Vivek A/L Ajit Singh

Abstract: Introduction: Chronic, nonspecific low back pain is a difficult ailment to treat and poses an economic burden in terms of medical expenses and productivity loss. The aim of this study was to determine the efficacy and safety of intramuscular metylcobalamin in the treatment of chronic nonspecific low back pain. Methods: This was a double-blinded, randomised, controlled experimental study. 60 patients were assigned to either the methylcobalamin group or the placebo group. The former received intramuscular injections of 500 mcg parenteral methylcobalamin in 1 ml solution three times a week for two weeks, and the placebo group received 1 ml normal saline. Patients were assessed with Oswestry Disability Index questionnaire Version 2.0 and Visual Analogue Scale pain score. They were scored before commencement of the injections and at two months interval. Results: Of the 60 patients, 27 received the placebo injections and 33 were given methylcobalamin injections. A total of 58 patients were available for review at two months (placebo: n is 26; methylcobalamin: n is 32). There was a significant improvement in the Oswestry Disability Index and Visual Analogue Scale pain scores in the methylcobalamin group as compared with the placebo group (p-value less than 0.05). Only minor adverse reactions such as pain and haematoma at the injection sites were reported by some patients. Conclusion: Intramuscular methylcobalamin is both an effective and safe method of treatment for patients with nonspecific low back pain, both singly or in combination with other forms of treatment.

Abstract: BACKGROUND We reviewed cases with Lisfranc injuries who presented to our center in order to study the adequacy of the treatment method and their final functional outcome. METHODS This is a retrospective review of 34 cases diagnosed with Lisfranc injuries treated at our center from 2000 to 2006. This review is aimed to determine the demography and functional outcome of all patients with Lisfranc injury treated during this period. RESULTS The injury was classified based on the "Hardcastle and Associates Classification". In our review, we found that the commonest Lisfranc injury was type B2 (41%). These injuries are mostly fixed with K-wires (76.5%). All patients assessed with Bristol Foot Score (BFS) had a good score in all categories, with a total score ranging from 16 to 25. CONCLUSION We concluded that all Lisfranc injuries, whether treated with closed or open fixation methods, demonstrated a good long-term functional outcome.

Abstract: Background: Oxidative stress is characterised by an increased level of reactive oxygen species (ROS) that disrupts the intracellular reduction-oxidation (redox) balance and has been implicated in various diseases including cancer. Malignant tumors of connective tissue or sarcomas account for approximately 1% of all cancer diagnoses in adults and around 15% of paediatric malignancies per annum. There exists no information on the alterations of oxidant/antioxidant status of sarcoma patients in literature. This study was aimed to determine the levels of oxidative stress and antioxidant defence in patients with primary bone and soft tissue sarcoma and to investigate if there exists any significant differences in these levels between both the sarcomas. Methods: The study cohort consisted of 94 subjects; 20 soft tissue sarcoma, 27 primary bone sarcoma and 47 healthy controls. Malondialdehyde (MDA) and protein carbonyls were determined to assess their oxidative stress levels while antioxidant status was evaluated using catalase (CAT), superoxide dismutase (SOD), thiols and trolox equivalent antioxidant capacity (TEAC). Results: Sarcoma patients showed significant increase in plasma and urinary MDA and serum protein carbonyl levels (p < 0.05) while significant decreases were noted in TEAC, thiols, CAT and SOD levels (p < 0.05). No significant difference in oxidative damage was noted between both the sarcomas (p > 0.05). Conclusions: In conclusion, an increase in oxidative stress and decrease in antioxidant status is observed in both primary bone and soft tissue sarcomas with a similar extent of damage. This study offers the basis for further work on whether the manipulation of redox balance in patients with sarcoma represents a useful approach in the design of future therapies for bone disease.

Abstract: Background: We report a series of six immunocompetent patients who were believed initially to have primary bone sarcomas, but turned out to have subacute osteomyelitis. Methods: Case report and review of relevant literature. Results: All our patients were treated with antibiotics and recovered fully from the infection. Only one patient had a recurrence with the same offending microorganism, which resolved after a longer period of intravenous antibiotic. Conclusions: Subacute osteomyelitis and bone tumors can be similar in presentation, and the key to proper diagnosis is histopathological and microbiological confirmation in biopsy specimens.

Abstract: We describe an unusual case of osteosarcoma in a Jehovah’s Witness patient who underwent chemotherapy and major surgery without the need for blood transfusion. This 16-year-old girl presented with osteosarcoma of the right proximal tibia requiring proximal tibia resection, followed by endoprosthesis replacement. She was successfully treated with neoadjuvant chemotherapy and surgery with the support of haematinics, granulocyte colony-stimulating factor, recombinant erythropoietin and intraoperative normovolaemic haemodilution. This case illustrates the importance of maintaining effective, open communication and exploring acceptable therapeutic alternative in the management of these patients, whilst still respecting their beliefs.

Abstract: Giant cell tumour is a locally aggressive tumour with a high incidence of local recurrence. The choice of treatment remains to be controversial. These tumours are usually managed with extended curettage in the early stage and with resection and replacements in the advance stages. This is an illustration of two case of Giant cell tumour, one of the proximal tibia and another of the distal radius that was treated with wide resection and osteoarticular allograft. Both patients developed recurrence of the disease within the allograft.

Abstract: Introduction: Sterilization and re-usage of tumour bone for reconstruction after tumour resection is now gaining popularity in the East. This recycle tumour bone needs to be sterilized in order to eradicate the tumour cells before re-implantation for limb salvage procedures. The effect of some of these treatments on the integrity and sterility of the bone after treatment has been published but there has yet been a direct comparison between the various methods of sterilization to determine the one method that gives the best tumour kill without compromising the bone’s structural integrity. Method: This study was performed to evaluate the effect of several sterilization methods on the mechanical behavior of human cortical bone graft and histopathology evaluation of tumour bone samples after being processed with 4 different methods of sterilization. Fresh human cortical tumour bone is harvested from the diaphyseal region of the tumour bone were sterilized by autoclave (n = 10); boiling (n = 10); pasteurization (n = 10); and irradiation (n = 10). There were also 10 control specimens that did not receive any form of sterilization treatment. The biomechanical test conducted were stress to failure, modulus and strain to failure, which were determined from axial compression testing. Statistical analysis (ANOVA) was performed on these results. Significance level (alpha) and power (beta) were set to 0.05 and 0.90, respectively. Results: ANOVA analysis of ’failure stress’, ’modulus’ and ’strain to failure’ demonstrated significant differences (p < 0.05) between treated cortical bone and untreated specimens under mechanical loading. ’Stress to failure’ was significantly reduced in boiled, autoclaved and irradiated cortical bone samples (p < 0.05). ’Modulus’ detected significant differences in the boiled, autoclaved and pasteurization specimens compared to controls (p < 0.05). ’Strain to failure’ was reduced by irradiation (p < 0.05) but not by the other three methods of treatments. Histopathology study revealed no viable tumour cell in any of four types of treatment group compared to the untreated control group. Conclusions: Sterilization of cortical bone sample by pasteurization and to a lesser extent, irradiation does not significantly alter the mechanical properties when compared with untreated samples. Mechanical properties degrade with the use of high temperature for sterilization (boiling). All methods of sterilization gave rise to 100 percent tumour kill.

Abstract: This is a presentation of a case of mono microbial necrotising fasciitis due to the unusual organism Salmonella enteritidis. The patient presented with swelling and blistering of the right calf. There are only five other such cases reported in the literature. This was the only case that had positive blood cultures for the organism. Prompt and appropriate treatment was intuited but the patient died because of multi-organ failure.

Abstract: A 68-year-old woman presented with a gradually increasing left gluteal swelling that she had first noted 2 years previously. The results of both clinical and radiological examinations were consistent with soft tissue sarcoma, but the final diagnosis after resection was haematoma.

Abstract: Introduction: The issue of whether to treat Jones fracture surgically or nonsurgically is still controversial. In our institution, most acute Jones fractures are treated conservatively. Objectives: This study assessed the functional outcomes of patients with acute Jones fractures that were treated conservatively by means of radiographic assessment, a physician-based scoring system and patient-based questionnaires. Methodology: In this study, 25 patients with Jones fracture treated in our institution between January 2002 to December 2006, were retrospectively reviewed. Injuries were classified according to Jones’ original description and the Torg classification. A simple patient satisfaction questionnaire was completed. Radiographic assessment of fracture union was recorded. Outcome instruments used were (a) the American Orthopaedic Foot and Ankle Society (AOFAS) clinical rating systemand (b) the American Academy of Orthopaedic Surgeons (AAOS) foot and ankle outcome questionnaire. Results: Of the 25 patients reviewed, 60% were very satisfied with the outcome, 28% were satisfied, 8% were fairly satisfied, and 4% were very dissatisfied. Based on radiographic and clinical assessments, one patient had delayed union and was treated surgically. The functional outcome scores were: mean AOFAS clinical rating score of 95.6 ± 7.7% (P < 0.005), mean AAOS foot and ankle score of 97.0 ± 4.4% (P < 0.005) and mean AAOS shoe comfort score of 90.2 ± 19.6% (P < 0.005). Conclusions: Acute Jones fracture can be treated conservatively with good functional outcome.

Abstract: Issues that had been encountered during proximal femoral fracture fixation using proximal femoral nail include i) the adequacy of the femoral neck width in the local population and ii) the potential difficulty encountered during fixation in certain prefixed angles as determined by the implant. This was a retrospective, descriptive study evaluating the anterior-posterior pelvic radiographs of 100 consecutive patients, from January to August 2007, managed at University Malaya Medical Centre, Kuala Lumpur. The femoral neck width in the population studied was adequate for placement of femoral neck screw and anti-rotation pin or hip pin using the proximal femoral nail implant. (mean = 34.0±3.7mm, min = 24.6mm). There was no significant difference between the working area using an implant angled at 130° or 135° (P=0.91). Both femoral neck width and neck shaft angle of the Malaysian population studied were not a factor influencing the placement of femoral neck lag screws and anti-rotation pin.

Abstract: We report a case of chronic recurrent multifocal osteomyelitis in a 9-year-old girl. She presented with a 9-month history of gradually worsening pain and swelling in her left foot. Non-steroidal anti-inflammatory drugs were prescribed but the symptoms persisted. She underwent curettage through a small oval corticotomy window on the first metatarsal bone. The pain and swelling improved promptly and she was able to walk without pain 2 weeks later. Curettage enabled rapid symptomatic relief and induced remission, with little risk of complications.

Abstract: Chondroblastoma is a rare primary benign tumour of bone with a relatively high incidence in older children (1). The knee, hip and shoulder are most common affected areas (2). The tumour usually involves the epiphysis before closure of the physis (3).Ninety percent of patients are between the ages of 5 to 25 years. Males predominate with a ratio of 3 to 2. There can be functional impairment and growth disturbances as the tumour is usually localised near a joint or growth plate. There is also a high rate of recurrences. Metastasis of a histologically benign chondroblastoma is rare (4). The suggested treatment for aggressive chondroblastoma ranges from simple curettage to wide resection with structural reconstruction (1).

Abstract: The goal of treatment in distal radius fracture is to restore the anatomy of the distal radius, however the criteria currently used to evaluate the quality of reduction are based on Western based published figures. This goal of this study was to investigate whether there are variations in the morphology of the distal radius among the multiracial population of Malaysia. Consecutive normal wrist radiographs of patients who presented to the accident and emergency unit in three major hospitals in Malaysia were measured. . The palmar tilt of the distal radius averaged 12.6o ± 3.55o, and the radial inclination averaged 25.1o ± 3.42o. The ulnar variance averaged – 0.1 ± 1.31mm, 38.4% of the patients had neutral ulnar variance, 28.8% have negative ulnar variance and 32.9% have positive ulnar variance. Our results indicate that distal radius morphometric parameters in the Malaysian population are comparable to Western figures.

Abstract: 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 satisfactoryfunctional outcome.

Abstract: A 35 kDa glycoprotein whose abundance was previously demonstrated to be enhanced in sera of patients with endometrial adenocarcinoma (n = 12), was isolated from pooled sera of three of the cancer patients using champedak galactose-binding lectin affinity chromatography in the present study. Subjecting it to 2-DE and MS/MS, the glycoprotein was identified as the O-glycosylated fragment of inter-a-trypsin inhibitor heavy chain H4 (ITIH4). When compared to control sera (n = 17), expression of the 35 kDa ITIH4 cleavage fragment was demonstrated to be significantly enhanced in sera of patients with breast carcinoma (n = 10), epithelial ovarian carcinoma (n = 10), and germ cell ovarian carcinoma (n = 10) but not in patients with nasopharyngeal carcinoma (n = 13) and osteosarcoma (n = 7). The lectin-based electrophoretic bioanalytical method adopted in the present study may be used to assess the physiological relevance of ITIH4 fragmentation and its correlation with different malignancies, their stages and progression.

Abstract: 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-comminuted isthmus fractures of the femur.

Abstract: Pleomorphic sarcoma is the most common sarcoma. Reports of outcome as well as evaluation of prognostic factors in the literature show great variation. We looked at our experience in treating this tumour at University Malaya Medical Center. This is a review of patients diagnosed with Pleomorphic Sarcoma from January 1990 to December 2005 at University Malaya Medical Center. Outcome measures studied are the overall survival, disease free survival and local recurrence of disease. Prognostic factors for survival and local recurrence which were studied are the tumour size, depth, stage, type of surgery, adjuvant therapy, and surgical margin. There were fifty four patients available for analysis of demographics. The mean age at presentation was 52.3 +/- 16.7 years. There were thirty male patients (56%) and twenty four female patients (44%) in the study population. The patients were predominantly Malay (44.4%) and Chinese (42.6%). There were two Indian patients (3.7%) and five patients from other races (9.3%). Thirty patients had disease affecting the extremities while six patients had disease affecting the trunk. Patients with tumour affecting the trunk had 100% mortality. In patients with tumour affecting the extremity, 46.7% presented with Stage 3 disease. The overall median survival was 39 months. The overall survival rate at 3 years was 53.3% and the 5 years was 30.0%. The disease free survival rate at five years was 27.6%. However, if patients who presented with metastasis were excluded, the 5 year survival rate was 60% while the disease free survival was 53.3%. Recurrence rate was 33.3%. Factors affecting survival was stage, size and location of tumour. No factors were found to correlate with higher local recurrence rate. In conclusion, Pleomorphic Sarcoma is a heterogenous disease with variable outcome. In our centre, late presentation with advanced disease significantly affects the overall outcome of this condition. Tumour size and location are important prognostic factors. Inherent tumour behavior and aggressiveness probably outweigh current treatment modalities as the most important prognostic factor in the management of Pleomorphic Sarcoma.

Abstract: A case of 28-year-old man with closed fracture dislocation of the radial head following a fall from height is reported. He was treated with radial head excision. The radial head is an important stabilizer of the elbow, thus the rationale of radial head excision in management of radial head fractures should be scrutinized. There is much debate regarding the optimal treatment for these fractures.

Abstract: Floating knee is referred to when there is an ipsilateral fracture distal end of femur and proximal tibia. It is considered an orthopaedic emergency as it an unstable situation. Such injuries can lead to kinking or injury of the popliteal artery by the mobile fracture segment. This is so because the artery is fixed at 2 points, the adductor hiatus proximally at the femur and the soleal arch distally at the tibia. Therefore, immediate stabilization of such fractures is crucial. There are various methods of fixation available. We describe a method that we feel is safe and technically less demanding compared to others.

Abstract: Background: Locked intramedullary nailing or interlocking nailing (ILN) is a proven mode of treatment for femoral shaft fractures. It can be inserted via the antegrade or retrograde approach. Retrograde approach is technically less demanding especially if the patient is overweight. But there are concerns with regard to the violation of the knee and its effect on subsequent knee function. Methods: We studied consecutive cases of femoral shaft fractures treated with locked intramedullary nailing at the Penang General Hospital, from 1st June 2004 to 1st June 2005. We looked at radiological and clinical union rates, union of fractures, alignment of the operated limb, and the knee function, using the Thoresen scoring system. Results: There were a total of 77 cases of femoral interlocking nails during the study period. Forty-two cases were antegrade nails and 35 cases were retrograde nails. Both groups of patients eventually achieved union of the fracture and retrograde nailing group showed significantly earlier union rate (p = 0.032). There is no significant difference between both groups, in regards to knee pain, swelling, and range of motion as well as postnailing femoral alignment. Conclusions: Both methods of nailing achieved excellent union rates with good alignment of the limb. Contrary to popular belief, we found that retrograde nailing does not give rise to a higher rate of knee complications. Therefore, we strongly recommend this approach of nailing as it is technically less demanding.

Abstract: This is to report on the use of growing endoprosthesis, also known as lengthening prosthesis in the management of four patients in the paedriatic age group in the Orthopaedic Oncolgy Unit at University Malaya Medical Centre. These are custom made prosthesis, designed and made in India based on measured roentrograms. The ages of these patients vary from 6 to 13 years old. These are cases of Osteosarcoma and Ewing's sarcoma around the knee. This is the first time these custom made prosthesis have ever been used in Malaysia. We feel that this is a feasible option for limb salvage in the treatment of primary bone tumours in growing children.

Abstract: We describe a case that initially presented to the oncology unit as what seemed like a soft tissue sarcoma arising from the thigh. Biopsy of this mass showed that it was a mucoepidermoid carcinoma. This is a very rare presentation of a non-salivary gland primary mucoepidermoid carcinoma.

Abstract: Glove perforation during surgery has always been a matter of concern as it increases the infection rate and the risk of transmission of blood borne diseases. To determine the common causes, the site and the awareness of glove perforations in orthopaedic surgery, a prospective study was conducted to assess the rate of glove perforation during 130 consecutive orthopaedic operations. All gloves worn by the surgical team were assessed after the surgery using the water-loading test. A total of 1452 gloves were tested, and the rate of perforation was 3.58%. Most of these perforations (61.5%) were unnoticed. The main surgeons had the most perforations (76.9%), followed by first assistants (13.5%) and second assistants (9.6%). Most perforations occurred at the non-dominant hand. The commonest site of perforation was the index finger followed by the thumb. Shearing force with instruments accounted for 45% of the noticed perforations. Majority of these occurred during nailing procedures (33%) and internal fixation without the use of wires (19%). Our rate of glove perforation is similar to other series. Most of them went unnoticed and were mainly due to shearing injuries rather than perforation by sharps. Therefore, there is an increased risk of contamination and break in asepsis during surgery.

Abstract: This is a report of a case of subperiosteal schwannoma arising from the surface of the ulna in a 28 years old lady. To our knowledge, this is only the second report, of schwannoma presenting as a surface lesion of a bone. Radiologically, it presents as a well-circumscribed lesion, scalloping the cortex of the bone.

Abstract: This is a report of a case of subperiosteal schwannoma arising from the surface of the ulna in a 28 years old lady. To our knowledge, this is only the second report, of schwannoma presenting as a surface lesion of a bone. Radiologically, it presents as a well-circumscribed lesion, scalloping the cortex of the bone.

Abstract: Background: Trigger finger (stenosing tenosynovitis) is a common problem encountered in orthopaedic practice. There are various methods of treatment ranging from conservative management to surgical release. Aim: To determine effectiveness of corticosteroid injection and percutaneous release; in terms of symptomatic relieve, patient satisfaction and complications. Material & Methods: Prospective study. All patients who presented with trigger finger Grade 2 and 3 were randomized into 2 groups. One group received corticosteroid injection and in the other group, percutaneous release was done. These patients were then assessed weekly over a period of one month and their progress noted. Results: We studied a total of 26 patients. Majority (65.4%) were females. The commonest age group is 50-60 years olds (45.6%). Thirty eight and a half percent were manual workers, 30.8% semi-professionals followed by 26.9% housewives. There was almost equal involvement of dominant (53.8%) and non-dominant hand (46.2%). The most common presenting symptom was pain with triggering (42.3%). The middle and ring were most commonly affected (42.2% each). The little finger was not involved at all. There was significant improvement in pain in the first two weeks in both groups but there was better improvement of pain in the corticosteroid group especially on the 1st and the 4th week. As for the triggering, there was significant improvement noted in 1st week but there was no difference in degree of improvement between both the groups. There was no significant difference was noted in the progress of swelling during the course of the treatment in either group. As for patient satisfaction, the percutaneous release group reached maximum satisfaction by 2 weeks as oppose to the corticosteroid group, which achieve maximum satisfaction 1 week later. The corticosteroid group had a complication rate of 10% whereas the percutaneous release group complication rate was 20%. The recurrence rate was 15%. There were 2 cases in each group. Occurring 2 to 9 months after the primary procedure. Conclusion: Trigger finger is a common condition amongst blue-collar workers. The commonly affected fingers are the centrally located on the palm. The group of patients treated with corticosteroid had better relieve of pain but took longer to achieve maximum satisfaction as compared to the group that underwent percutaneous release. Both method of treatment eventually gave similar results after 3 weeks but the percutaneous release group had a higher complication rate. Recurrence was equal in both groups.

Abstract: Postoperative leg swelling after a total knee replacement is common complaint amongst patients. We studied leg swelling by constructing a novel, simple and cost water volumeter. A pilot study was conducted on 15 volunteers by two observers and each observer took a total of three readings. The mean intraobserver variation was 0.2 percent and mean interobserver variation was 0.3 percent, indicating a highly acceptable level of accuracy. The water volumeterwas then used in a randomized prospective study was conducted to determine the relationship between postoperative leg swelling and Fraxiparine, a low molecular weight heparin. From the period of 1st January 2000 till 31th October 2000, a total of 36 patients were enrolled in the study. 18 patients in the study group received fraxiparine and 18 patients in the control group did not. The leg volume was measured preoperatively and on postoperative days 5, 7 and 10. We found that both groups developed maximum swelling at postoperative day 5 and this decreased to almost normal at day 10. However the fraxiparine group was statistically less swollen (4%) than the control group (10%) on day 5 and also on day 7 (−0.2% vs 7%). These findings were independent of whether the patient underwent bilateral or unilateral surgery. We conclude that low molecular weight heparins are effective in reducing postoperative leg swelling in total knee replacement.