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A New Approach to Body Donation for Medical Education: The Silent Mentor Programme

Malaysian Orthopaedic Journal.2018;12(2):68-72. doi:10.5704/MOJ.1807.015

Cadaveric dissection is an integral component of medical education. There had been concerns about negative impact on medical students exposed to deceased donors before their clinical years, but most studies reported overall positive outcome following this form of teaching. Due to reducing number of body donations in most parts of the world, many institutions are adopting alternative models especially for the teaching of gross anatomy. A new body donation programme that incorporate humanistic values in the procurement process was initiated by Tsu Chi University of Taiwan in 1996. Early observations following teaching with the socalled “silent mentors” noted less negative emotional impact on the students. With increasing number of body donation following the initiation of the silent mentor programme as reported in some regions, we will be able to continue the time-honoured cadaveric dissection for anatomy teaching, at the same time promoting humanistic values on junior doctors.

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Closed Intramedullary Locking Nailing for Metacarpal Fractures: A Retrospective Study of Sixty-six Fractures

Ghazala C ; Choudhry N ; Rajeev A

Malaysian Orthopaedic Journal.2018;12(2):7-14. doi:10.5704/MOJ.1807.002

Introduction:Metacarpal fractures are frequent injuries in the young male working population and the majority are treated non-operatively. There is a growing trend to surgically treat these fractures, with the aim of reducing the deformity and shortening the rehabilitation period. The aim of this retrospective case series is to report on our experience and clinical outcomes of using percutaneous flexible locking nails for the management of displaced metacarpal fractures. This study is a retrospective review of 66 fractures that were managed at our centre over a 7-year period. Materials and Methods: Records of 60 patients were retrospectively reviewed. Indications for surgery were a displaced metacarpal shaft or neck fracture with associated rotational deformity, or multiple metacarpal fractures. The fracture was reduced by closed manipulation, and a flexible pre-bent locked intramedullary nail (1.6mm diameter) was inserted through a percutaneous dorsal antegrade approach, facilitated by a specially designed pre-fabricated awl. The implant was removed at union. Patients were followed-up in clinic until the fracture had united. Results:The mean union time was seven weeks (range 2 to 22 weeks) and there were nine (14%) delayed unions (>3 months) and no non-unions. The nail had migrated in three cases (5%) and caused skin impingement in two cases (3%). There was one infected case (2%). Rotational clinical deformity was evident for two (3%) cases. Conclusion: The use of a minimally-invasive locked intramedullary nailing for unstable metacarpal fractures has a significantly low complication rate, with predictable union times and good functional outcomes.

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Outcome of Tendon Transfers for Radial Nerve Palsy in a Malaysian Tertiary Centre

Richford J ; Abdullah S ; Norhafizah M ; Juliana I ; Rashdeen F ; Razana A

Malaysian Orthopaedic Journal.2018;12(1):1-6. doi:10.5704/MOJ.1803.001

Tendon transfers for radial nerve palsy is a common operation with good results. We did a retrospective study on twenty patients with radial nerve palsy who underwent tendon transfer surgery and recovered between January 2008 and December 2012. Outcomes measured were motor power of wrist extension, finger extension, grip strength and DASH scores. There was significant improvement of motor power of wrist and finger extension between the preoperative period and three months post-operatively, between the pre operative period and six months post operatively and between three and six months postoperatively (p = 0.0005). Grip strength improved significantly as well between preoperative, three and six months postoperatively (p = 0.0005). DASH scores reflecting patient satisfaction at six months postoperatively showed only mild or moderate difficulty of function.

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Comparison of Adductor Canal Block Versus Local Infiltration Analgesia on Postoperative Pain andF unctional Outcome after Total Knee Arthroplasty: A Randomized Controlled Trial

Kampitak W ; Tanavalee A ; Ngarmukos S ; Amarase C ; Songthamwat B ; Boonshua A

Malaysian Orthopaedic Journal.2018;12(1):7-14. doi:10.5704/MOJ.1803.002

Introduction:Total knee arthroplasty (TKA) is associated with intense postoperative pain for which effective analgesia is essential to facilitate early postoperative recovery. Adductor canal block (ACB) and local infiltration analgesia (LIA) have become increasingly involved in postoperative pain management after TKA. We aimed to compare their efficacy and outcomes in patients undergoing TKA. Materials and Methods: Sixty patients undergoing unilateral TKA were randomized to receive either postoperative single-injection ACB (Group A) or LIA (Group L) during the operation. All patients received spinal anaesthesia. Primary outcome was total morphine consumption over postoperative 24 hours. Visual analog pain scale, time to first and total dosage of rescue analgesia, performance-based evaluations [timed-up and go (TUG) test, quadriceps strength], side-effects, length of hospital stay and patient satisfaction were measured. Results: Fifty-seven patients were available for analysis. Median total morphine consumption over 24 and 48 postoperative hours of Group A were significantly less than Group L (6/10 mg vs 13/25 mg, p, 0.008 and 0.001, respectively). Similarly, Group A had significantly lower VAS at postoperative 6, 12 and 18 hours, VAS at ambulation on postoperative (POD) 1-3, better TUG tests on POD 2 and during POD 3 than those of Group L. However, quadriceps strength and patient satisfaction were not different between both groups. Conclusion:Patients undergoing TKA with single-injection ACB required less postoperative opioids than those with LIA. Furthermore, multimodal analgesia using ACB provided better postoperative analgesia, as well as performance-based activities, than those with LIA.

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Can the Pirani Score Predict the Number of Casts and the Need for Tenotomy in the Management of Clubfoot by the Ponseti Method?

Sharma A ; Shukla S ; Kiran B ; Michail S ; Agashe M

Malaysian Orthopaedic Journal.2018;12(1):26-30. doi:10.5704/MOJ.1803.005

Introduction:We assessed the role of the Pirani score in determining the number of casts and its ability to suggest requirement for tenotomy in the management of clubfoot by the Ponseti method. Materials and Methods:Prospective analysis of 66 (110 feet) cases of idiopathic clubfoot up to one year of age was done. Exclusion criteria included children more than one year of age at the start of treatment, non-idiopathic cases and previously treated or operated cases. Results: The initial Pirani score was (5.5±0.7) for the tenotomy group and the initial Pirani score was (3.3±1.6) for the non-tenotomy group. There was a significant difference between the initial Pirani score for the tenotomy and the nontenotomy group with t= -7.9, df= 64 p<0.0001. The tenotomy group had a significantly higher number of casts (four to seven) compared to non-tenotomy group (two to five) t=-10.4, df=64, p<0.0001. Spearman’s rank correlation coefficient was significant and confirmed positive correlation between the initial Pirani score and the number of casts required to correct the deformity (r = 0.931, p<0.0001). Conclusion: Initial high Pirani score suggests the need for greater number of casts to achieve correction and probable need for tenotomy. The number of casts required in achieving complete correction increases with increase in the initial Pirani score. The initial high hindfoot score (2.5-3) signifies the probable need of a minor surgical intervention of percutaneous tendoachilles tenotomy. Based on the initial Pirani score, parents can be informed about the probable duration of treatment and the need for tenotomy.

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Acetabulum Protrusion Following Ceramic Liner Fracture: A Case Report

Aytekin K ; Esenyel CZ

Malaysian Orthopaedic Journal.2018;12(1):45-47. doi:10.5704/MOJ.1803.010

Hip arthroplasty is an extremely satisfying treatment method for coxarthrosis which is in increasing use throughout the world. However, loosening of the prosthesis is a significant complication and to overcome this, ceramic liners are increasingly being selected. If the survival of ceramic surfaces is prolonged, there is a risk of fracture of the ceramic materials. New ceramic materials developed to overcome this problem are more resistant. The case presented here is of a patient in whom liner fracture developed following ceramic-ceramic hip arthroplasty. The ceramic femoral head was observed to have protruded into the defect created in the acetabular component. Acetabular revision was applied to the patient.

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Role of Serum Osteoprotegerin as a Diagnostic Indicator of Primary Osteoporosis in Perimenopausal and Postmenopausal Women: An Indian Perspective

Pandey A ; Khan YA ; Kushwaha SS ; Mohammed F ; Verma A

Malaysian Orthopaedic Journal.2018;12(1):31-35. doi:10.5704/MOJ.1803.006

Introduction:Osteoporosis (OP) is a major health problem in the older population. The aim of the study was to assess the role of serum osteoprotegerin (OPG) as a diagnostic indicator of primary osteoporosis in peri- and postmenopausal women in an Indian population. Materials and Methods: After ethical approval, 90 cases (45 cases and 45 controls) of peri- and post-menopausal females above 40 years of age presenting to our outpatient department were included in the study. It was a case controlled study conducted between July 2014 to July 2015. Based on the clinical features, t-score and radiological evidence from the DEXA scan, they were equally divided into two groups (cases and controls). Serum osteoprotegerin (OPG) levels were measured amongst cases and controls. Results:The total calcium (mg/dl) level was lower among the cases and the difference was significant (p-Value= <0.001). Similarly, alkaline phosphatase (u/l), osteoprotegerin (u/ml) levels were higher in the cases as compared to controls and the difference was significant (p-Value= <0.001). The mean osteoprotegerin level showed a slight increase with increase in severity of the grading of BMD of spine. The results suggested a cut-off value of ≥10.5 u/ml (86.7% sensitive and 80% specific with accuracy of 84.5%) between normal and osteoporosis. Conclusion: From the present study, we conclude that osteoprotegerin is a valid biomarker to diagnose postmenopausal women with low bone mineral density.

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Actinomycosis of Distal Phalanx Twenty Years after Flap Reconstruction of Index Finger: A Case Report

Prashant N ; Azuhairy A

Malaysian Orthopaedic Journal.2018;12(1):48-50. doi:10.5704/MOJ.1803.011

Actinomycosis is a chronic granulomatous suppurative infection caused by anaerobic bacteria from genus Actinomyces which are normal flora of mouth, colon and vagina. Actinomycosis of upper extremity is rare. We report a case of actinomycosis of the distal phalanx of finger many years after flap reconstruction. The patient presented with two months’ history of chronic discharging sinus from the tip of his right index finger, which had sustained a degloving injury 20 years previously. It had been treated with an anterior chest wall flap which had healed uneventfully but was bulky due to excess tissue from the donor site. Radiograph revealed osetomyelitis changes of distal phalanx. Debulking surgery with curettage of the distal phalanx was done. Wound healing was uneventful. He was treated with six weeks of metronidazole and ciprofloxacin. The discharge from the distal phalanx cultured actinomycosis odontolyticus. Histopathology of the debrided tissue showed chronic inflammation. As far as we are aware, there are no reports of actinomycosis in a flap involving the finger treated previously with a chest wall skin flap. The infection was probably dormant for many years before manifesting as a discharging sinus. Although the finger flap was bulky, it was not problematic until it started to have serous discharge. With a thorough debridement of all infected tissue, six weeks of antibiotic was adequate. Ciprofloxacin was prescribed based on discharge culture sensitivity. Metronidazole was added as actinomycosis is anaerobic. Response was prompt as patient was not immunocompromised. At follow-up six months post-surgery the finger had recovered with good function. If not for the discharging sinus, patient would probably have tolerated his bulky finger for the rest of his life.

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Extracellular Vesicles in the Synovial Joint: Is there a Role in the Pathophysiology of Osteoarthritis?

Esa A ; Connolly KD ; Williams R ; Archer CW

Malaysian Orthopaedic Journal.2019;13(1):1-7. doi:10.5704/MOJ.1903.012

The role of extracellular vesicles (EV) in osteoarthritis has become the focus of much research. These vesicles were isolated from several cell types found in synovial joint including chondrocytes and synovium. As articular cartilage is an avascular tissue surrounded by synovial fluid, it is believed that EV might play a crucial role in the homeostasis of cartilage and also could hold key information in the pathogenesis of osteoarthritis. This is thought to be due to activation of pro-inflammatory factors leading to a catabolic state and degradation of cartilage. In addition, due to the nature of articular cartilage lacking neuronal innervation, knowledge of EV can contribute to identification of novel biomarkers in this debilitating condition. This can be either directly isolated from aspirate of synovial fluid or from peripheral blood. Finally, EVs are known to shuttle important signalling molecules which can be utilised as unique modality in transferring therapeutic compounds in a cell free manner.

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Are Gap and Cast Indices Predictors of Efficacy of Reduction in Fractures of Both Bones of the Leg? A Cohort Study

Shalabh K ; Ajai S ; Vineet K ; Sabir A

Malaysian Orthopaedic Journal.2018;12(2):15-19. doi:10.5704/MOJ.1807.003

Introduction: Non-operative management has successfully been practised for long in diaphyseal fractures of both bones of the leg. This study attempts to establish an acceptability criteria for plaster cast in order to predict future loss of reduction and its adequacy. Materials and Methods: A total of forty subjects were included as per inclusion-exclusion criteria. Gap and cast indices were calculated in the immediate post reduction phase and at third week follow-up visit. Results: The mean values of gap and cast indices in the immediate post-reduction phase were 0.35±0.220 and 0.99±0.08 respectively and at the third week follow-up the mean value for both the parameters in those without loss of reduction were 1.11±0.50 and 1.03±0.09 respectively and in those with loss of reduction were 0.84±0.44 and 1.01±0.06 respectively. Conclusion: Gap and cast indices are not informative in assessing adequacy of reduction in diaphyseal fractures of both bones of the leg.

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