaced fracture-dislocation. Excision of radial head or tricepsplasty were performed if the reduction was impossible in neglected elbow dislocation. Despite a good results in acute simple dislocation, 33.07% had flexion contracture of between 5 to 30 degrees. In fracture dislocation, satisfactory results were seen in whom the elbow was immobilized for three weeks or less. Neglected-dislocation is associated with poor functional outcome, 37.5% were good and 62.5% were poor. Prolonged immobilization after injury was strongly associated with an unsatisfactory result. The results indicate that early properly supervised active motion is a key factor in the rehabilitation of elbow dislocation.
Acromio-clavicular joint (ACJ) dislocation usually occurs in young adults following trauma or sports injury. Fourteen patients underwent surgical treatment for symptomatic total ACJ dislocation (Rockwood and Matsen Type III-VI) in our unit between January 1996 and June 1997. Eight patients were operated within three weeks of injury and six in the chronic period (after three weeks). In the acute group, two patients had Botsworth procedure and six had Weaver-Dunn operations. All six in the chronic group had Rockwood procedure. Nine patients achieved excellent outcome with full range of shoulder movement, pain free and return to work within three months of surgery. Two patients had good outcome. Three other patients had satisfactory outcome with tolerable pain and light duty at three months. Two patients developed chronic shoulder pain and one had painful hypertrophic surgical scar. Two patients had screw breakage requiring revision surgery. In conclusion, surgical treatment for ACJ dislocation produces good results. We suggest that surgical treatment be the treatment of choice for young patients requiring early recovery and good shoulder function.
It is usually a major task providing soft tissue cover to significant defects of the lower leg. A wide variety of flaps and techniques are available, each with its advantages and limitations. Previously described anatomic study of the septocutaneous vessels of the leg have indicated a consistent lower most perforator at 9-12 cm from the tip of the medial malleolus. An island fasciocutaneous flap based on this perforator vessels can be raised subfascially. After the vessels have been dissected clean down to the posterior tibial artery, it can be rotated up to 180 degrees degrees. Successful soft tissue reconstruction was achieved in 18 patients. Most of the tissue loss was due to trauma and were around the ankle and the heel. There were 7 minor complications which resolved completely after 2 months. Its simplicity of design and elevation plus its extensive arc of rotation makes it a reliable and versatile flap in the reconstruction of lower leg defects.
We review 81 cases of acute haematogenous osteomyelitis from 1983 to 1990 to establish current pattern of clinical presentation, modes of treatment and success of therapy. Majority of the patient (70%) presented within a week of symptom and significant number of them came with fever and swelling of the affected limb. Sedimentation rate was found to be raised in all of them. Fifty-four (55%) of them were treated surgically. The average antibiotic time was one week by intravenous administration followed by additional oral therapy for period up to four weeks. Average follow-up was 9 months. Six of them (7.5%) end up with various complication which was believed to be due to delay in getting medical treatment.
Forty-one patients with 42 joint infections were admitted to the hospital between June 1989 and June 1994. An overview on the behaviour of septic arthritis in both children and adults, at presentation and after various types of treatment was done. There were 32 knees, 7 hips, 2 elbows and 1 shoulder. Duration of symptoms, type of organism, type of joint drainage, presence of preexisting joint problems and presence of osteomyelitis are among the important factors with prognostic significance. Seventy three percent of patients with less than 7 days duration of symptoms had satisfactory results. Whereas when the duration of symptoms exceeded 7 days, 75% of the patients had unsatisfactory outcome. All cases with poor outcome had positive cultures. Staphylococcus aureus was responsible for 77% of the culture-positive cases. All Staphylococcus aureus in this study were penicillin-resistant but sensitive to cloxacillin. There were 3 instances where Staphylococcus became resistant to cloxacillin following recurrence of septic arthritis. However, they were still sensitive to third generation cephalosporin. Staphylococcus aureus was capable of producing poor results even when the case was treated early. Other organisms were gram-negative bacilli which infect patients with suppressed immune system, that is, intravenous drug abuser, systemic steroid therapy and diabetes mellitus. Open arthrotomy was the method of drainage used in all hip sepsis. This method was also the most reliable method of joint drainage in other joints compared to aspiration method when frank pus was already present. Most immuno-compromised patients recovered badly from septic arthritis. Associated adjacent osteomyelitis, preexisting chronic arthritis and recent intra-articular fractures were also noted to adversely affect the functional outcome.
The presentation and management of psoas abscess was studied prospectively in 5 patients and retrospectively in 4. 3 patients had bilateral abscesses. All patients had back pain and a mass in loin or iliac fossa. 7 patients had no hip findings. One patient had a perinephric abscess and another had radiological features of tuberculosis of the spine. In the other seven no cause for the abscess could be identified. Ultrasonography demonstrated the abscess in all patients; CT scanning done in 5 patients was confirmatory. Drainage was done by an extraperitoneal route. Biopsy of the abscess wall in 2 patients demonstrated tuberculosis. They, the patient with TB spine and 3 others put empirically on anti-tuberculosis chemotherapy responded well. The perinephric abscess grew Pseudomonas sensitive to gentamycin, but she and two other patients died due to multiorgan failure.
We studied 95 patients who underwent knee Arthroscopy under local anaesthesia between JANUARY 1995 till 1997. Materials used were 1% Xylocaine and 0.25% Bupivacaine of 20 mls each combined with midazolam 2 mg and IV pethidine 30 mgm for sedation. The patients were attached to monitors (pulse Oxymeter, ECG and BP and pulse recorders) and blood less field was created using a tornquet. The procedures lasted about 45 minutes. 90 out of 95 patients completed the procedures successfully without any complications. 2 developed respiratory embarrassments and were intubated and ventilated. 3 procedures abandoned and converted to general anaesthesia. The range of procedures done include meniscectomy, meniscal repair, synovial biopsy, debridement for osteoarthrosis, shaving of osteophytes, drilling of cartilage and bones and removal of loose bodies. This study is to show that knee arthroscopy under LA is a safe alternative in hospitals where GA time is limited.
This paper summarises our experience of twenty one patients with degenerative arthritis treated by bilateral simultaneous total knee replacement (BSTKR) in Tawakal Hospital in a period of twenty two months vis. January 1994 to November 1995. The results were analysed according to the scoring system of Hospital for Special Surgery. The preliminary observations were encouraging, 90% excellent, 8% good and 2% fair results. The benefits, safety and cost effectiveness of the procedure as compared to the unilateral staged knee replacement are discussed. We recommend that BSTKR be routinely practised for appropriate situations in all institutions where the expertise and facilities are available.
From January 1992 to January 1996, thirty-three patients with persistent clinical and functional knee instability due to anterior cruciate insufficiency underwent ACL reconstruction using central third of the bone-patellar ligament-bone graft. An early experience was presented with average follow-up of 9.8 months (range six to thirty-three months). There thirty-two male and two females. The average age was twenty-four months. Eighty-three percent were involved in football injury. The average time interval from initial injury to operation was twenty-five months. Majority presented with knee pain and giving way. Meniscal tear was the commonest associated injury in more than 70 percent; the lateral meniscus being more frequently injured (42 percent) than the medial meniscus (15 percent). Using modified criteria by Paterson and Trickey (1986), nine patients (27 percent) had good results and twenty-two (67 percent) has satisfactory results. Two patients (6 percent) who had post-operative infection were graded as poor. Functional stability was achieved in twenty-eight (85 percent) and instability persisted in five (15 percent). There were marked clinical improvement in the Lachman and anterior drawer grading post-operatively. The accelerated rehabilitation programme was effective in obtaining early clinical improvement and in reducing post-operative knee stiffness.
A study was carried out on 24 patients (36 clubfeet) surgically treated at the Orthopaedic Department National University of Malaysia, Kuala Lumpur, over a period of four and half years. Nine feet underwent posterior release, 24 feet underwent posteromedial release combined with Evan's procedure. The overall operative result was 63.3% good, 9.5% fairly and 27.2% poor. Patients who underwent surgery between 3 to 12 months showed a high percentage of good results (66.7%). Metatarsal adduction was found to be the commonest residual deformity (63.9%), followed by heel varus (11.1%), cavus (11.1%) and equinus (5.6%). Inadequacy of primary surgery and post operative period of immobilization resulted in a significant high failure rate.
A retrospective study was conducted in 130 patients who underwent replantation or revascularization of 195 amputations in Hand and Microsurgery Unit Hospital Kuala Lumpur from 1990 to 1995. There were 130 patients with 195 amputations in the duration of 6 years study, which were mainly males (111 patients, 85.4%). The commonest age group involved was 19-25 years old (49 cases, 63.7%). There were 146 complete amputations replanted and 49 cases of incomplete amputations were revascularized. The commonest part involved was thumb and index finger (23% of cases each) and majority was caused by industrial accident (60.8%). However in pediatric age group home accident was the leading cause of the amputation (93.8%). The overall survival rate for the amputation was 65.6%. Revascularization had a better survival rate (77.6%) than replantation (61.6%). A clean cut wound and ischaemic time less than 12 hours gave better survival rate. However, there was no significant different chance of survival on distribution of injured parts and ischaemic time (< 12 hours).