Gentamicin, whether administered either intravenously, incorporated into bone cement or for local intra-operative irrigation, is a commonly used antibiotic in orthopaedic practice. The former two have been well studied, however the literature on the therapeutic efficacy and safety of gentamicin irrigation is sparse. The objective of this study was to assess systemic absorption of gentamicin irrigation in joint replacement surgery. This was a non-randomised, prospective study. Ninety-eight patients (group A) who underwent total joint replacement and 40 patients (group B) who underwent hemi-arthroplasty were treated traoperatively with gentamicin irrigation. Serum gentamicin levels were assayed at 4 hours and 24 hours post-surgery. Sixteen of 98 patients in group A (16%) and 12 out of 40 patients in group B (30%) were found to have serum gentamicin level above 2mcg/ml at 4 hours post-surgery. We conclude that intra-articular gentamicin irrigation is systemically absorbed at substantial levels.
We report a case of 29-year-old female who presented with right heel pain that worsened over a period of two years. The onset of pain was followed by swelling at the medial aspect of right ankle. She was initially treated for plantar fasciitis with multiple steroid injections over the heel. Subsequent MRI revealed a well-defined heterogeneous lesion in continuity with the medial plantar nerve. Excision biopsy was performed and histopathological evaluation revealed monophasic synovial sarcoma. The patient subsequently underwent wide resection and free tissue transfer followed by radiotherapy and chemotherapy. This case highlights an unusual site and presentation of synovial sarcoma which led to delayed diagnosis and treatment.
Infection after joint replacement surgery is problematic and difficult to treat. The utility of antibiotic laden bone cement for reduction of risk of infection in primary and revision joint replacement surgery has already been established in many studies. In this study, we examined the efficacy of bone cement containing cefuroxime, employing a modified in vitro Kirby-Bauer susceptibility model for investigation of 13 strains of organisms that are found in orthopaedic infections. Organisms investigated were broad spectrum and effective for Gram-positive, Gram-negative, aerobic organisms and anaerobes. Simplex P with added cefuroxime was effective against 8 out of 13 strains. Cefuroxime is stable during exothermic polymerisation of the cement, and is released from the cement at concentrations high enough to inhibit the growth of most organisms encountered after joint arthroplasty.
A rare case of spontaneous bilateral stress fractures of femoral neck leading to coxa vara in a young female with history of chronic renal disease and secondary osteomalacia is described. Once the underlying disease was controlled, the fracture was treated by valgus osteotomy with good result.
We report here a rare presentation of an extra-nodal non-Hodgkin's lymphoma. Both clinical presentation radiological findings were suggestive of psoas abscess. Surgical debridement was performed and histopathological examination of the tissue sample revealed the diagnosis of non-Hodgkin's lymphoma. It is therefore important to note that non-Hodgkin's lymphoma can mimic psoas abscess and that psoas lesion with vertebral involvement does not necessarily indicate infection. It is always advisable to obtain needle biopsy to establish diagnosis before embarking on surgical intervention. The practice to send any suspicious tissue obtained intra-operatively for histopathological examination is also warranted.
Bone lengthening with distraction osteogenesis involves prolonged application of an external fixator frame. Qualitative and quantitative evaluation of callus has been described using various imaging modalities but there is no simple reliable and readily available method. This study aims to investigate the use of a densitometer to analyze plain radiographic images and correlate them with the rate of new bone formation as represented by the bone healing index. A total of 34 bone lengthening procedures in 29 patients were retrospectively reviewed. We used an X-Rite 301 densitometer to measure densities of new callus on plain radiographs taken at 4 and 8 weeks after surgery. Patients aged below 16y had significantly lower BHIs indicating faster bone healing and shorter duration of treatment. The ratio of radiographic densities between centre and edge of the new bone measured from plain radiographs taken at 8 weeks correlated positively with the eventual BHI of the patient. This method provides a simple and easy way to predict the rate of bone healing at an early stage of treatment and may also allow remedial action to be taken for those with poor progress in bone formation.
The safety of simultaneous bilateral total knee arthroplasty (TKA) remains controversial. The objective of the current study was to investigate perioperative morbidity and mortality rates within 30 days of simultaneous bilateral TKA. A detailed analysis of medical, surgical and anaesthesia records of 183 consecutive patients who underwent total knee arthroplasty between 2002 and 2006 was performed. The mean age of the patients was 67.6 years old. More than 80% had one or more co-morbidities, but none of them had ASA score greater than class 2. The mean hospital stay was 10 days, and the mean surgical time 156 minutes. Less than half of the patients (42.6%) required blood transfusion. The rate of perimorbidity was 15.3 % and there was no mortality in this series. We believe that simultaneous bilateral total knee arthroplasty is a safe and cost effective option for our patients, provided that patients are selected and informed appropriately.
MeSH terms: Anesthesia; Anesthesiology; Blood Transfusion; Humans; Length of Stay; Morbidity; Comorbidity; Arthroplasty, Replacement, Knee; Operative Time
Aim: This study was designed to evaluate the use of ultrasound in diagnosis of infection and tumour of long bones. Methodology: Patients referred from the orthopaedic unit with doubt regarding long bone clinical and/or radiological signs which could be tumour or infection were enrolled in this study. Analysis of ultrasound characteristics included presence of pericortical fluid over normal cortex well away from the primary lesion, wavy contour sign (fluid tracking in and out muscle planes), subperiosteal fluid and soft tissue mass displacing adjacent muscle planes. Results: Fourteen out of 15 patients with confirmed osteomyelitis were diagnosed by ultrasound examination. Ultrasound as a diagnostic tool has a sensitivity of 93% and specificity of 100%. The most accurate indicator was pericortical fluid noted up to several centimetres from the long bone abnormality seen on plain x-rays. Conclusion: Ultrasound is a safe, fast, cost-effective imaging modality that can play an important role in diagnosis of osteomyelitis as it then serves as a tool for ultrasound guided aspiration.
MeSH terms: Bone and Bones; Humans; Neoplasms; Orthopedics; Osteomyelitis; Radiology; X-Rays; High-Energy Shock Waves
Int roduction: Treatment of calcaneal fracture is still controversial and indication for surgery is not well
established. We are reporting the mid term outcome of calcanel fractures treated conservatively. Material and Methods: Patients admitted with calcaneal fractures from 1st November 2002 till 31st December 2004 and were treated conservatively were included in this study. The fractures were grouped according to Essex-Lopresti classification and their outcomes were assessed with the Maryland foot score. We also looked at time to weight bearing and returning to occupational activity. Results: Forty-four patients were included for evaluation. Patients with extraarticular calcaneal fractures had significantly higher rating scores compared to those with intraarticular fractures (98.2 and 88.8 respectively, with a p value = 0.0001). Generally, both group of patients had a good clinical outcome. 18 of the 44 patients (41%) started partial weight bearing before or at 6 weeks and 31 patients (72%) were able to start full weight bearing by 12 weeks. 31 patients (72%) were back to work 12 weeks after the injury. Conclusion: Conservative management for calcaneal fractures is an acceptable mode of treatment with satisfactory.
MeSH terms: Calcaneus; Foot; Humans; Maryland; Weight-Bearing; Ankle Injuries; Fractures, Bone; Intra-Articular Fractures; Return to Work
Interlocking intramedullary nailing is suitable for comminuted femoral isthmus fractures, but for noncomminuted fractures its benefit over unlocked nailing is debatable. This study was undertaken to compare outcomes of interlocking nailing versus unlocked intramedullary nailing in such fractures. Ninety-three cases of noncomminuted femoral isthmus fractures (Winquist I and II) treated with interlocking nailing and unlocked nailing from 1 June 2004 to 1 June 2005 were reviewed; radiological and clinical union rates, bony alignment, complication and knee function were investigated. There was no statistical significant difference with regard to union rate, implant failure, infection and fracture alignment in both study groups. Open fixation with unlocked femoral nailing is technically less demanding and requires less operating time; additionally, there is no exposure to radiation and cost of the implant is cheaper. We therefore conclude that unlocked nailing is still useful for the management of non-comminute isthmus fractures of the femur.
Interlocked intramedullary nailing is accepted as the gold standard for femoral shaft fractures. However for Winquist type I and II femoral fractures at the isthmus region, unlocked intramedullary nailing (Küntscher nailing) is still a good option. We performed a retrospective study on 86 patients with a total of 88 femoral shaft fractures around the isthmus that presented at our institution between 1 January 1988 and 31 August 2003. All patients (84.1% Winquist type I and 15.9% Winquist Type II fractures) were treated with unlocked intramedullary nail. The average time to union was 16 weeks with 97.7% rate of union. There were two cases (2.3%) of infection and non-union each. Overall results were comparable to standard interlocking intramedullary nailing. We conclude that unlocked intramedullary nailing is a good treatment option for Winquist Type I and II femoral fracture around the isthmus with its good union rate and minimal complications.
Purpose: To evaluate the usefulness of ultrasound guidance in percutaneous needle biopsy for musculoskeletal tumours.
Methods: Forty-five consecutive patients underwent ultrasound-guided needle biopsy. An additional group of 50 patients who underwent needle biopsy without ultrasound guidance was retrospectively selected as historical control. The sample was considered adequate when a diagnosis can be made, and diagnostic when the diagnosis is similar to the final report based on the excised tumour.
Results: Adequacy of the biopsy samples was 84% in ultrasound-guided group as compared 76% in the group with no ultrasound guidance. Diagnostic accuracy was 64% in the ultrasound-guided group and 52% in the group without ultrasound guidance. Both of these differences were not statistically significant.
Conclusions: Ultrasound guidance did not provide a significant advantage in the biopsy of musculoskeletal tumours. Diagnostic accuracy seems to improve with the use of larger 14 gauge biopsy needle but further evaluation is necessary.
This study evaluates the outcome of anterior cruciate ligament (ACL) reconstruction with arthroscopy using the bone–patella tendon-bone method. We performed this procedure in 24 patients with the average age of 33.1 years (range: 17-51 years ) between 2004 and 2006. Sixteen of the 24 patients were available for evaluation using the Lysholm Knee Score and International Knee Documentation Committee (IKDC) system. Based on the Lysholm score, there was a statistically significant improvement in knee function when comparing pre- and post-surgical scores (p
Male factor infertility which accounts for 30-50% of infertility is a major problem faced by married couples. Congenital absence of the vas deferens, though uncommon, remains the most common abnormality seen in extratesticular ductal and ejaculatory system, accounting for 1-2% of male infertility. It may be unilateral or bilateral. Association with renal abnormality has also been reported with congenital absence of vas deferens (1). The patients are asymptomatic and the congenital abnormality is usually detected when investigation for infertility is carried out. We present a case of an unusual presentation of congenital bilateral absence of vas deferens (CBAVD).
MeSH terms: Humans; Infertility, Male; Kidney; Male; Urogenital Abnormalities; Vas Deferens; Male Urogenital Diseases
Intrapulmonary bronchogenic cyst is a rare congenital lesion originating from abnormal budding of the embryonic foregut. It is less common than mediastinal bronchogenic cyst. We describe a case of intrapulmonary bronchogenic cyst and discuss the treatment of this condition.
A 65-year-old lady with cholelithiasis underwent an elective laparoscopic cholecystectomy (LC) and was discharged on post-operative day 2. She was re-admitted after five days with right hypochondriac pain and fever. Investigations revealed a drop in hemoglobin. Computed tomography showed a large intrahepatic subcapsular collection without intra-abdominal collection. She was treated with intravenous antibiotics. Percutaneous aspiration of intrahepatic subcapsular collection under ultrasound guidance revealed old blood. Hence diagnosis of intrahepatic subcapsular hematoma (ISH) was made. She improved and was discharged after a two weeks' hospital stay. Follow-up ultrasonography examination two months later revealed complete resolution of the hematoma. We report this case due to its rarity and review the previously documented cases of this complication.
The aim of this study was to determine whether the home environment was a risk factor for falls occurring at home among the elderly in the Masjid Tanah community, Malaysia. An analytical cross-sectional study conducted from early June 2006 until May 2007 in six randomly selected villages in Masjid Tanah Province. A total of 516 participants were included in this study. Overall prevalence of falls among the study participants was 27.3%. Home falls accounted for 66.7% of the total falls. In conclusion, there was no association between home environment and home fall in this study. Logistic regression analysis showed that having a depressive mood was the main determinant for home falls among the elderly in this study.
The objective of this study was to determine the prevalence of sleep disturbance with work characteristics among nurses in the Melaka Hospital, Malacca, Malaysia. This was a cross sectional study conducted in Melaka Hospital. Universal sampling was conducted and a Malay version of the Pittsburgh Sleep Quality Index (PSQI) questionnaire was used in data collection. Socio-demographic characteristics such as age, marital status, number of children and work characteristics such as type of work schedule and duration were also enquired. Factors associated with poor sleep quality were compared between those nurses with good sleep quality by using logistic regression. There were 607 nurses who completed the questionnaire with a response rate of 73.1%. There was a moderate prevalence (57.8%) of poor sleep quality (PSQI > 5) in all study subjects. The prevalence of sleep disturbance was more widespread among nurses who worked shifts (62.0%) compared to non-shift working nurses (41.5%) p
MeSH terms: Cross-Sectional Studies; Sleep Initiation and Maintenance Disorders; Malaysia; Nurses; Surveys and Questionnaires; Sleep Wake Disorders; Prevalence; Logistic Models; Marital Status
This is a retrospective case control study conducted between 1 January 2005 and 30 June 2006 at the Hospital Tuanku Jaafar, Seremban, Malaysia. The objective was to study the maternal sociodemographics and foetal characteristics associated with premature delivery. There were 387 cases selected universally and 387 controls selected by using systematic random sampling involving every 13 cases. The patients were women who had delivered their babies before 37 completed weeks, while the control were women who had term deliveries during the same period. Data were collected using structured questionnaire through secondary data. Results showed that having multiple pregnancies (OR=8.33, 95% CI: 2.91, 23.84), congenital abnormality (OR=4.6, 95% CI: 0.98, 21.84) and intrauterine growth retardation (OR=15.59, 95% CI: 3.69, 65.82) were the risk factors of premature delivery. Being an ethnic Indian also raised the odds (OR=1.67, 95% CI: 1.14, 2.43) but this was not significant in the multivariate analysis. Other sociodemographic characteristics did not contribute significantly to the risk factors for premature delivery in this sample. In conclusion, foetal characteristics were found to be significantly associated with premature delivery after adjustment for other confounding factors.
Study site: Hospital Tuanku Jaafar, Seremban, Negeri Sembilan, Malaysia
The state of Selangor, Malaysia, is facing a significant rise in the number of malaria cases with the incidence varying from 20 to 90 per 100,000 persons in a population. A study was carried out to describe the distribution of malaria cases in relation to the growing number of foreign workers in Selangor. Data were reviewed using the return forms "PBV (M) 101", a summary of malaria cases in Selangor for 2006 and Annual Reports of Vector-Borne Disease Control Unit, Selangor State Department for 2001- 2005. The malaria cases in Selangor varied between 172 cases in 2001 and 90 cases in 2006. Most of the cases were contributed by foreign workers, who were predominantly male of economically active age group and came from malaria endemic countries. Most of these cases were concentrated in the urban districts. Malaria is still endemic in Selangor. Malarial infection has the potential of contributing to an urban outbreak of malaria.