The management of pink pulseless limbs in supracondylar fractures has remained controversial, especially with regards to the indication for exploration in a clinically well-perfused hand. We reviewed a series of seven patients who underwent surgical exploration of the brachial artery following supracondylar fracture. All patients had a non-palpable radial artery, which was confirmed by Doppler ultrasound. CT angiography revealed complete blockage of the artery with good collateral and distal run-off. Two patients were more complicated with peripheral nerve injuries, one median nerve and one ulnar nerve. Only one patient had persistent arterial constriction which required reverse saphenous graft. The brachial arteries were found to be compressed by fracture fragments, but were in continuity. The vessels were patent after the release of obstruction and the stabilization of the fracture. There was no transection of major nerves. The radial pulse was persistently present after 12 weeks, and the nerve activity returned to full function.
Humerus ; Fractures, Bone

Open tibial fractures result in high rates of complications. This study aims to elucidate the risk factors causing these complications, and suggest antimicrobial regimens based on the organisms grown in post-operative infections. Over a period of five years, 173 patients had sustained open tibial fractures and undergone operative treatment at a single institution. All surgical data was gathered retrospectively through online medical records. Thirty-one patients (17.9%) had sustained post-operative bony complications, while infective complications were reported in 37 patients (21.4%). Patients with Gustilo type III fractures were found to be more than three times as likely to sustain post-operative infective (p=0.007) or bony (p=0.015) complications, compared to Gustilo type I or II fractures. The fracture location and time taken to fixation did not significantly affect the complication rate, but results were trending towards significance. The commonest cause of infective complications were hospital-acquired organisms, such as Methicillin-resistant staphylococcus aureus (40.5%). Closer monitoring of patients sustaining high grade Gustilo open fractures, as well as antimicrobial prophylaxis for both hospital-acquired organisms and environmental contaminants, will result in the best outcome for patients. Further studies with larger sample sizes are warranted, to determine the significance of fracture location and time taken to fixation on complication rates.
Tibial Fractures

Introduction: Worldwide estimates are that 9.6% of men and 18.0% of women aged over 60 years have symptomatic osteoarthritis. The current treatment options vary from conservative to joint replacement. Recently, debridement of the joint has become an option for symptomatic relief. We evaluated the outcome of arthroscopic debridement with autologous conditioned plasma. The latter helps to promote cellular repair. We have evaluated our results over a two year period. Materials and Methods: We retrospectively analyzed a cohort of 52 patients who underwent arthroscopic knee debridement with autologous conditioned plasma in 2011. The patients were followed up in clinic till discharge. The case notes were reviewed and baseline demographic data obtained. This included age, medical history, occupation, range of movement, BMI measurements, duration of operation and radiographic scores. We analyzed the outcomes against those factors. Results: Of the 52 patients in our study, 16 were female and 36 were male. The mean follow-up period in the clinic was 6.5 months. The Kellgren-Lawrence score was 21.2% Grade 1, 13.5% Grade 2, 51.9% Grade 3 and 13.5% Grade 4. Improvement in range of movement was seen in 32.7% of patients. Conclusions: This study shows that arthroscopic debridement with autologous conditioned plasma (ACP) has a role to play in the treatment of osteoarthritis. In view of these findings, we recommend that surgeons should consider arthroscopic debridement with autologous conditioned plasma as part of their treatment armamentarium.
Osteoarthritis

Introduction: The role of surgery in skeletal metastasis is to reduce morbidity and improve the quality of life in terminally ill patients. We report our experience with patients who underwent skeletal reconstructive surgery for metastatic bone tumour of the femur. Materials and Methods: Twenty nine operations for skeletal metastasis of the femur performed in our centre between 2009 and 2015 were included in this study. We evaluated the choice of implant, complications, survival rate and functional outcome. Fourteen patients were still alive at the time of this report for assessment of functional outcome using Musculoskeletal Tumour Society (MSTS) form. Results: Plating osteosynthesis with augmented-bone cement was the most common surgical procedure (17 patients) performed followed by arthroplasty (10 patients) and intramedullary nailing (2 patients) There were a total of five complications which were implant failures (2 patients), surgical site infection (2 patients), and site infection mortality (1 patient). The median survival rate was eight months. For the functional outcome, the mean MSTS score was 66%. Conclusion: Patients with skeletal metastasis may have prolonged survival and should undergo skeletal reconstruction to reduce morbidity and improve quality of life. The surgical construct should be stable and outlast the patient to avoid further surgery.
Femur

Introduction: Treatment of heterotopic ossification (HO) of the elbow is challenging and fraught with complications. Patients who sustain direct trauma to the elbow joint, the central nervous system, and thermal burns are at increased risk for development of HO. There is a paucity of studies and reports on patient’s self-evaluation after the excision of the heterotopic ossification. Materials and Methods: This retrospective study assessed outcomes after excision of heterotopic ossification around the elbow in a cohort of ten patients operated from 2012 to 2015. The outcome assessment was done by the Mayo Elbow Performance index (MEPI) and the American Shoulder and Elbow Surgeons-Elbow score (ASES-E scores). Results: The mean follow-up was 18.11 months after the operation. The Mayo Elbow Performance Score was excellent in two elbows, good in six and fair in two. The mean gain in flexion-extension arc after excision of HO was 80 degrees. All of the patients had residual flexion deformity postoperatively. Eight of the nine patients were able to do activities requiring flexion at final follow-up. Conclusion: Excision of HO around the elbow is associated with satisfactory patient-rated outcomes in spite of failure to regain full range of motion.

Introduction: There is no large population size study on school screening for scoliosis in Malaysia. This study is aimed to determine the prevalence rate and positive predictive value (PPV) of screening programme for adolescent idiopathic scoliosis. Materials and Methods: A total of 8966 voluntary school students aged 13-15 years old were recruited for scoliosis screening. Screening was done by measuring the angle of trunk rotation (ATR) on forward bending test (FBT) using a scoliometer. ATR of 5 degrees or more was considered positive. Positively screened students had standard radiographs done for measurement of the Cobb angle. Cobb angle of >10° was used to diagnose scoliosis. The percentage of radiological assessment referral, prevalence rate and PPV of scoliosis were then calculated. Results: Percentage of radiological assessment referral (ATR >5°) was 4.2% (182/4381) for male and 5.0% (228/4585) for female. Only 38.0% of those with ATR >5° presented for further radiological assessment. The adjusted prevalence rate was 2.55% for Cobb angle >10°, 0.59% for >20° and 0.12% for >40°. The PPV is 55.8% for Cobb angle >10°, 12.8% for >20° and 2.6% for > 40°. Conclusions: This is the largest study of school scoliosis screening in Malaysia. The prevalence rate of scoliosis was 2.55%. The positive predictive value was 55.8%, which is adequate to suggest that the school scoliosis screening programme did play a role in early detection of scoliosis. However, a cost effectiveness analysis will be needed to firmly determine its efficacy.

Introduction: Diagnosis of subungual glomus tumour is mostly based on detailed history and clinical examination. Recently, Magnetic Resonance Imaging (MRI) and Ultrasound have been proposed as the imaging modality to confirm the clinical diagnosis and in planning the surgical management of these tumours. However, these imaging modalities are not routinely available in rural setting and also are expensive. Due to these limitations, we set out to establish that diagnosis and management of these rare tumours can be based solely on a battery of clinical tests and history taking. Materials and Methods: Retrospectively, we reviewed nine cases of glomus tumour. A clinical evaluation proforma was developed on the basis of clinical history and specific clinical test for diagnosis of these tumours. All the cases were evaluated and treated surgically by a single surgeon with a specific technique. Post-operatively, diagnosis was confirmed by histopathological examination. Results: Females (77.78%) were predominantly affected in this series and the tumours commonly occurred in the right hand (66.66%). Spontaneous pain, cold sensitivity test and Love’s Pin test was positive in all cases (100%). Hildreth’s test was positive in 88.89%. In none of the cases the tumours recurred during minimum follow-up of one year. In all cases, histopathological examination confirmed the preoperative diagnosis of glomus tumours. Conclusion: Diagnosis of glomus tumours can be made clinically based on history taking and clinical examination. Magnetic Resonance Imaging and Ultrasound are not necessary for diagnosis and management of typical subungual tumours.

Acromioclavicular joint (ACJ) dissociation is one of the common injuries affecting adults. The stability of ACJ largely depends on the integrity of acromioclavicular ligament, coracoclavicular ligament, capsule, trapezius muscle and deltoid muscle. The injury has been classified by Rockwood into six types and treatment options can be guided by the classification. TightRope fixation is one of the many surgical procedures available to address acromioclavicular joint separation. It consists of tensioning of a no. 5 Fibrewire suture secured at both ends to lowprofile metallic buttons. Despite various advantages of using this technique, complications such as suture cut-out, clavicle fracture and suture failure have been documented. The author presents a case of a type III acromioclavicular joint dissociation treated with TightRope which suture cutout was noted intra-operatively. Decision to amend the fixation using a cut one-third tubular plate as an additional anchor for the metallic button on the clavicle was made. Patient’s progress was evaluated using the University of California at Los Angeles Shoulder Score (UCLA Shoulder Score) and significant improvement was noted six months post operatively. We propose this technique as a solution to the encountered problem.
Acromioclavicular Joint

Intra-articular synovial haemangioma of the knee is a benign tumour. However, diagnostic delay leads to degenerative changes in the cartilage and osteoarthritis due to recurrent haemarthrosis. Therefore, treatment should be performed immediately. We report the case of a localized synovial haemangioma arising from the medial plica in a 38-year old female presenting with pain and restricted range of motion in the right knee joint. Initially, we diagnosed this case as a localized pigmented villonodular synovitis (LPVS) based on MRI and arthroscopic findings and performed only arthroscopic en bloc excision of the mass and synovectomy around the mass for diagnostic confirmation. Fortunately, there was no difference in the treatment approaches for LPVS and localized haemangioma and the synovial haemangioma had not recurred at the 3-month postoperative follow-up with MRI. The patient’s clinical symptoms resolved and had not relapsed two years after surgery.
Osteoarthritis

Missed Monteggia fracture leading to chronic radial head dislocation is a known complication. The surgical treatment options remain challenging. The aim of treatment is to reduce the radial head and to maintain the stability of the elbow in all ranges of motion. A few surgical techniques have been described with complications. We report the case of a 13 years old boy with chronic radial head dislocation as a result of an unrecognised Monteggia fracture-dislocation for eight years. We successfully reduced the radial head and corrected the cubital valgus from 45 degrees to 10 degrees with a proximal ulna osteotomy and gradual distraction with 2-pin Monotube external fixator. The correction was uneventful with good functional outcome.