Introduction: Staphylococcus aureus is the leading biofilmforming microorganisms in orthopaedic implant infections. The biofilms formed are difficult to eradicate and resistance to antibiotics. This current study aims to determine the effectiveness of povidone-iodine; an antiseptic solution in eradicating S. aureus biofilm on stainless steel alloy. In addition to the usual Colony-Forming Unit (CFU) used for verification, Scanning Electron Microscope (SEM) is used to validate the formation and eradication of the biofilms. Materials and methods: This is an in vitro study where the biofilm is formed by inoculating clinically isolated S. aureus, incubated for 24 hours onto stainless steel alloy 316L implants. The implants are then irrigated using povidoneiodine solution with varying concentrations (5 and 10%) and durations (30, 60, and 180 seconds). The anti-biofilm effect was evaluated using plating and SEM methods to confirm its effectiveness. The process is repeated after 24 hours of postirrigation reincubation to detect any rebound growth. Results: No biofilm seen after irrigation with povidoneiodine at 5% and 10% concentrations at 30, 60 and 180 seconds, respectively, in both CFU count and SEM. This result is replicated after 24 hours of reincubation, in assessing for rebound growth. Conclusion: Our study supports that a minimum of 5% povidone-iodine with a minimum irrigation time of 30 seconds are effective at eliminating S. aureus biofilm on stainless steel alloy implants. Both CFU count and SEM yield similar value in validating the presence of biofilm. Additionally, SEM allows visualisation of the morphology of the biofilm.

Introduction: Medial open wedge high tibial osteotomy (MOWHTO) is one of the modalities to treat unicompartmental knee osteoarthritis (KO). Many studies have shown good outcomes of MOWHTO, but there are no published series of Malaysian patients. The aim of this study is to determine the outcome of MOWHTO in primary medial compartment KO in a university teaching hospital in Malaysia. Materials and methods: This is a retrospective study of patients who underwent MOWHTO in our Joint Reconstruction Unit between 2017 and 2022 with a minimum of 12 months follow-up. Results: Data from a total of 15 knees were reviewed. The mean age of patients was 41.8 years, and the mean BMI was 31.7. The mean Kellgren-Lawrence (KL) osteoarthritis grade was 2.87 (±0.52). The mean hip knee angle (HKA) preoperatively was 12.26° varus and post-operatively was 3.33° valgus. Mean correction of HKA was 13.59°. The results revealed an improvement in all patients, as observed from the significant mean difference between pre-operative (38.53) and post-operative (77.60) Knee Injury and Osteoarthritis Outcome (KOOS) (p-value<0.001) scores. Patients who were above 50 years old showed a significantly better improvement in KOOS score compared to those below 50 (p-value <0.05). There was no significant difference observed between BMI and KOOS score improvement (Fstat=0.580, p-value >0.05). Conclusion: MOWHTO is a good treatment option in medial compartment primary KO with varus deformity among Malaysian population. A larger sample size with a longer follow-up period is needed to draw a definitive conclusion

Introduction: The occurrence of rotator cuff tendinopathy, which is invariably symptomatic, increases as populations age, being largely observed among patients with diabetes. The objective of the present study is to find out the occurrence of rotator cuff tendinopathy in elderly diabetic patients who were asymptomatic, composed of healthy individuals and those with diabetes mellitus. Materials and methods: The participants in this study included 87 elderly diabetic patients and 56 controls (mean age: 69.3±4.9 and 71.8±3.6, respectively), who were asymptomatic from shoulder. All patients, including, underwent shoulder MRI examination using 1.5 tesla MRI. Results: We recorded greater tendons thickness in the diabetic patients as compared with the controls (supraspinatus tendon: 6.6±0.7mm vs 5.3±0.8mm, p<0.001; biceps tendon: 3.9±0.7mm vs 3.1±0.8mm, p<0.002). Moreover, higher incidence of supraspinatus tendon tear was noted in diabetics as compared to biceps tendon (major tears: 32 (36.7%) vs 6 (10.7%), p=0.052; minor tears: 51 (58.6%) vs 11 (19.6%), p=0.032). Conclusions: The present study suggests that age-related rotator cuff tendinopathy is more prevalent among patients with diabetes. Therefore, MRI is an investigation of choice for early detection i.e., at pre-symptomatic stages of rotator cuff tendinopathy, as the patients may develop symptoms later. Keywords: asymptomatic

Introduction: With surgical advancements and improved implants and instrumentation, nailing is the procedure of choice in subtrochanteric fractures. However, failure in achieving reduction of the multidirectional displacement of the fragments prior to passing the nail, contributes to delayed/non-unions at the fracture site leading to implant failures. In this study, we aim to analyse the factors affecting union of closed subtrochanteric fractures treated by nailing. Materials and methods: In this retrospective study, closed subtrochanteric fractures treated with cephalomedullary nailing between 2015 and 2019 were included. Demographic, surgical and radiological data were retrieved and analysed. A total of 60 cases were eligible to be included in the study. Results: Majority of patients were male (50), with a mean age of 46.07±16.40 years. Twenty-two fractures were multifragmentary having a separate butterfly fragment. In 27 patients mini-open technique was used to get the anatomical alignment and to hold reduction until fixation. Overall, the mean time for union was 7.63±5.85 months. We had nine delayed unions and eight non-unions. Varus alignment in the coronal plane of more than 8.5° was the only significant factor associated with delayed or non-union apart from loss of medial continuity. Conclusion: We recommend achieving fracture reduction with less than 8.5° of varus malalignment in the coronal plane. Varus malalignment is poorly tolerated in fractures at this region. To achieve this, we suggest having a very low threshold to minimally open the fracture site for reduction of these fractures, which does not have any negative effect on the fracture union.

Introduction: Congenital talipes equino-varus (CTEV) is amongst one of the most common paediatric foot deformities. Ponseti’s method is the standard way of treatment, however, some patients are left with residual or partially corrected deformities. Dynamic supination is one amongst them, where the foot supinates in swing phase of the gait cycle. It is due to a strong tibialis anterior and its weak antagonist. Materials and methods: We undertook a prospective interventional study in thirty patients of CTEV with residual dynamic supination deformity and treated them with tibialis anterior tendon transfer (TATT) using a button anchor. Minimum follow-up was six months after the surgery. Functional, subjective and objective evaluation was done using foot posture index (FPI), disease specific instrument (DSI) for clubfoot, clinician satisfaction grading and videotaped functional gait analysis. Statistical analysis was done using paired ‘t’ test and calculating p values. Results: We achieved good to excellent results in 93.3% of our patients and fair in 6.66%. None of our patients had poor results. Mean FPI improved from -1.93 to +0.3, DSI values also showed a significant reduction from 18.17 +/- 1.09 to 13.37 +/- 1.54 after surgery. A total of 90% had satisfactory gait post-surgery at 6 months follow-up. Conclusion: Tibialis anterior tendon transfer using a button anchor is effective in treatment of residual dynamic supination deformity.

Introduction: The primary issue following lumbar discectomy for disc herniation is the risk of reherniation in the post-operative period. Many surgical techniques have been proposed to treat disc reherniation, however, the optimal one remains variable. This meta-analysis aimed to investigate the prevalence of symptomatic reherniation after using a Bone-anchored annular closure device following lumbar discectomy and the contributing factors. Materials and methods: Identification of published literature was performed on PubMed, Google Scholar, Scopus, and Web of Science databases. Studies published until 14 February 2024 reported the prevalence of symptomatic reherniation after using a Bone-anchored annular closure device following lumbar discectomy and the associated contributing factors. A random effects model was used to conduct Bayesian frequentist network meta-analysis and pair-wise meta-analysis, with the assessment based on standardised mean difference (SMD) and 95% confidence interval (CI). Results: Eleven studies published in 2012 − 2022 recruiting a total of 5195 patients were included in the meta-analysis. The prevalence of reherniation in ACD and control groups was 23.2% (95% CI: 18.2% − 28.1%) and 36.4% (95% CI: 28.2% − 44.5%), respectively. The moderator effect of sample size is significant for pooled data of the ACD group (p-mod=0.002), but not for the control group (pmod=0.278). After the adjustment with sample size, the prevalence rates were 13.6% (95% CI: 6.2% − 21.1%) and 29.6% (95% CI: 14.9% − 33.2%) for ACD and control groups, respectively. Conclusion: Comparatively to lumbar discectomy alone, using a Bone-anchored annular closure device following lumbar discectomy decreased the symptomatic reherniation rate and post-operative complications, as well as the necessity for subsequent surgeries.

Introduction: There remains little evidence on rehabilitation protocols for proximal humerus fractures (PHFs), although early mobilisation has been associated with positive clinical outcomes. There may be a potential role in allowing patients with more stable fractures to undergo an accelerated rehabilitation process to facilitate quicker return to function, although it must be balanced with safety concerns of premature mobilisation and logistical concerns of implementation with excessive stratification. The study aim was to report the overall safety and outcomes of a simple and implementable 2-tier stratified rehabilitation protocol based on fracture stability adopted by our institution for nonoperatively treated PHFs. Materials and methods: Patients in our institution (level 1 trauma centre) with non-operatively treated PHFs underwent a stratified rehabilitation protocol that classified patients into Accelerated versus Standard arms - with more stable fractures undergoing an accelerated rehabilitation programme. The Oxford Shoulder Score (OSS), Quick Disabilities of the Arm, Shoulder and Hand Score (QuickDASH), EuroQol-5-Dimensions (EQ5D) questionnaires, shoulder range of motion (ROM) and grip strength were measured at six months and one year postinjury. The frequency of adverse events requiring surgical intervention was noted. Results: We included 164 patients and 43% (71/164) went through the accelerated protocol. Overall, patients had favourable OSS (median[range] 47[44-48]), EQ5D (median [range] 1.0[0.82-1.00]), QuickDASH scores (median[range] 2.3[0- 10.7]), and shoulder ROM and grip strength above the requirement for functional activities of daily living at 1 year. There were no adverse events reported 1-year post-injury. Conclusion: This study was the first to report the safety and outcomes of a stratified rehabilitation protocol for PHFs. Our simple 2-tier stratified rehabilitation protocol which allowed a shorter period of rehabilitation and earlier return to function for patients with more stable PHFs is implementable, safe and had overall favourable functional outcome scores.

Patellar tendon rupture is an uncommon but serious complication that results in loss of knee extension during and after total knee arthroplasty (TKA), significantly impacting the patient’s quality of life. Various surgical treatments, ranging from initial repair to reconstruction, are available and accessible. In recent years, the peroneus longus tendon autograft has been utilised to restore the knee extensor system. The purpose of this case report was to present the case of a patient who had a traumatic patellar tendon rupture following TKA and requiring surgery along with peroneus tendon augmentation. A 71-year-old woman underwent bilateral robotic-assisted cruciate retaining TKA for a Grade IV arthritic knee. Post surgery, on day five patient had a history of a fall at home, following which she was unable to extend her knees. On evaluation through ultrasonography and radiographs, she was found to have a ruptured patellar tendon and sprain of the medial collateral ligament. Primary repair of the tendon along with augmentation with the peroneus tendon was performed, and the patient was followed for 12 months, at the end of which, the patient was able to achieve a good functional outcome. In conclusion, early results from patellar tendon reconstruction using an ipsilateral peroneus longus tendon autograft following TKA suggest that this technique is effective for managing acute post-traumatic patellar tendon rupture. It facilitates early recovery, yields favourable outcomes, and may reduce the risk of infection.

Traumatic crush injury of the thumb is devastating and often resulted in poor functional outcome. Various reconstruction options available according to surgical expertise. Masquelet technique is well-established in the long bones of lower limb. Only a handful of cases reported for thumb, especially in Asia region. We described a case of crush injury of right thumb following a trauma. The bony defect was initially filled with antibiotic spacer and subsequent reconstruction with tricortical iliac graft, a modified Masquelet two-stage technique. It is a versatile tool which provide satisfactory functional outcome and hand appearance.

Giant Cell Tumour (GCT) of bone is a benign, locally aggressive neoplasm. GCT of the foot is rare, comprising of about 5% of cases of all GCTs. GCT of Calcaneus is exceedingly rare, comprising of 1.2% of all calcaneal tumours. Due to its uncommon occurrence at this site, diagnosis can be delayed. In this report, we present the case of a Campanacci Grade 3 GCT of calcaneus in a 43-year-old female patient with 8 months history of worsening pain and disability. We treated her successfully by resection of Oscalcis and reconstruction with a femoral head allograft and K-wire fixation, a relatively cheaper and technically lesser challenging method of reconstruction. Three years’ postsurgery, she remains disease free, and her graft has healed. She continues to walk independently and remains disease free clinically and radiologically. We discuss a comparison with other reported cases where surgeons have opted for detailed intra-lesional curettage (DILC) and cementoplasty to fill the defect for a Grade 2 disease, some have even used a sural for soft tissue coverage with a maximum follow-up of two years. While in our patient we went for Calcanues resection and reconstruction with allograft because of a Grade 3 disease that poses greater risk of local recurrence with just DILC. Our patient has a three-year follow-up where she remains disease free