Introduction: The Malaysian Orthopaedic Journal (MOJ) (ISSN 1985-2533 / 2232-111X) is the official publication of the Malaysian Orthopaedic Association (MOA) and the ASEAN Orthopaedic Association (AOA). In May 2007, MOA published the first standalone issue of MOJ with the aim of disseminating new knowledge and providing updates in orthopaedics, trauma and musculoskeletal research. Since then, MOJ has grown significantly, achieving indexing in numerous databases and attaining a 2nd Quartile (Q2) rank in the Scopus database in 2022. This bibliometric analysis aims to explore the trends and distribution of articles published in MOJ. Materials and methods: Bibliometric data for MOJ was extracted from the SCOPUS database, covering the years from its indexing to 2022. Information such as authors, country, document type, author’s keywords, citations, and other parameters were extracted using the bibliometrix package in the R Studio software. The data were then presented in tables and illustrative graphs using the same software. Results: A total of 305 articles were retrieved from the Scopus database during the study period. Two-thirds of the articles were original articles and review articles. The highest number of citations received by an article is 56, and top ten articles in MOJ were authored by researchers from seven different countries, highlighting the journal’s diversity. Despite receiving submissions from various countries, there is minimal collaboration between authors of different countries. Keywords such as “covid-19” and “pandemic” dominate the authors’ keyword section due to the once-in-alife-time COVID-19 which during the study period, resulting in numerous publications related to this issue. Conclusion: This bibliometric analysis reviews all the articles indexed in the Scopus database and provides insight into the contributors’ information and the trends in orthopaedic research. By identifying the lack of collaboration between countries, it is hoped that this analysis can inspire more orthopaedic surgeons and researchers to collaborate and produce high-quality publications.

Introduction: Orthopaedic theatre lists are an important tool which must convey essential information to all staff to run an effective and safe theatre list. However, there are no set standards or guidelines on the components of an Orthopaedic theatre list. The objective of this study is to formulate guidelines for elective Orthopaedic theatre lists which improve efficiency and reduce errors. Materials and methods: We looked at 326 elective Orthopaedic theatre lists from October to November 2018. Various factors such as: theatre and patient demographics, surgical team, type of anaesthesia, Surgery, acronyms and finally extra information such as allergies. Additionally, a survey was distributed to a variety of theatre staff to understand their requirements from a theatre list. Thereafter, we created a proforma for waiting list coordinators. Subsequently, we re-audited six more weeks of theatre lists (255) from November to December 2019. Results: The orthopaedic consultant in charge was noted for 100% of patients compared to 85% previously. There was an improvement in documenting the required anaesthesia such as noting 14.5% required spinal compared to 0.3% previously. Prosthesis/equipment was mentioned for 34% of patients compared to 23%. Fluoroscopy was noted as being required for 25% of patients compared to 11%. Conclusion: We believe standards should be in place in order for us to follow to ensure we carry out safe and efficient Orthopaedic theatre lists, and these standards should entail the parameters we have audited. The ‘William Harvey theatre list standard’ should be used as a gold standard for all elective Orthopaedic theatre lists.

Introduction: Increase in the number of primary shoulder arthroplasty has led to an increase in the number of revisions which presents many complex challenges and often has inferior outcomes. Materials and methods: Data was collected retrospectively, and patients were classified using Dines classification. Comprehensive case reviews were done to identify preoperative and intra-operative challenges. The primary outcome measure was Oxford shoulder score (OSS). The secondary measures were range of motion (ROM) and patient satisfaction (very satisfied, satisfied, not satisfied or worse). Results: A total of 32 patients were identified with a mean age of 67.64 years and the most common cause of revision was a combination of bone and soft tissue failure (39.3%). All patients (n=8) with hemiarthroplasty had rotator cuff deficiency while patients with resurfacing had both rotator cuff failure and bony erosion. Four patients needed a proximal humeral osteotomy and six patients needed allograft reconstruction of the glenoid for bone loss. Twentyone shoulders were revised to reverse total shoulder arthroplasty (TSA), 2 to anatomical TSA and 5 were left with cement spacer in situ. Mean duration of follow-up was 41.6 months. Mean OSS at the last follow-up was 26.88 with statistically significant improvement in ROM. There was no statistical difference in clinical outcomes (p>0.05) based on the type of primary prosthesis or cause of revision. A total of 70% patients were pain free. Patients with infection had inferior outcomes with a mean OSS of 17. Conclusion: Management of patients with failed shoulder arthroplasty is often challenging but has good clinical outcome except in infections.

Introduction: Despite recent advances, management of distal tibial fractures is challenging, with high rate of complications. Fibula pro tibia plating technique fixes fibula and tibia together, via laterally placed fibular plate without disturbing the tibial soft tissue sleeve. We contemplated this pilot study to assess effectiveness of fibula pro tibia plating in management of distal tibia fibula fractures. Materials and methods: A total of 30 patients with distal tibia fibula fractures with fracture line extending within 5cm from tibial plafond were managed with fibula pro tibia plating, with or without minimal articular fixation. Outcome evaluation was done by union, union time, alignment and functional outcome as assessed by AOFAS score. Results: Mean age in the series was 39.4 years with male to female ratio of 3:2. Mean duration of surgery, blood loss and C arm exposure were 79 minutes (range 52 to 98min), 80ml (range 62 to 102ml) and 48 shoots (range 36 to 81 shoots), respectively. All fractures united in mean union time of 10.2 weeks (range 9 to 14 weeks) with acceptable alignment in all the patients except one. Mean AOFAS score was 86.3 (range 70 to 93) with 29 patients having good to excellent outcome. One patient had varus malunion and in one case infection was seen. Conclusion: Fibula pro tibia plating can be successfully used to manage complex distal tibia fractures which leaves the soft tissue and periosteal sleeve undisturbed, thus avoiding wound related problems and leading to early union.

Introduction: Post-trauma patients are at risk of developing symptoms of post-traumatic stress disorder (PTSD) and major depression. The primary goal of this study is to estimate the prevalence of PTSD and depression symptoms in patients who have been hospitalised for the treatment of physical trauma. Additionally, we wanted to compare the prevalence of PTSD or depression symptoms alone versus PTSD associated with depression symptoms, in orthopaedic post-trauma patients. Materials and methods: This study had involved orthopaedic post-trauma patients in the orthopaedic ward and clinic of Hospital Tuanku Jaafar (HTJ), Seremban, Malaysia, using an online questionnaire, which consist of English and Malay language. We then determined the prevalence of depression and PTSD symptoms in orthopaedic post-trauma patients and compared this prevalence to the severity of the injuries sustained and any association between PTSD and depression symptoms. Results: Only 12.9% of the participants are likely to have post-traumatic stress disorder (PTSD) symptoms and 43.3% of participants have depression symptoms. There is no significant association between patient demographics and severity of the injuries with the prevalence of post-traumatic stress disorder (PTSD) and depression symptoms. However, of those deemed likely to have PTSD, 93.5% of them had both post-traumatic stress disorder (PTSD) symptoms as well as depressive symptoms. Conclusion: Only a few of the participants are likely to develop post-traumatic stress disorder (PTSD) while almost half of the participants are likely to have developed depression. Physicians caring for trauma patients should screen them for early symptoms of PTSD and depression and treat them accordingly.

Introduction: Post-operative urinary retention (POUR) is a common complication after total knee arthroplasty (TKA) and may result in severe complications such as urinary tract infection and deep joint sepsis, leading to prolonged hospital stay and increased medical costs. Hence a retrospective study was performed to identify the incidence and modifiable factors associated with POUR after elective TKA in Asian patients with the aim to prevent POUR and its undesirable consequences. Materials and methods: The medical records of 496 consecutive patients who underwent elective TKA between 1 August 2017 and 30 July 2018 were reviewed. There were 154 male (31.0%) and 342 female (69.0%) patients with an average age of 68 years old. The incidence of POUR was analysed with respect to various modifiable and nonmodifiable risk factors, including patient demographics, medical comorbidities, duration of surgery, type of intraoperative anaesthesia and post-operative analgesia and early initiation of physiotherapy using univariate and multivariate analyses. Results: A total of 120 (24.2%) of the 496 patients who underwent elective TKA developed POUR. The odds of a patient with patient-controlled analgesia (PCA) and peripheral nerve block (PNB) developing POUR were 4.2 times and 4.7 times that of a patient without PCA and PNB, respectively. Age, male gender and type of anaesthesia were not found to be significant. Conclusion: In our study population, the incidence of POUR after elective TKA was 24% with major modifiable risk factors being associated with the use of PCA and PNB as post-operative anaesthesia. POUR can have deleterious effects thus alternative post-operative analgesia should be considered.

Introduction: Non-union of long bones is a common challenge in the treatment of fractures. Bone grafting is commonly used to treat atrophic non-union, but mechanical displacement of the graft may occur, resulting in delay or failure of treatment. Fibrin glue has demonstrated positive results in management of bone defects in neurosurgery and oromaxillary facial surgery, however, there has yet to be any study on its use in long bone fractures. Materials and methods: We conducted a prospective randomised controlled trial at a single tertiary centre involving adult patients with long bone fractures that had undergone non-union and requiring bone grafting only. Autologous iliac crest bone graft was applied to the debrided non-union site, with additional fibrin glue applied for the intervention arm. Patients were followed-up with serial radiographs until clinical and radiographical union. Results: Ten patients (3 male, 7 female), of mean age 41.7 (19 – 63) were recruited over five years, with one drop out. Eight out of nine fractures united after treatment. One patient underwent hypertrophic non-union requiring re-fixation and bone grafting. There was no difference in the time to union for patients in the fibrin glue group (19.5 weeks) versus the control group (18.75 weeks) (p=0.86). There were no complications sustained from usage of fibrin glue. Conclusions: Fibrin glue appears to be a safe adjunct for treatment of non-union of long bone fractures across varying fracture sites by holding the bone graft in place despite not demonstrating a faster time to union.

Introduction: Bony surface cleaning using a pulse lavage device (PLD) is essential for modern cementation of hip and knee arthroplasties. This costly single-use device is a medical waste and unaffordable for some patients. Reprocessing is a worldwide standard strategy to solve this problem. To determine the technical properties and biological safety of a reprocessed PLD handpiece and compare its performance under different power supplies. Materials and methods: Eight brand-new disposable PLDs were tested for baseline technical properties (flow rate, pulse frequency, and peak pressure). Thereafter, they were reprocessed and retested for 10 rounds using two different power supplies. An adenosine triphosphate (ATP) swab test was performed on the PLD accessory parts after cleansing and disinfection. Passed-through isotonic sodium chloride solution ejected from the reprocessed PLD underwent aerobic bacterial culture. The unit costs of production were analysed. Results: The mean flow rate of the disposable PLD (1.5±0.1 L/min) was less than that of reprocessed PLD using DC15V battery (2.5±0.3 L/min, p<0.001) and AC/DC15V3A adapter (6.1±0.4 L/min, p<0.001). The mean pulse frequency and peak pressure of the disposable PLD and reprocessed PLD using DC15V battery were not different (18.5±0.8 vs 18.8±2.5 Hz, p=0.155 and 0.37±0.04 vs 0.38±0.03 N/mm2 , p=0.640, respectively), but were lower than those using AC/DC15V3A adapter (47.0±2.7 Hz, 0.45±0.03 N/mm2 , p<0.001). All ATP swab tests, and aerobic fluid cultures yielded negative results. The total cost of reprocessing was 10% of disposable PLD. Conclusions: A disposable PLD handpiece can be reprocessed without deteriorating its technical properties and used with either retrieved DC15V battery or AC/DC15V3A adapter for the power supply. As the biological safety of reprocessed and disposable PLDs was comparable, it may be clinically utilised with 90% cost reduction.

Introduction: The popular wound closure methods for carpal tunnel decompression (CTD) include non-absorbable and absorbable sutures which have comparable results in clinical outcomes. However, these wound closure methods are recommended to keep a wound dry which may limit some ADLs. We conducted a prospective randomized controlled trial that compares clinical outcomes and costeffectiveness in a skin closure following CTD between absorbable sutures plus a 2-octyl cyanoacrylate tissue adhesive (2OCA) versus non-absorbable skin sutures plus a waterproof dressing (NSPWD). Materials and methods: We enrolled 120 patients undergoing CTD into two groups: 2OCA and NSPWD, with 60 patients in each group. Number of dressing changes, Quick DASH, pain VAS, cosmetic VAS, patient satisfaction VAS, and Hollander wound evaluation score, costeffectiveness, and post-operative complications were collected at pre-operative period and two and six weeks postoperatively. Results: Slightly better patient satisfaction VAS (7.9 vs 7.2, p=0.018) and cosmetic VAS (8.0 vs 7.2, p=0.025) were observed in 2OCA at 2 weeks. Meanwhile, NSPWD revealed lesser times of dressing change (Median, mode, IQR: 0/0/0 vs 2/3/2, p<0.001). The total wound-related costs include dressing change and suture removal cost ($15.9 for 2OCA vs $19.2 for NSPWD, p=0.002) although an initial woundrelated cost in 2OCA was higher ($15.7/case vs $7.9/case, p<0.001). Conclusions: Our study revealed that the supplementary tissue adhesive to absorbable sutures following CTD could reduce total wound-related costs while clinical outcomes might not be considered clinically significant.