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Abstract

Combined Meeting of the th Malaysian Orthopaedic 46Association Annual General Meeting / Annual Scientific Meeting th ASEAN 10 Association Meeting 2016 Fundamentals In Orthopaedics – Back To Basics

Pre-Conference Day Conference Days 25th May 2016 26th to 28th May 2016

Persada International Convention Centre, Johor Bahru, .

www.moa-home.com

Abstract CD (Please click on the links below to view the respective categories of abstracts.)

Oral Presentations Abstracts

Poster Presentations Abstracts      (Click Here...)  Combined Meeting of the 46th Malaysian Orthopaedic Association Annual General Meeting / Annual Scientific Meeting & 10th ASEAN Arthroplasty Association Meeting 2016

   26th May 2016 (Thursday) - Lecture Hall MOA 1, Level 3 TIME TOPIC SPEAKER 0700 -1730 REGISTRATION COUNTER OPENS SUBIR SENGUPTA MEMORIAL LECTURE Chairperson Prof Dr Saw Aik 0830 - 0900 Prevention And Early Detection Of DDH - The Japanese SM 01 Prof Dr Makoto Kamegaya Experience OPENING CEREMONY 0900 - 1030 Orthopaedics At The Frontlines In A Changing Globalised World. SK 01 Roles And Responsibilities. Dato' Dr Ahmad Faizal Mohd Perdaus A View From A Humanitarian And Colleauge. 1030 - 1100 TEA BREAK & EXHIBIT VISIT SPORTS Dr Shamsul Iskandar Hussein Chairperson Dr Raymond Yeak Dieu Kiat Revision Anterior Cruciate Ligament Reconstruction: Analysis 1100 - 1112 SX 01 Of Causes Of Failures, Preoperative Clinical Evaluation And Dr Deepak V. Patel Planning, Surgical Technique, And Clinical Outcomes SLAP (Superior Labrum Anterior Posterior) Lesion Of The 1112 - 1124 SX 02 Shoulder: Classification, Evaluation, And Current Concepts Of Prof Dr Yoo Jae Chul Management Arthroscopic Surgery Of The Elbow: Indications Of Surgery, 1124 - 1136 SX 03 Dr Deepak V. Patel Operative Technique, Clinical Outcomes, And Complications Update In Rotator Cuff Surgery And Biological Enhancement Of 1136 - 1148 SX 04 Prof Dr Yoo Jae Chul Cuff Repair 1148 - 1155 Q & A Session All Speakers Above FREE PAPER PRESENTATIONS 1155 - 1202 FX 01 Review of Biomechanics Of A Good Golf Swing And Injuries Assoc Prof Dr Mohamed Razif Mohamed Ali Reverse Shoulder Arthroplasty (RSA) With Latissimus Dorsi 1202 - 1209 FX 02 Transfer For Humeral Head Osteonecrosis With External Dr Tan Kean Tee Rotation Pseudoparesis: A Case Report The Lever Sign Test: Testing The Sensitivity Via Diagnostic 1209 - 1216 FX 03 Dr Raymond Yeak Dieu Kiat The Outcome Of Multiligament Knee Injuries: The Hospital 1216 - 1223 FX 04 Dr Raymond Yeak Dieu Kiat Serdang Experience Complication Following Arthroscopic ACL Reconstruction - 1223 - 1230 FX 05 Dr Rushdi Isnin A 7 Years Follow Up With Special Emphasis On Arthrofibrosis MEDAPHARMA LUNCH SYMPOSIUM Chairperson Dato' Dr Lim Boon Ping 1230 - 1300 Prevention And Treatment Of Knee Osteoarthritis With Glucosamine Professor Jean-Yves Reginster Sulfate: From Clinical Studies To Real Life Fundamentals In Orthopaedics – Back To Basics

   26th May 2016 (Thursday) - Lecture Hall MOA 1, Level 3

1300 - 1400 LUNCH & EXHIBIT VISIT TIME TOPIC SPEAKER PRESIDENT'S FORUM Chairperson Assoc Prof Dr Abdul Halim Abd Rashid 1400 - 1425 SPF 01 Barefoot Running - Back To Basics Dr Robert Penafort 1425 - 1450 SPF 02 Orthopaedic Training In Malaysia - The Future Prof Dato' Dr Mohamad Abd Razak 1450 - 1515 SPF 03 Starting A New Specialty - My Personal Experience Prof Dr Zulmi Wan 1515 - 1530 Q & A Session All Speakers Above 1530 - 1600 TEA BREAK & EXHIBIT VISIT SPINE Chairperson Dr Mohd Hisam Muhamad Ariffin Where Is My Pain Coming From: The Pathogenesis Of 1600 - 1610 SS 01 Dato' Dr Fazir Mohamad Discogenic Back Pain 1610 - 1620 SS 02 The Role Of Interventional Radiologist Assoc Prof Dr Ahmad Sobri Muda 1620 - 1630 SS 03 My Preferred Fusion Technique In Discogenic Back Pain Dr Wong Chung Chek 1630 - 1640 SS 04 Lumbar Disc Replacement (LDR) Dr Ahmad Sabri Omar Video Assisted Thoracoscopic Decompression In Caries Spine 1640 - 1650 SS 05 Prof Dr Sudhir K. Kapoor Of Dorsal Area 1650 - 1700 SS 06 Tuberculosis Of The Spine Dr Shaharuddin Abdul Rhani Appropriate Choice Of Plate For Posterior - CT Study 1700 - 1710 SS 07 Dr Li Charles Churk Hang Of 122 Chinese Adult Subjects 1710 - 1730 Q & A Session All Speakers Above

1930 - Late PRESIDENT'S DINNER ( BY INVITATION ONLY ) ! Combined Meeting of the 46th Malaysian Orthopaedic Association Annual General Meeting / Annual Scientific Meeting & 10th ASEAN Arthroplasty Association Meeting 2016

   26th May 2016 (Thursday) - Lecture Hall MOA 2, Level 2 TIME TOPIC SPEAKER 0700 -1730 REGISTRATION COUNTER OPENS 0830 - 1030 Main Sessions In Lecture Hall MOA 1 1030 - 1100 TEA BREAK & EXHIBIT VISIT ORTHOPAEDIC RESEARCH Chairperson Dr Suzita Mohd Noor Recessive Osteogenesis Imperfecta Resulting From Mutation Of 1100 - 1120 SR 01 Asst Prof Dr Thomas J. Carney BMP1 And Insights From Modelling 1120 - 1130 SR 02 May The Fluorophores Be With You Dr Anwar Norazit 1130 - 1140 SR 03 Targeting Angiogenesis In Osteoarthritis Dr Dharmani Devi Murugan 1140 - 1150 SR 04 Osteoarthritic : The Maturity Paradox Assoc Prof Dr Ilyas Khan 1150 - 1200 SR 05 Infection Dr Thomas Fintan Moriarty Antibacterial Nanoparticles: Is It Potentially Useful For 1200 - 1210 SR 06 Prof Dr Tunku Kamarul Zaman Tunku Zainol Abidin Orthopaedic Implants Of The Future? Electroanalgesia For The Management Of Nociceptive And 1210 - 1220 SR 07 Prof Dr Marzida Mansor Neuropathic Pain 1220 - 1230 Q & A Session All Speakers Above 1230 - 1300 MEDAPHARMA LUNCH SYMPOSIUM IN LECTURE HALL MOA 1 1300 - 1400 LUNCH & EXHIBIT VISIT TRAUMA Chairperson Dr Khairul Nizam Rozali Antibiotic Coated Implants In The Prevention Of Implant Related 1400 - 1420 ST 01 Dr Thomas Fintan Moriarty Osteomyelitis 1420 - 1440 ST 02 Rationale Of LCP Selection In Tibial Plafond Fractures Dr Jamal Ashraf 1440 - 1502 Q & A Session All Speakers Above FREE PAPER PRESENTATIONS Minimally Invasive Plate Osteosynthesis Of Distal 1502 - 1509 FT 01 Fractures Versus Open Reduction And : A Dr Jade Ho Pei Yuik Retrospective Study Post Traumatic Osteomyelitis Of The Femur Or : An 1509 - 1516 FT 02 Evaluation Of The Clinical Outcome, Functional Outcome, And Dr Khairul Rizal Zayzan Quality Of Life Reemergence Of Double Plating In Bicondylar Tibial Plateau 1516 - 1523 FT 03 Fracture Fixation. A Retrospective 5 Year Review Of Tibial Dr Wong Yih Jiun Plateau Fracture Fixation Outcomes In Tertiary Hospital Beware The Deadly Thorn: A Three Year Review Of Necrotising 1523 - 1530 FT 04 Dr Timothy Cheng Fasciitis In The Palm Oil Town Of Lahad Datu 1530 - 1600 TEA BREAK & EXHIBIT VISIT ONCOLOGY FREE PAPER PRESENTATIONS Chairperson Dr Sa'adon Ibrahim The Recycling Of Autoclaved Autografts In Proximal Tibia And 1600 - 1607 FO 01 Dr Evelynn Tan Distal Femur Reconstruction: Case Series Ceftaroline Fosamil Impregnated Allograft To Minimize Infection 1607 - 1614 FO 02 Dr Lim Han Sim In Orthopaedic Oncology Reconstructive Surgery. Is It Possible? Outcome Of Skeletal Reconstruction Surgery In Metastatic Bone 1614 - 1621 FO 03 Dr Ikhwan Zuchri Tumors Evaluation Prognostic Factors And Survival Range In Patients 1621 - 1628 FO 04 Dr Mahmoud Faisal Abumarzouq With Metastatic Bone Disease Surgical Management Of Pelvic Tumor: 10 Years UMMC 1628 - 1635 FO 05 Dr Salim Hamood Al-Busaidi Experience 1635 - 1642 FO 06 Reconstruction In Sarcoma Prof Dr Wan Faisham Nu'man Wan Ismail

1930 - Late PRESIDENT’S DINNER ( BY INVITATION ONLY )

Fundamentals In Orthopaedics – Back To Basics "

   26th May 2016 (Thursday) - Lecture Hall MOA 3, Level 2 TIME TOPIC SPEAKER 0700 -1730 REGISTRATION COUNTER OPENS 0830 - 1030 Main Sessions In Lecture Hall MOA 1 1030 - 1100 TEA BREAK & EXHIBIT VISIT PAEDIATRICS Chairperson Dr Ferdhany Muhamad Effendi Paediatric Orthopaedic Training In ASEAN - Current And Future 1100 -1115 SP 01 Prof Dr Lee Eng Hin Challenges Challenges In Managing Congenital Talipes Equinovarus In 1115 -1130 SP 02 Dr Kamariah Nor Mohd Daud Malaysia 1130 - 1145 SP 03 Prophylactic Pinning In Slipped Capital Femoral Epiphyses Prof Dr Makoto Kamegaya Economic Impact Of Managing Late Presentation Of 1145 - 1200 SP 04 Dr Mohd Anuar Ramdhan Ibrahim Developmental Dysplasia Of Hip (DDH) 1200 - 1223 Q & A Session All Speakers Above FREE PAPER PRESENTATIONS 1223 - 1230 FP 01 Hip Spica Strength: A Comparison Between Two Techniques Dr Kwong Lee Wan 1230 - 1300 MEDAPHARMA LUNCH SYMPOSIUM IN LECTURE HALL MOA 1 1300 - 1400 LUNCH & EXHIBIT VISIT LLRS Dr Ramesh Naidu Chairperson Dr Nazari Ahmad Tarmuzi 1400 - 1412 SL 01 Management Of Traumatic Bone Loss Dr Suhael Ali Khan 1412- 1424 SL 02 Acute Correction For Limb Deformities Prof Dr Saw Aik 1424 - 1436 SL 03 Pilon Fractures: Current Update Dr Hemant K. Sharma 1436 - 1448 SL 04 Turning A New Leaf. Fidelity - 8D By Ilizarov Technique Prof Dr Md Mofakhkharul Bari 1448 - 1500 SL 05 Role Of Ilizarov Surgery In Infection Following Internal Fixation Dato' Dr Thirumal Manickam The Use Of Ring Fixators For Treatment Of Complications Of 1500 - 1512 SL 06 Asst Prof Dr Diarmuid Murphy Trauma 1512 - 1524 SL 07 TKR In Presence Of Deformity Dr Hemant K. Sharma 1524 -1530 Q & A Session All Speakers Above 1530 - 1600 TEA BREAK & EXHIBIT VISIT 1600 - 1730 MOA LEADERSHIP MEETING

1930 - Late PRESIDENT’S DINNER ( BY INVITATION ONLY ) # Combined Meeting of the 46th Malaysian Orthopaedic Association Annual General Meeting / Annual Scientific Meeting & 10th ASEAN Arthroplasty Association Meeting 2016

   26th May 2016 (Thursday) - Lecture Hall AAA, Level 2 TIME TOPIC SPEAKER 0700 -1730 REGISTRATION COUNTER OPENS 0830 - 1030 Main Sessions In Lecture Hall MOA 1 1030 - 1100 TEA BREAK & EXHIBIT VISIT THE FUNDAMENTALS Dr Jamal Azmi Mohamad Chairperson Dr Jose Antonio G. San Juan 1100 -1110 SA 01 Patient Selection And Preparation For Arthroplasty Dr Ahmad Hisham Abd Rashid 1110 - 1120 SA 02 Infection Prevention In Arthroplasty Dr Pruk Chaiyakit Thromboprophylaxis In Arthroplasty - Does One Size Fit All 1120 - 1130 SA 03 Asst Prof Dr Diarmuid Murphy Populations? 1130 - 1140 SA 04 Perioperative Pain Management Dr Jose Antonio G. San Juan 1140 - 1150 SA 05 Levels Of Evidence In Knee Arthroplasty Dr David Choon Siew Kit 1150 - 1200 SA 06 The Learning Curve: How I Improve My Outcome Assoc Prof Dr Christopher S. Mow 1200 - 1230 Q & A Session All Speakers Above 1230 - 1300 MEDAPHARMA LUNCH SYMPOSIUM IN LECTURE HALL MOA 1 1300 - 1400 LUNCH & EXHIBIT VISIT KNEE - PRIMARY TOTAL KNEE ARTHROPLASTY Dr G. Ruslan Nazaruddin Simanjuntak Chairperson Prof Dr Aree Tanavalee 1400 - 1410 SA 07 Knee Implant Choice: How Do I Decide Dr Sureshan Sivananthan 1410 - 1420 SA 08 Perioperative Blood Management In Total Knee Arthroplasty Dr Rizki Rahmadian 1420 - 1430 SA 09 Addressing The Varus Deformed Knee Prof Dr Aree Tanavalee 1430 - 1440 SA 10 Addressing The Valgus Deformed Knee Prof Dr Azhar Mahmood Merican 1440 - 1450 SA 11 Addressing Fixed Flexion And Recurvatum Deformities Assoc Prof Dr Wilson Wang 1450 - 1500 SA 12 Rehabilitation Protocols Pre And Post Total Knee Arthroplasty Dr Dilbert Arriesgado Monicit 1500 - 1530 Q & A Session All Speakers Above 1530 - 1600 TEA BREAK & EXHIBIT VISIT KNEE - COMPLEX PRIMARY TOTAL KNEE ARTHROPLASTY Dato’ Dr Badrul Shah Badaruddin Chairperson Assoc Prof Dr Lo Ngai Nung Tibial Plateau Fractures: Internal Fixation Vs Total Knee 1600 - 1610 SA 13 Dr Faesal Abdarrab Maodah Arthroplasty 1610 - 1620 SA 14 Managing Patella In Primary Total Knee Arthroplasty Dr Le Phuc 1620 - 1630 SA 15 When Do I Decide To Perform High Tibial (HTO) Dr Saw Khay-Yong 1630 - 1640 SA 16 When Do I Decide To Perform UKR Dr Srihatach Ngarmukos 1640 - 1650 SA 17 When Do I Do Patellofemoral Replacement? Assoc Prof Dr Lo Ngai Nung 1650 - 1730 Q & A Session All Speakers Above

1930 - Late PRESIDENT’S DINNER ( BY INVITATION ONLY ) Fundamentals In Orthopaedics – Back To Basics $

  27th May 2016 (Friday) - Lecture Hall MOA 1, Level 3 TIME TOPIC SPEAKER 0700 -1730 REGISTRATION COUNTER OPENS 0800 - 0830 PLENARY 1 Chairperson Dr Jamal Azmi Mohamad SPL 01 How I Face The Complications In Total Hip Arthroplasty? Prof Dr Yoon Teak Rim MAHMOOD MERICAN BEST MASTERS THESIS JUDGING Chairperson Asst Prof Dr Kamarul Ariffin Khalid Prof Dr Makoto Kamegaya Judges Dr Thomas Fintan Moriarty Prof Dr Edward H.M. Wang Motor Endplate And Distal Nerve Stump Morphology As 0830 - 0848 MMA 01 Prognostic Factors For The Outcome Of Neurotisation In Dr Khoo Saw Sian Patients With Brachial Plexus Injury Effects Of Exercise Training On The Cartilage Of Young & Older 0848 - 0906 MMA 02 Dr Tan Kean Tee Rats: A Preliminary Study A Cadaveric Study: Mechanical Analysis Of Five Methods Of 0906 - 0924 MMA 03 Dr Low Weng Kong Tibiotalar Using Screw Fixation Technique Comparison Of Anxiety Reaction In Children During Cast 0924 - 0942 MMA 04 Dr Nurul Aishah Mohamed Zain Removal Using Oscillating Saw Versus Cast Shear Role Of Platelet Rich Concentration In Enhancing The Potential 0942 - 1000 MMA 05 Dr Mohamed Faizal Abdul Manan Of Mesenchymal Stem Cells In Cartilage Regeneration In Vivo 1000 - 1030 TEA BREAK & EXHIBIT VISIT SUBIR SENGUPTA BEST PUBLISHED CLINICAL PAPER AWARD PRESENTATION Chairperson Assoc Prof Dr Abdul Halim Abd Rashid Peri-Operative Outcome In Posterior For 1030 - 1045 FSS 01 Adolescent Idiopathic Scoliosis: A Prospective Study Comparing Assoc Prof Dr Chris Chan Yin Wei Single Versus Two Attending Surgeons Strategy P.BALASUBRAMANIAM BEST PUBLISHED TRANSLATIONAL (NON CLINICAL) PAPER AWARD PRESENTATION Chairperson Assoc Prof Dr Abdul Halim Abd Rashid Comparison Between Percutaneous Fluoroscopic-Guided And 1045 - 1100 FPB 01 Conventional Open Pedicle Screw Placement Techniques For Prof Dr Kwan Mun Keong The Thoracic Spine: A Safety Evaluation In Human Cadavers

continue on next page % Combined Meeting of the 46th Malaysian Orthopaedic Association Annual General Meeting / Annual Scientific Meeting & 10th ASEAN Arthroplasty Association Meeting 2016

  27th May 2016 (Friday) - Lecture Hall MOA 1, Level 3 TIME TOPIC SPEAKER BEST BASIC SCIENCE POSTER AWARD JUDGING Chairperson Assoc Prof Dr Azura Mansor Prof Dr Yoon Taek Rim Judges Prof Dr John Fairclough Asst Prof Dr Thomas J. Carney Cooling Material Composite For Cost-Effective Transportation Of 1100 - 1112 BBS 01 Saravana Ramalingam Bone Allografts Accuracy Of Ottawa Ankle Rule For Diagnosis Of Ankle 1112 - 1124 BBS 02 Dr Syed Jeffrey Syed Ahmad Kabeer Fractures In Acute Ankle Injuries Caffeic Acid Phenethyl Ester Significantly Inhibits Bone 1124 - 1136 BBS 03 Resorption In A Murine Calvarial Model Of Polyethylene Dr Muhamad Syahrul Fitri Particle-Induced Peri-Prosthetic Osteolysis The Role Of Stretch-Activated Calcium Channel On The 1136 - 1148 BBS 04 Tenogenic Differentiation Of Human Mesenchymal Stromal Nam Hui Yin Cells In Vitro Incorporation Of PDGF-BB In 3D Coragraft For Differentiation Of 1148 - 1200 BBS 05 Saktiswaren Mohan Mesenchymal Stromal Cells In Vitro PFIZER LUNCH SYMPOSIUM Chairperson TBC 1200 - 1230 Understanding Post Surgical Pain Dr Jose Antonio G. San Juan 1230 - 1400 LUNCH & EXHIBIT VISIT CURRENT ISSUES IN MEDICAL PUBLISHING Chairperson Prof Dr Saw Aik Submitting Manuscripts 1400 - 1412 SPJ 01 Submitting Manuscripts - To Which Journal Should I Submit? Prof Dato' Dr Tunku Sara Tunku Ahmad Yahaya 1412 - 1424 SPJ 02 What Are The Common Problems With Language? Prof Dato' Dr Abdul Hamid Abdul Kadir 1424 - 1436 SPJ 03 Illustrations In Medical Writing Prof Dr Sharaf Ibrahim Challenges In Medical Publishing 1436 - 1448 SPJ 04 Open Access Journals Prof Dr Lee Eng Hin 1448 - 1500 SPJ 05 Predatory Journals And Publishers Prof Dr Saw Aik 1500 - 1512 SPJ 06 How To Become A Good Peer Reviewer Prof Dr Saw Aik 1512 - 1530 Q & A Session All Speakers Above 1530 - 1600 TEA BREAK & EXHIBIT VISIT 1600 - 1730 MOA ANNUAL GENERAL MEETING IN LECTURE HALL MOA 2

1930 - Late CONFERENCE DINNER Fundamentals In Orthopaedics – Back To Basics &

  27th May 2016 (Friday) - Lecture Hall MOA 2, Level 2 TIME TOPIC SPEAKER 0700 -1730 REGISTRATION COUNTER OPENS 0830 - 1030 Main Sessions In Lecture Hall MOA 1 1030 - 1100 TEA BREAK & EXHIBIT VISIT ONCOLOGY Chairperson Dr Lim Chiao Yee Updates And Histopathological Approaches In Diagnosis Of Soft 1030 - 1038 SO 01 Dr Noraini Mohd Dusa Tissue Sarcoma New Techniques In Achieving Better Surgical Margins In Soft 1038 - 1046 SO 02 Prof Dr Vivek Ajit Singh Tissue Sarcoma Surgery Resection Of Soft Tissue Sarcoma: Planning, Margins Versus 1046 - 1054 SO 03 Prof Dr Zulmi Wan Functions Risk Factors For Recurrence And Mortality In Adult Soft Tissue 1054 - 1102 SO 04 Prof Dr Edward H. M. Wang Sarcomas Of The Extremities Latissimus Dorsi Motorised Muscle Transfer For Reconstruction 1102 - 1110 SO 05 Of Quadriceps Femoris Following Oncological Resection Of Prof Dr Wan Faisham Nu'man Wan Ismail Sarcoma 1110 - 1118 SO 06 Step Closures In Soft Tissue Tumour Surgery Assoc Prof Dr Wan Azman Wan Sulaiman 1118 - 1126 SO 07 Principles And Advances In Radiotherapy And Brachytherapy Prof Dr Biswa Mohan Biswal Chemotherapy And Targeted Therapy In Soft Tissue Sarcomas: 1126 - 1134 SO 08 Assoc Prof Dr Marniza Saad Can We Improve Survival? 1134 - 1142 SO 09 Managing Fungating Wounds Dr Chye Ping Ching 1142 - 1200 Q & A Session All Speakers Above 1200 - 1230 PFIZER LUNCH SYMPOSIUM IN LECTURE HALL MOA 1 1230 - 1400 LUNCH & EXHIBIT VISIT FOOT & ANKLE Chairperson Assoc Prof Dr Mohd Yazid Bajuri 1400 - 1412 SF 01 Overuse Injuries Of The Foot Dr Mohd Asni Alias 1412- 1424 SF 02 Approach To Medial Foot Pain Assoc Prof Dr Aminudin Che Ahmad 1424 - 1436 SF 03 Management Of Metatarsalgia Dr Mohana Rao 1436 - 1448 SF 04 Management Of Toe Deformities Dr Low Tze Choong 1448 - 1500 SF 05 Neuropathic Foot Assessment Dr Edewet Anak Daun 1500 - 1512 SF 06 Foot And Ankle Amputation Update Dr Mohammad Izani Ibrahim 1512 - 1530 Q & A Session All Speakers Above 1530 - 1600 TEA BREAK & EXHIBIT VISIT 1600 - 1730 MOA ANNUAL GENERAL MEETING

1930 - Late CONFERENCE DINNER IN LECTURE HALL MOA 1 ' Combined Meeting of the 46th Malaysian Orthopaedic Association Annual General Meeting / Annual Scientific Meeting & 10th ASEAN Arthroplasty Association Meeting 2016

  27th May 2016 (Friday) - Lecture Hall MOA 3, Level 2 TIME TOPIC SPEAKER 0700 -1730 REGISTRATION COUNTER OPENS 0830 - 1030 Main Sessions In Lecture Hall MOA 1 1030 - 1100 TEA BREAK & EXHIBIT VISIT HAND Chairperson Assoc Prof Dr Jamari Sapuan 1030 - 1042 SH 01 Usage Of Adrenaline In Assoc Prof Dr Shalimar Abdullah 1042 - 1054 SH 02 A Common Sense Approach To Upper Limb Infection Prof Dato' Dr Tunku Sara Tunku Ahmad Yahaya 1054 - 1106 SH 03 Plaster Of Paris In Hand Practice Prof Dr Manohar Arumugam Management Of Complex Regional Pain Syndrome Of The 1106 - 1118 SH 04 Dr Lai Hou Yee Upper Limb 1118 - 1139 Q & A Session All Speakers Above FREE PAPER PRESENTATIONS Use Of Computed Tomography In Determining The Occurrence 1139 - 1146 FH 01 Of Dorsal And Intra-Articular Screw Penetration In Volar Locking Dr Diong Teik Wei Plate Osteosynthesis Of Distal Radius Fracture Comparison Between Usage Of Sponge Foam And Orthoban As 1146 - 1153 FH 02 Undercast Padding In The Treatment Of Distal Radius Fracture Dr Joanne Ngim Hui Ling With Plaster Of Paris Ophalmic Scalpel The Sungai Buloh Sword For Percutaneous 1153 - 1200 FH 03 Dr Nishand Guruseelan Release Of Trigger Finger 1200 - 1230 PFIZER LUNCH SYMPOSIUM IN LECTURE HALL MOA 1 1230 - 1400 LUNCH & EXHIBIT VISIT OSTEOPOROSIS Chairperson Dato' Dr Lim Boon Ping 1400 - 1405 CHAIRMAN'S INTRODUCTION Bone Failure: Fragility Fractures & Its Implication For 1405 - 1430 SOS 01 Prof Dr Chan Siew Pheng Subsequent Mortality 1430 - 1455 SOS 02 Osteoporosis Treatment: Does Benefit Outweigh The Risk? Dr Hew Fen Lee 1455 - 1520 SOS 03 What's Next After A Fragility Fracture Assoc Prof Dr Alexander Tan Tong Boon 1520 - 1530 Q & A Session All Speakers Above 1530 - 1600 TEA BREAK & EXHIBIT VISIT PARAMEDIC Chairperson Raja Peramal 1600 - 1645 SPA 01 Universal Portable Traction Device (UPTD) Dr Tejinderpal Singh Bhullar 1645 - 1730 SPA 02 Bone Banking: What Is It All About Rajendran Krishnan

1930 - Late CONFERENCE DINNER IN LECTURE HALL MOA 1 Fundamentals In Orthopaedics – Back To Basics

  27th May 2016 (Friday) - Lecture Hall AAA, Level 2 TIME TOPIC SPEAKER 0700 -1730 REGISTRATION COUNTER OPENS Main Sessions In Lecture Hall MOA 1 KNEE - REVISION TOTAL KNEE ARTHROPLASTY 0800 -0830 Dato' Sri Dr Zulkharnain Ismail Chairperson Dr Lai Choon Hin 0830 - 0840 SA 18 Addressing Bone Loss: Diagnostic And Management Dr Karina E. M. Besinga 0840 - 0850 SA 19 Instability After Total Knee Arthroplasty Assoc Prof Dr Nor Hamdan Mohamad Yahaya 0850 - 0900 SA 20 The Painful Total Knee Arthroplasty Dr Lai Choon Hin 0900 - 0910 SA 21 Help, My Knee Is Infected! Prof Dr Thanainit Chotanaphuti 0910 - 0920 SA 22 The Stiff Knee After Total Knee Arthroplasty Dr Herminio R. Valenzuela Management Of Peri-Implant Fractures Around A Total Knee 0920 - 0930 SA 23 Dr Jamal Ashraf Arthroplasty 0930 - 1000 Q & A Session All Speakers Above 1000 - 1030 TEA BREAK & EXHIBIT VISIT HIP - PRIMARY TOTAL HIP ARTHROPLASTY Prof Dr Azhar Mahmood Merican Chairperson Dr Thana Turajane 1030 - 1040 SA 24 Biomechanics Of Hip Arthroplasty Dr Charlee Sumettavanich 1040 - 1050 SA 25 How Do I Decide On My Total Implants Dr Shaifuzain Ab Rahman 1050 - 1100 SA 26 Surgical Approaches To The Hip Dr Mohammad Zaim Chilmi 1100 - 1110 SA 27 Pre-Operative Templating For Total Hip Arthroplasty Dr Marcelino T. Cadag 1110 - 1120 SA 28 NOF Fractures: Hemiarthroplasty Or Total Hip Arthroplasty? Dr Mark Chong Seng Ye 1120 - 1130 SA 29 Myths Or Fact: Do's and Dont’s Of Total Hip Arthroplasty Dr Thana Turajane 1130 - 1140 SA 30 Recurrent Hip Dislocation Post Total Hip Arthroplasty Dr Viroj Larbpaiboonpong 1140 - 1200 Q & A Session All Speakers Above 1200 - 1230 PFIZER LUNCH SYMPOSIUM IN LECTURE HALL MOA 1 1230 - 1400 LUNCH & EXHIBIT VISIT HIP: COMPLEX PRIMARY TOTAL HIP ARTHROPLASTY & ADVANCES IN TOTAL HIP ARTHROPLASTY Dr David Choon Siew Kit Chairperson Asst Prof Dr Pornpavit Sriphirom 1400 - 1410 SA 31 Total Hip Arthroplasty For Dysplastic Hips: Management Of LLD Dr Lai Choon Hin Total Hip Arthroplasty For Dysplastic Hips: Determining Cup 1410 - 1420 SA 32 Prof Dr Azhar Mahmood Merican Position And Femoral Version 1420 - 1430 SA 33 Total Hip Arthroplasty Following Acetabular Fractures Dr Deejay Pacheco Osteonecrosis Of The Femoral Head: How To Preserve The 1430 - 1440 SA 34 Prof Dr Yoon Taek Rim Head? 1440 - 1450 SA 35 Direct Anterior Approach Dr G. Ruslan Nazaruddin Simanjuntak 1450 - 1500 SA 36 Computer Assisted: Navigation & PSI In Total Hip Arthroplasty Asst Prof Dr Pornpavit Sriphirom 1500 - 1530 Q & A Session All Speakers Above 1530 - 1600 TEA BREAK & EXHIBIT VISIT continue on next page  Combined Meeting of the 46th Malaysian Orthopaedic Association Annual General Meeting / Annual Scientific Meeting & 10th ASEAN Arthroplasty Association Meeting 2016

  27th May 2016 (Friday) - Lecture Hall AAA, Level 2 TIME TOPIC SPEAKER AAA FREE PAPER PRESENTATION Dr Mohd Fairuz Suhaimi Chairperson Dr Ahmad Hisham Abd Rashid Impact Factor In Tissue Tension Of Extension And Flexion Gap 1600 - 1607 FA 01 Balance In Computer Assisted Surgery Total Dr Bernard Prakash Devadasan (CAS TKR) Permanent Mobile Cement Spacer In Octagenarians With 1607 - 1614 FA 02 Dr Bernard Prakash Devadasan Infected Total Knee Replacement-Innovative Technique Fretting Corrosion At Modular Taper Junction: What About 1614 - 1621 FA 03 Dr Martin Zimmermann Ceramic Femoral Heads? Periprosthetic Infection (PJI): Does The Bearing Sufrace 1621 - 1628 FA 04 Dr Martin Zimmermann Play A Role? The Accuracy And Reliability Of A Knee Radiographic Series 1628 - 1635 FA 05 In Predicting The Suitability Of UKA In Patients With Knee Dr Muhammad Zaid Ahmad Osteoarthritis Femoral Neck Fractures: The Paradigm Shift Towards Total Hip 1635 - 1642 FA 06 Arthroplasty? A 5 Year Retrospective Review Of Local Surgical Dr Ahmad Fauzey Kassim Trends And Outcomes In Two Tertiary Hospitals Total Hip Replacement Acetabular Posterior Superior Screw: 1642 - 1649 FA 07 How Long Do You Need It? A 5 year Retrospective Of How Long Dr Sanjiv Rampal Posterior Superior Screw Used In Tertiary Hospital A Prospective Comparative Study Of Functional Outcome Of 1649 - 1656 FA 08 Total Knee Arthroplasty (TKA) For Primary Osteoarthritis In Dr Tan Chin Siong Patients Aged Less Than 60 Years 1656 - 1703 FA 09 Reducing Blood Loss In Total Knee Replacement Dr Wong Tung Sing Measurement Of Femoral Anteversion And Its Relation To 1703 - 1710 FA 10 Dr Zaim Thajudeen Lesser Trochanter And Linea Aspera; A 3D CT Study

1930 - Late CONFERENCE DINNER IN LECTURE HALL MOA 1 Fundamentals In Orthopaedics – Back To Basics

   28th May 2016 (Saturday) - Lecture Hall MOA 1, Level 3 TIME TOPIC SPEAKER 0700 -1730 REGISTRATION COUNTER OPENS PLENARY 2 Chairperson Dato' Dr Badrul Shah Badaruddin 0800 - 0830 Prevention Of Perioperative Infection: Role Of Evidence-Based SPL 02 Prof Dr Charles E. Edmiston Practices To Improve Patient Outcomes In Total Joint Surgery PLENARY 3 0830 - 0900 Chairperson Prof Dr Tunku Kamarul Zaman Tunku Zainol Abidin SPL 03 Biofilm And Implant Related Infection: How To Win The Battle Dr Thomas Fintan Moriarty DIABETIC FOOT - ROLE OF ORTHOPAEDIC SURGEON Chairperson Dr Mohammad Anwar Hau Abdullah 0900 - 0910 Pathophysiology, Clinical And Classification of Diabetic Foot Dr Mohammad Anwar Hau Abdullah 0910 - 0920 Foot At Risk - Screening And Examination Assoc Prof Dr Aminudin Che Ahmad 0920 - 0930 Infected Foot Dr Mohd Asni Alias 0930 - 0940 Critical Limb Ischemia In Diabetic Foot: Role Of Interventional Radiologist Assoc Prof Dr Rozman Zakaria 0940 - 0950 Charcot Foot Assoc Prof Dr Mohd Yazid Bajuri 0950 - 1000 Reconstructive Challenges In Diabetic Foot Assoc Prof Dr Wan Azman Wan Sulaiman 1000 - 1010 Major Amputation - Indication, Risk And Prognosis Dr Mohammad Anwar Hau Abdullah 1010 - 1030 Q & A Session All Speakers Above 1030 - 1100 TEA BREAK & EXHIBIT VISIT HISTORY TAKING AND EXAMINATION TECHNIQUE Chairperson Assoc Prof Dr Mohamed Razif Mohamed Ali 1100 - 1110 Clinical - What To Ask And How I Examine The Degenerative Shoulder Assoc Prof Dr Mohamed Razif Mohamed Ali 1110 - 1120 Clinical - What To Ask And How I Examine The Spine Prof Dr Mohd Imran Yusof 1120 - 1130 Clinical - What To Ask And How I Examine The Hip Dr Shahrul Hisham Sulaiman 1130 - 1140 Clinical - What To Ask And How I Examine The Knee For Sport Injuries Dr Shamsul Iskandar Hussein 1140 - 1150 Clinical - What To Ask And How I Examine The Malignant Tumor Prof Dr Zulmi Wan 1150 - 1157 Concise Approach To How I Examine For Shoulder Instability Dr Hishamudin Masdar 1157 - 1204 Concise Approach To How I Examine For Spinal Deformity Dato’ Dr Azmi Baharudin 1204 - 1211 Concise Approach To How I Examine For Brachial Plexus Assoc Prof Dr Jamari Sapuan 1211 - 1218 Concise Approach To How I Examine For Cerebral Palsy Assoc Prof Dr Mohd Shukrimi Awang 1218 - 1225 General Evaluation Of Trauma Patients Dato' Dr Abdul Rauf Hj Ahmad 1225 - 1230 Q & A Session All Speakers Above

continue on next page ! Combined Meeting of the 46th Malaysian Orthopaedic Association Annual General Meeting / Annual Scientific Meeting & 10th ASEAN Arthroplasty Association Meeting 2016

   28th May 2016 (Saturday) - Lecture Hall MOA 1, Level 3 TIME TOPIC SPEAKER 1230 - 1300 MUNDIPHARMA LUNCH SYMPOSIUM Chairperson Dato’ Dr Azmi Baharudin Chronic Pain Control: What’s Adequate And Appropriate Dr Joseph Pergolizzi 1300 - 1400 LUNCH & EXHIBIT VISIT SURGICAL APPROACH - BASIC STEPS IN ORTHOPAEDIC SURGERY Chairperson Prof Dr Wan Faisham Nu’man Wan Ismail 1400 - 1409 Deltopectoral Approach For Bankart Lesion Datuk Dr Mohd Asri Abd Ghapar 1409 - 1418 Exploration Radial Nerve And Lower 3rd Humerus Fracture Assoc Prof Dr Jamari Sapuan 1418 - 1427 Chevron Osteotomy Intercondylar Humerus Approach Dr Suhaeb Abdulrazzaq Mahmod 1427 - 1436 Radial Head Fracture Prof Dr Wan Faisham Nu'man Wan Ismail 1436 - 1445 Zone II Flexor Tendon Injuries - How To Optimize Outcome? Assoc Prof Dr Abdul Nawfar Saudagatullah 1445 - 1454 - Tips And Tricks Dato’ Dr Azmi Baharudin 1454 - 1503 Kocher-Langenbeck Approach To The Acetabulum Dato' Dr Abdul Rauf Hj Ahmad 1503 - 1512 Neck Of Femur Fracture Prof Dr Mohammad Hassan Shukur 1512 - 1521 Gastrocnemius Flap Prof Dr Zulmi Wan 1521 - 1530 Q & A Session All Speakers Above 1530 - 1600 TEA BREAK & EXHIBIT VISIT BACK TO BASICS IN ORTHOPAEDICS Chairperson Dr Mohamad Yazid Din 1600 - 1609 Prophylactic Antibiotics Dr Mohamad Yazid Din 1609 - 1618 Damage Control In Orthopaedic Trauma Prof Dr Mohammad Hassan Shukur 1618 - 1627 Open Fracture Tibia "Principle And Update" Dato' Dr Abdul Rauf Hj Ahmad 1627 - 1636 Metastases 'Pathophysiology And Principle Of Treatment' Assoc Prof Dr Azura Mansor 1636 - 1645 Spinal Stenosis 'Evaluation And Treatment' Dato’ Dr Azmi Baharudin 1645 - 1654 Thoraco Lumbar Fracture Principle Of Treatment Prof Dr Mohd Imran Yusof 1654 - 1703 Evaluation Of Chronic Shoulder Pain Assoc Prof Dr Mohamed Razif Mohamed Ali 1703 - 1712 Angular And Rotational Deformity In Children Assoc Prof Dr Mohd Shukrimi Awang 1712 - 1721 Ankle Instability Assoc Prof Dr Aminudin Che Ahmad 1721 - 1730 Q & A Session All Speakers Above CLOSING CEREMONY Fundamentals In Orthopaedics – Back To Basics "

   28th May 2016 (Saturday) - Lecture Hall MOA 2, Level 2 TIME TOPIC SPEAKER 0700 -1730 REGISTRATION COUNTER OPENS 0800 -0830 Main Sessions In Lecture Hall MOA 1 HUMANITARIAN Chairperson Dr Ferdhany Muhamad Effendi 0900 - 0920 SHU 01 Volunteering: How To Help Responsibly Assoc Prof Dr Shalimar Abdullah 0920 - 0940 SHU 02 Humanitarian: Floods 2014 Dr Nor Faissal Yasin 0940 - 1000 SHU 03 Practicing Orthopaedics Outside Your Comfort Zone Dr Mohd Ikraam Ibrahim The Nepal Earthquake 2015, MERCY Malaysia’s Emergency 1000 - 1020 SHU 04 Dr Mohamed Ashraff Mohd Ariff Response 1020 - 1030 Q & A Session All Speakers Above 1030 - 1100 TEA BREAK & EXHIBIT VISIT PHYSIOTHERAPY MANAGEMENT OF ORTHOPAEDIC CONDITIONS Chairperson Thomas Ng Chao Feng 1100 - 1230 SPH 01 Physiotherapy Management Of Orthopaedic Conditions Nur Hidayah Ong Abdullah 1230 - 1300 MUNDIPHARMA LUNCH SYMPOSIUM IN LECTURE HALL MOA 1 1300 - 1400 LUNCH & EXHIBIT VISIT THE BASICS PRINCIPLES OF MANIPULATIVE & JOINT MOBILIZATION THERAPY Chairperson Mustaffa Sultan The Basic Principles Of Manipulative & Joint Mobilization 1400 - 1530 SPH 02 Thomas Ng Chao Feng Therapy Q & A Session 1530 - 1600 TEA BREAK & EXHIBIT VISIT

CLOSING CEREMONY IN LECTURE HALL MOA 1 # Combined Meeting of the 46th Malaysian Orthopaedic Association Annual General Meeting / Annual Scientific Meeting & 10th ASEAN Arthroplasty Association Meeting 2016

   28th May 2016 (Saturday) - Lecture Hall AAA, Level 2

TIME TOPIC SPEAKER 0700 -1730 REGISTRATION COUNTER OPENS 0800 -0830 Main Sessions In Lecture Hall MOA 1 HIP : REVISION TOTAL HIP ARTHROPLASTY Dr Jamal Azmi Mohamad Chairperson Assoc Prof Dr Christopher S. Mow 0900 - 0910 SA 37 Bone Loss In Revision Total Hip Arthroplasty Dr Jonathan Flordelis Management Of Periprosthetic Fracture After Total Hip 0910 - 0920 SA 38 Dr Mohammad Zaim Chilmi Arthroplasty 0920 - 0930 SA 39 Pain After Total Hip Arthroplasty Assoc Prof Dr Wilson Wang How To Avoid Limb Length Discrepancy After Total Hip 0930 - 0940 SA 40 Dr Ahmad Hisham Abd Rashid Arthroplasty 0940 - 0950 SA 41 Infection After Total Hip Arthroplasty Dr Cok Gde Oka Dharmayuda Osseointegration In Uncemented Total Hip Arthroplasty: A 5 0950 - 1000 SA 42 Prof Dr M. Amjad Hossain Years Follow Up 1000 - 1030 Q & A Session All Speakers Above 1030 - 1100 TEA BREAK & EXHIBIT VISIT BASIC SCIENCE OF THE HIP AND KNEE Dato' Dr Badrul Shah Badaruddin Chairperson Dr G. Ruslan Nazaruddin Simanjuntak 1100 - 1110 SA 43 Biomechanics Of Total Knee Arthroplasty Dr Mohd Fairuz Suhaimi 1110 - 1120 SA 44 Bearing Materials Used In Total Knee Arthroplasty Prof Dr Ahmad Hafiz Zulkifly 1120 - 1130 SA 45 Bearing Material Used In Total Hip Arthroplasty Dr Ariyanto Bawono 1130 - 1140 SA 46 Stable Fixation In Total Hip Arthroplasty Assoc Prof Dr Christopher S. Mow 1140 - 1230 Q & A Session All Speakers Above MUNDIPHARMA LUNCH SYMPOSIUM IN LECTURE HALL MOA 1 1300 - 1400 LUNCH & EXHIBIT VISIT

CLOSING CEREMONY IN LECTURE HALL MOA 1 SM01 Prevention And Early Detection Of DDH - The Japanese Experience -

Makoto Kamegaya Chiba Child & Adult Orthopaedic Clinic, Chiba, Japan

I would like to dedicate this lecture to Prof Subir Sengupta. The incidence of DDH in Japan used to be more than 1%. It was higher than in other Asian countries. Since DDH prevention the campaign launched in the middle of 1970s, the incidence has been dramatically reduced to around 0.1%. During the same period, several screening systems were introduced for early diagnosis and treatment. Our Chiba group (Matsudo scoring system) showed 6 clinical criteria which were each assigned some points according to their importance. Babies with more than 2 total points needed radiological examination. In early 1990, ultrasound screening was adopted for early detection of DDH. Since then, it has prevalently been used for the screening. However, recent reports found that the effect of ultrasound screening in reducing the prevalence of late DDH was at best marginal, and that universal ultrasound screening was not necessary, but recommended selective ultrasound screening for neonates with abnormal or suspicious clinical findings. Therefore, we have been consistently performing ultrasound examination in selective cases, based on clinical examination, which scored more than 2 points, instead of radiological examination. Even though this has been our group practice, we and other Japanese Pediatric Orthopaedic Surgeons who use general ultrasound screening have reported more cases of late diagnosed DDH in the past 10 years. This is likely due to an overall decline in awareness of DDH prevention, insufficient instruction for the clinical examiners, and insufficient education and information of DDH for parents. Now, we instruct general Orthopaedic doctors, post-natal nurses, obstetricians, pediatricians and babies’ families to understand how to prevent and to screen DDH for early detection using leaflets, in which the details of clinical evaluation are explained. Proper clinical evaluation based on the proper instruction will create appropriate selective groups for further ultrasound examination. This should reduce the rates of splintage and late detection of DDH.

SK01 Orthopaedics At The Frontlines In A Changing Globalised World. Roles And Responsibilities. A View From A Humanitarian And Colleague.

Ahmad Faizal Mohd Perdaus MERCY Malaysia

Mankind has never known such a world since the dawn of recorded history. The world is globalised, physical geographical boundaries are blurred, human beings are more connected and surrounded by technology than ever before, and in many ways there have been more advances in every field of human endeavour in the last century and a half than there had been in the preceding three thousand years. At the same time the world is faced with more challenges in every aspect.

Every great development, and every great advance in technology has been accompanied by more risks and adverse effects. There is more inequality in the world today although there is more wealth to go around. Although there has not been a global war and singular major conflict for the last 70 years, there have been many smaller conflicts of which some have lasted longer than either the First or Second World Wars. More people are displaced throughout the world now than at any other time since the end of the Second World War. Natural disasters have become more severe, more frequent and have had far more devastating impact as the areas that have been affected tend to be more developed and populated than they were before. Natural and man-made phenomena combine to accelerate and aggravate the impact of climate change, making the world less secure.

All is not lost though, as advances that benefit everyone have also taken place. Not least in the overall field of medicine and healing as well as healthcare in general. Specifically, the field of orthopaedics has grown and advanced by leaps and bounds over the last half century, There is more knowledge, more skill sets, more methods and techniques available. These advances have also been varied and diverse, ranging from new surgical techniques to new fixation modalities to the use of digital technology and 3-D printing. There are also new frontiers in robotics and bionics, with even newer Nano-technology coming to the fore.

Being both biological and yet mechanical in nature, orthopaedics has a lot of room for interaction between different technologies, granting it pride of place among medical and surgical specialties in today's inter-connected world. In humanitarian action, which is becoming increasingly important as the world grapples with all its problems, both man-made and natural, orthopaedics surgery has traditionally been involved in emergency medical relief. However, the last few years has seen more room for more active and deeper roles for the orthopaedic surgeon, both in trauma care as well as rehabilitation and specific areas such as orthotics and prosthetics. SX01 Revision Anterior Cruciate Ligament Reconstruction: Analysis Of Causes Of Failures, Preoperative Clinical Evaluation And Planning, Surgical Technique, And Clinical Outcomes

Deepak Patel Seton Hall University, South Orange, New Jersey, U.S.A.

Revision of an anterior cruciate ligament (ACL) reconstruction is a complex clinical problem. Causes of primary ACL graft failure include error in the surgical technique (femoral and/or tibial tunnel malposition); recurrent trauma causing injury to the primary ACL graft; failure to diagnose and treat concomitant meniscal root detachment; failure to recognize and treat associated ligamentous injury (such as posterolateral corner, PCL, or MCL injury); failure to identify and correct the coexisting varus or valgus malalignment; and failure to recognize presence of an increased posterior tibial slope. Factors such as decreased hamstring autograft size (8 mm in diameter or less), decreased patient age (under 20 years), and use of allografts may all increase the risk of early revision after ACL reconstruction. Preoperative counseling should be undertaken. Patients should not have unrealistic expectations regarding the functional outcome of their knees after revision ACL surgery. The primary goal of revision ACL reconstruction is to improve knee stability, joint function, activity level, and patient satisfaction. A detailed history should be obtained and a meticulous physical examination should be performed. The preoperative radiographic work-up should include good-quality plain radiographs, a CT scan, and MRI of the knee. Preoperative planning should address the issues of graft selection, skin incision(s) placement, removal of the previously failed ACL graft (if necessary), removal of the preexisting hardware (if required), anatomic tunnel placement, method of graft fixation, correction of coexisting varus or valgus malalignment, correction of increased posterior tibial slope, and treatment of associated, symptomatic ligamentous laxity. The femoral and tibial tunnel bone stock should be carefully evaluated and if required, autogenous of the widened, osteolytic osseous tunnels should be undertaken to restore the depleted bone stock. Revision ACL reconstructions can be performed using autogenous grafts or allografts. Graft selection should be made on a case-by-case basis. There is a general consensus that the outcomes for revision ACL reconstruction are less satisfactory compared to those of the primary reconstruction.

Ction.

SX02 SLAP (Superior Labrum Anterior Posterior) Lesion Of The Shoulder: Classification, Evaluation, And Current Concepts Of Management

Jae Chul Yoo Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Recently, as increasing the population of athletes involved overhead throwing, patients who underwent injuries to glenoid labrums are being common. In addition, superior labral anterior posterior (SLAP) lesions can cause significant shoulder pain and dysfunction, understanding SLAP lesions is important for physicians who practice in sports medicine. Andrews et al. described anterosuperior labral tears in throwing athletes with painful shoulders for the first time. Snyder et al. reviewed 700 shoulders with arthroscopy and coined the term ‘‘SLAP’’ in the literature primarily. Although the true incidence of SLAP lesions is unknown, several authors have reported rates over a range of 6% to 26% in the general population undergoing shoulder arthroscopic surgery. These SLAP lesions can be associated with other shoulder injuries, including rotator cuff tears, glenohumeral instability, and isolated biceps tendon ruptures. Several theories have been introduced to clarify the pathogenesis of SLAP tears including direct traumatic injuries on the arms, contracture of glenohumeral ligaments, and the “peel-back mechanism”. Detection of SLAP lesions has been advanced in diagnostic imaging, including magnetic resonance imaging (MRI). Despite these improvements, diagnosis of the SLAP lesions is remained as a challenge for physicians because of physical examination tests that are nonspecific and an often variable. This session introduces reviews of the related anatomy, classification system, pathophysiology, and diagnostic evaluation of SLAP tears. In addition, nonoperative treatment strategies and surgical techniques including labral repair.

SX03 Arthroscopic Surgery Of The Elbow: Indications Of Surgery, Operative Technique, Clinical Outcomes And Complications

Deepak Patel Seton Hall University, South Orange, New Jersey, U.S.A.

In the past few decades, advances in surgical technique, instrumentation, and expanded indications have led to significant growth in arthroscopic surgery of the elbow. The indications for elbow arthroscopy include removal of loose bodies, débridement of synovial plicae, débridement for osteoarthritis and septic arthritis, for inflammatory arthritis, release of capsular contracture, débridement and/or release of the extensor carpi radialis brevis for lateral epicondylitis (tennis elbow), and treatment of osteochondral defects and osteochondritis dissecans of the capitellum. Arthroscopic elbow surgery is also useful for the diagnosis and management of chronic elbow instability. Endoscopic techniques may also be used in the treatment of distal biceps tendon rupture and triceps tendon avulsion. Arthroscopically-assisted fracture fixation can be used in the treatment of displaced radial head, coronoid and capitellum fractures in adults, and displaced radial neck and lateral humeral condyle fractures in children. Other posttraumatic conditions may be treated arthroscopically, such as arthrofibrosis or delayed radial head excision. Elbow arthroscopy can be performed in supine, prone or lateral decubitus. Patient positioning, portal placement, and specific instruments vary among surgeons. A thorough understanding of the surgical anatomy of the elbow is essential to minimize injury to the neurovascular structures. A 4.0 mm arthroscope is usually used; however, a 2.7 mm arthroscope may be used for small elbow and for patient with restricted range-of-motion. Both 30° and 70° angulation arthroscopes should be available. The advantages of elbow arthroscopic surgery include better visualization of intra-articular structures, less soft tissue trauma from open surgical incisions, and the ability to begin early postoperative motion. Arthroscopic skills and experience of the surgeon, knowledge of the surgical anatomy of the elbow, patient positioning, and portal selection and placement are critical factors to ensure a successful outcome with minimal postoperative complications and surgical morbidity.

SX04 Update In Rotator Cuff Surgery And Biological Enhancement Of Cuff Repair

Jae Chul Yoo Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Rotator cuff tears are the most common soft tissue injury in the shoulder joint. Despite the advancement of surgical techniques and instruments in rotator cuff repair, still high rate of retear reported. In order to overcome high failure rate, there is a growing interest in reduce failure rate by mechanical properties of surgical repairs. Although single-row repair remain the most cost effective technique to management rotator cuff tear, some clinical studies and biological intervention introduced to improve tissue healing and clinical outcome of rotator cuff repair. Recently, biological studies focused on healing process, especially regeneration of native insertion site and prevention of scar formation by the use of growth factors, stem cells therapy. To achieve this goal, animal studies about repair tissue, biological studies about tendon healing, growth factors, stem cells and tissue are also reported. Experimental application of growth factors and platelet-rich plasma in animal demonstrate promising result but application of these techniques in human rotator cuff repair is still limited. Therefore further clinical trials and surveillance are needed to prove clinical efficacy of brand new biological stretegies. As Review up-to-date articles about mechanical and biological enhancement providing future directions to improve clinical outcomes after rotator cuff repair.

FX01 Review Of Biomechanics Of A Good Golf Swing And Injuries

1Ali, Razif; 1Ng WM; 1Alfaiadh, Zubair; 1Teo SH; 2Razman, Rizal

1Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, 50603 , Malaysia. 2Biomechanics Department, University Malaya Sports Centre, 50603 Kuala Lumpur, Malaysia.

INTRODUCTION: Although appearing simple, a proper commoner injuries incurred in the bad golf mechanical golf swing is one of the most swing are most famously, the back followed difficult moves to master in sports. Review of by the shoulder, elbow and the wrist. The various issues in recent scientific analysis other common injury in golf but not usually were examined. associated with the swing is on the knees due to squatting and kneeling. Swinging harder MATERIALS & METHODS: does little to generate additional club head Three-dimensional kinematics and kinetics velocity. Swinging the golf club further were examined in professional and amateur (expanded range of motion) has the potential golfers. A multi-camera Motion Analysis to generate additional club head velocity if the System (Motion Analysis, Inc.) tracked subject possess sufficient muscular power. passive-reflective markers were strategically Exercise programs thus should promote placed on the golfer and the club. Multi body flexibility and strength training for power as analysis software was used. opposed to just strength development. The average weekend golfer typically starts RESULTS: out with the hardest swing of the day - the Upper-torso rotation, pelvic rotation, X-factor drive off the first tee; without body (relative hip-shoulder rotation), O-factor conditioning, this leads to the myriad of (pelvic obliquity), S-factor (shoulder injuries. Professional golfers usually do not obliquity), were assessed and found to be co- have as many injuries as amateur golfers related to the clubhead speed at impact (CSI). because they play with better form and better The torques and range of motion of the wrists conditioning. Studies have shown that most are important factors in generating club head golf injuries are a result of poor techniques. velocity, more so than the speed of the hands. In addition, the actions of the wrists identified CONCLUSION: the better golfer more so than the speed of the Biomechanical factors highly correlated hands. to golf swing power generation and may provide a basis for strategic training and injury DISCUSSIONS: prevention. Professional golfers have already At certain phases of the swing, the movements conditioned their bodies to tolerate a swing, of the pro golfer are almost indistinguishable which may not be ideal for the average player. from one another. Biomechanic factors such the X-factor ( the REFERENCES: relative rotation of the hips to the shoulders ) 1. Evans K et al; Improving golf and the S – factor ( the angle of the leading performance: current research and shoulder to the level ground ) are highly implications from the clinical consistent and higher in degree among the pro- perspective; Braz J Phys Ther , 2015 golfers. The peak free moment, X-factor and (19); 381-9 S-factor are highly consistent, highly 2. Meister DW et al; Rotational correlated to the club head speed at impact; all Biomechanics of the Elite Golf Swing; appear to be essential to the golf swing power J Appl Biomech 2011 Aug;27(3):242- generation among professional golfers. The 51

ABSTRACT TRUNCATED FX02 Reverse Shoulder Arthroplasty (RSA) With Latissimus Dorsi Transfer For Humeral Head Osteonecrosis With External Rotation Pseudoparesis: A Case Report

Tan KT; Ng WM; Teo SH; Mohamed Al Fayyad, M Zubair; Mohamed Ali, M Razif Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia.

INTRODUCTION: 15º retroversion and broached to 9 mm. Next, RSA is a viable option for patients with the glenoid was reamed and the trial shoulder forward flexion (FF) and abduction implantation was performed. After pseudoparesis.. However, this does not confirming the size, trial implants were address external rotation (ER) pseudoparesis. removed and washout was done. The anterior To improve shoulder ER, various surgical proximal humerus was drilled (size 2.5 mm, procedures were described. These include total 6 holes), and Ethibond® 5 sutures were latissimus dorsi transfer, teres major transfer passed through the drilled holes, followed by (L’Episcopo procedure), and combined cementation, and reverse shoulder latissimus dorsi and teres major transfer. arthroplasty implantation (Aequalis™ Reversed, Tornier). After the cement CASE SUMMARY: hardened, the subscapularis with its bony A 61 years old lady sustained a fracture of attachment was repaired transosseusly to the proximal left humerus in a motor-vehicle anterior proximal humerus via the Ethibond® accident 3 years ago. Open reduction, plating 5 sutures prepared earlier. Next, the and rotator cuff repair with suture anchor latissimus dorsi was passed posteriorly and were done. Three months following the laterally to the humerus and repaired primary surgery, the suture anchor protruded transosseusly to the anterior proximal and was removed. Since then, she had humerus via the Ethibond® 5 sutures. The persistent mechanical pain. Her range of pectoralis major were repaired to its original active abduction, FF, internal rotation, and insertion site, and soft-tissue tenodesis of the ER were 0-45º, 0-75º, 0-90º, and 0 long head of biceps was done on the respectively. There were abduction lag of pectoralis major. 135º, forward flexion lag of 105º, and external rotation lag of 45º. CT scan showed DISCUSSIONS AND CONCLUSION: osteonecrosis of left humeral head with a Most reports found that RSA with latissimus massive defect of greater tuberosity displaced dorsi transfer, with or without teres major rotator cuff suture anchor. transfer, improved shoulder ER (1-4). RSA with latissimus dorsi transfer with or without SURGICAL TECHNIQUE: teres major transfer is a viable option for Deltopectoral approach was used to expose patients requires reverse shoulder arthroplasty the deltopectoral groove, where the cephalic with external rotation lag. vein and deltoid were retracted laterally. Pectoralis major tenotomy was performed REFERENCES: and tagged with stay sutures. Next, the 1. Boileau P, Chuinard C, Roussanne Y, latissimus dorsi insertion tendon was Bicknell RT, Rochet N, Trojani C. Reverse identified, tagged with stay sutures, shoulder arthroplasty combined with a tenotomised, proximally released with blunt modified latissimus dorsi and teres major dissection and mobilised. Next, the tendon transfer for shoulder pseudoparalysis subscapularis insertion was osteotomised to associated with dropping arm. Clin Orthop mobilise the subscapularis. This was followed Relat Res. 2008;466(3):584-93. by tenotomy of the long head of biceps. Once 2. Boughebri O, Kilinc A, Valenti P. the joint was accessed, the head was cut in Reverse shoulder arthroplasty combined with ABSTRACT TRUNCATED FX03 The ‘Lever Sign’ Test: Testing The Sensitivity Via Diagnostic Arthroscopy

RDK Yeak1; Paisal Hussin2 1 Department of Orthopaedic Surgery, , Jalan Puchong, 43000 , , Malaysia. 2 Department of Orthopaedics, Faculty of Medicine, University Putra Malaysia, 43000 Serdang, Selangor, Malaysia.

INTRODUCTION: relevance of this test in diagnosing ACL A new clinical test for the diagnosis of rupture. anterior cruciate ligament (ACL) rupture known as the "Lever Sign" has recently been REFERENCES: described. This prospective study focused on 1. Lelli A, Di Turi RP, Spenciner DB, Dòmini two groups of patients divided based on M. The "Lever Sign": a new clinical test for diagnostic arthroscopy findings and the the diagnosis of anterior cruciate ligament clinical phase of the injury (acute or chronic). rupture. Knee Surg Sports Traumatol Arthrosc. We hope to confirm the sensitivity of the sign 2014 Dec 25. thru diagnostic arthroscopy which is the gold standard for definitive diagnosis. 2. Alper Deveci, Deniz Cankaya, Serdar Yilmaz, Güzelali Özdemir, Emrah Arslantaş METHODS: and Murat Bozkurt. The arthroscopical A total of 30 patients at Serdang Hospital were and radiological corelation of lever sign test evaluated and divided into two, equal-sized for the diagnosis of anterior cruciate ligament groups based on time elapsed from injury and rupture. SpringerPlus (2015) 4:830 DOI diagnostic arthroscopy findings: Group A 10.1186/s40064-015-1628-9. (acute phase with positive diagnostic arthroscopy findings for ACL rupture) and Group B (chronic phase with positive diagnostic arthroscopy findings for ACL rupture). Clinical assessment was performed with the Lever Sign test by four blinded orthopaedic surgeons prior to diagnostic arthroscopy. The Lever Sign test involves placing a fulcrum under the supine patient's calf and applying a downward force to the quadriceps. Depending on whether the ACL is intact or not, the patient's heel will either rise off of the examination table or remain down. The Lever Sign test was also performed on the un-injured leg of all 30 patients as a control. Our inclusion criteria included single ACL rupture and we excluded multiligamentous injuries.

DISCUSSIONS AND CONCLUSION: The Lever sign test showed promising results for patients with acute and chronic ruptures of the ACL with high sensitivity of nearly 100%. Our small series study suggests that the Lever sign test should be included in routine clinical practice in view of its high sensitivity. Hence, further study involving a bigger sample group would be needed to determine the clinical FX04 The Outcome Of Multiligament Knee Injuries: The Hospital Serdang Experience

RDK Yeak1; Paisal Hussin2; M Zaidi1; NM Nizlan2 1 Department of Orthopaedic Surgery, Serdang Hospital, Jalan Puchong, 43000 Kajang, Selangor, Malaysia. 2 Department of Orthopaedics, Faculty of Medicine, University Putra Malaysia, 43000 Serdang, Selangor, Malaysia.

INTRODUCTION: negative anterior drawer test. As for the Multiligament knee injuries involve at least 2 posterior drawer test, majority 83% (n=10) major ligaments and may require extensive showed grade 1 laxity. All the knees were surgery and rehabilitative intervention to stable in the posterolateral corner as assessed prevent long term morbidity or disability. The by the dial test. Majority 50% (n=6) showed purpose of this study is to report the clinical grade 1 laxity for the varus stress test at 30 outcomes post-multiligament reconstruction in degrees. On the other hand, there were 5 cases relation to the rehabilitation. that did not involve the PLC. The anterior drawer test showed majority 60% (n=3) of METHODS: negative results. The posterior drawer test Patients who underwent surgical treatment of showed 5 cases (100%) of grade 1 laxity and multiligament knee injury between January the 1 case (100%) that involved the MCL 2011 and July 2015 at Hospital Serdang were showed normal valgus stress test at 30 retrospectively reviewed. The demographics, degrees. As for the range of motion, those ligament injury and interval from time of with PLC had an average of 133 degrees of injury to surgery were recorded. The patients flexion and those cases that did not involve the were divided into three groups, early (<3 PLC had an average of 135 degrees of flexion. months), delayed (3months till 1 year) and No loss of extension was reported. chronic surgical intervention (>1 year). All the patients underwent single stage surgical DISCUSSION AND CONCLUSION: reconstruction of the multiligament knee The posterolateral corner reconstruction injuries and were followed up for an average however was successful in providing the of 9months (5 to 36months) by a sports patients with a stable knee in patients with surgeon and a sports physician. A specific PLC injury. The range of motion of those with protocol was instituted for the patients with combined PLC injury (133 degrees) is PLC injury and those without PLC injury. comparable to those without PLC injury (135 Outcome measures were determination of the degrees) with a near normal full range of ligamentous stability as well as the range of motion. The timing of surgery does not affect motion. the outcome in terms of stability and range of motion of combined PLC injury as the acute, RESULTS: delayed as well as the chronic cases showed Data were collected from 17 male patients. similar outcome in our small series study. We The average age was 28 years old (15 to 52 postulate that early motion with proper years) at the time of the surgery. There were 1 rehabilitation protocol would improve the acute case, 4 delayed cases and 12 chronic outcome. cases. The time of injury to surgery ranged from 3 months to 20 years. The most common REFERENCES: injury was the 5 cases of combined 1. Fanelli GC et al. Current Concepts: The ACL/PCL/PLC, followed by 4 cases of Multiple-Ligament Injured Knee. ACL/PCL, 3 cases of ACL/PLC, 4 cases of Arthroscopy: The Journal of Arthroscopic and PCL/PLC and 1 case of ACL/PCL/MCL. The Related Surgery, Vol 21, No 4 (April), 2005: results were divided into those with and pp 471-486. without PLC injury. There were 12 cases that involved PLC. Post-operatively, after rehabilitation, majority 75% (n=9) showed FX05 Complication Following Arthroscopic ACL Reconstruction – A 7 Years Follow Up With Special Emphasis On Arthrofibrosis

2 2 2 1 1 1 1 1 Rushdi I ; Sharifudin S ; Shukur A ; Allan R ; Rajkumar V ; Rajvinder S ; Janarthan N ; Azrin M ; Ramanathan R1; Allan CKH2 1Department of Orthopaedic, Hospital Raja Permaisuri Bainun, Jalan Raja Ashman (Jalan Hospital), 30450 Ipoh, . 2 Department of Orthopaedic, Hospital Teluk Intan, Jalan Changkat Jong, 36000 Teluk Intan, Perak, Malaysia.

INTRODUCTION: used does not have significant differences. Our Anterior cruciate ligament (ACL) is frequently study showed 3 out of 56 BPTB grafts (5%) injured and its reconstruction is among the while 5 ot of 110 patients of the hamstring most commonly performed orthopaedic group (5%) developed arthofibrosis. Meniscal surgical procedures. Although ACL procedures do not have an influence in the reconstruction generally yields good results, outcome related to risk of arthrofibrosis. Other recovery can be hampered by the development complication encountered were local infection of postoperative complications. (1%), hypertrophic scar (3%), chronic regional The aim of our study is to review pain syndrome (3%). complications following arthroscopic ACL reconstruction done in Hospital Raja DISCUSSIONS: Permaisuri Bainun Bainun Ipoh and Hospital Pre operative patient selection is important in Teluk Intan with emphasis on arthrofibrosis. reducing complication of ACL reconstruction. Arthrofibrosis was defined as loss of 15 Patient subjected for surgery are more than 45 degrees or more extension with or without years old, injury more than 3 weeks, has no or flexion loss compared to the contralateral minimal effusion, has extension lag less than knee. 10 , flexion more than 110 and can ambulate without aid. This is because all these are risk METHODS: factor for difficult rehabilitation thus prone to This cross sectional study was carried out by arthrofibrosis. reviewing the records of patients who underwent ACL reconstruction surgery done CONCLUSION: between March 2007 and December 2014. The 4.8% incidence of arthrofibrosis following Data includes timing of surgery, pre and post ACL reconstruction can be further reduced operative range of motion, post operative with proper prevention measures. This complications, graft choice, associated includes thorough preoperative evaluation, procedures were analysed using SPSS to proper timing of surgery as well as aggressive identified the risk factors for developing postoperative physical therapy with judicious complications with emphasis on arthrofibrosis. use of cryotherapy & NSAIDS. Patients included are patient who fulfilled pre operative criteria selection and compliant to REFERENCES: post operative rehabilitation program. 1. Hermann O. Mayr. Arthrofibrosis following ACL reconstruction – reasons and outcome. RESULTS: Arch Orthop Trauma Surg (2004) 124 : 518– There were a total of 200 case records with 522 166 patients (83%) completed follow up to 1 2. Strum GM , Friedman MJ, Fox JM et al: year. Eight out of 166 patients (4.8%) Acute anterior cruciate ligament reconstruction developed arthrofibrosis in the post operative : Analysis of complications. Clin Orthop period. Early surgical intervention is a risk 1990;253:184-189 factor of developing arthrofibrosis. One patient 3. K. Donald Shelbourne. Classification and (0.8%) developed arthrofibrosis as surgery was Management of Arthrofibrosis of the Knee performed 2 weeks after trauma. Type of graft after Anterior Cruciate Ligament

ABSTRACT TRUNCATED SPF01 Barefoot Running – Back To Basics

Robert Penafort KPJ Damansara Specialist Hospital, Petaling Jaya, Selangor, Malaysia

Humans have been running for millions of years. The early human were able to outrun most other species and till today remains the only primate capable of endurance running. For millions of years, humans ran barefoot. Evidence of shoes or other forms of footwear, which were minimalist in nature, first appeared about 40,000 years ago for protection of the sole from the elements and injury. Since the 1970s, ‘running shoes’ came in vogue, with all the major shoe manufacturers boasting the most sophisticated cushions and heels and contours that could spring man into a spped beast. There was NO scientific evidence to justify it.

Barefoot running, which is gradually gaining popularity among endurance runners, has also caught the interest of researchers. Research has shown that runners who gradually switch over to barefoot running develop improved musculature and arch anatomy over time. This lecture intends to discuss the benefits of barefoot/minimalist running while cautioning the shod runners the dangers of discarding their footwear overnight

‘all writers who have reported their observations of barefoot peoples agree that the untrammeled feet of natural men are free from the disabilities commonly noted among shod(shoe wearing) people - hallux valgus, bunions, hammer toe and painful feet’ S.F.Stewart "Footgear - It's History, Uses and Abuses"

SS01 Where Is My Pain Coming From: The Pathogenesis Of Discogenic Back Pain Fazir Mohamad Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

Research shows that an estimated 80% of the population will suffer from lower back pain (LBP) at some time in their lives. Many of these people will probably suffer LBP on many occasions, and chronic LBP is the biggest factor limiting activity in young adults under the age of 45. Only a small proportion (approximately 20%) of LBP cases can be attributed with reasonable certainty to a pathologic or anatomical entity. Thus, diagnosing the cause of LBP represents the biggest challenge for doctors in this field. Persistent LBP treatments are often unsatisfactory due to the lack of a precise diagnosis. Discogenic low back pain (DLBP) is a common cause of disability, but its pathogenesis is poorly understood. At present, there is still no ideal diagnostic method for DLBP in clinical practice, prompting many academicians and clinicians to search for an accurate and reliable method of diagnosis. DLBP is a multi-factorial and complex disease. The diagnosis of DLBP remains an intractable problem, despite the gold standard of discography in current clinical practice. SS03 My Preferred Fusion Technique In Discogenic Back

Wong Chung Chek General Hospital, Kuching, Malaysia

Discogenic low back pain is the commonest cause of chronic debilitating back pain. Surgery for discogenic back pain has been controversial, and the result has not been very promising. However, non-surgical management of back pain has also not shown superior result. Careful patient selection and pain source identification are very important to a successful outcome with surgery for discogenic low back pain. Provocative discography and positive disc block with local anaesthetic help to identify pain source prior to surgery. Anterior fusion surgery with interbody fusion cages has the advantage of preserving the posterior lumbar spinal structures and musculatures. It has the largest footprint of interbody structural support available, ensuring good restoration of segmental lordosis. The disadvantages of anterior surgery include difficult anterior approach to the lower lumbar spine, risk of major vessel injury, retrograde ejaculation and impossibility of anterior revision surgery. With our small series, we found anterior fusion surgery for discogenic lumbar back pain a rewarding treatment for patients and surgeons.

SS04 Lumbar Disc Replacement (LDR)

Ahmad Sobri Omar Perdana Specialist Hospital, Kota Bharu, Kelantan, Malaysia

Discogenic lumbar back pain is a challenging entity to treat. The result of arthreodesis may be compromised in the short term by psuedoarthrosis and in the long term by the pain at the iliac crest donor and by the junctional degeneration. The lumbar disc replacement surgery which was supposed to addressed these issues showed a surged in the early 2000 s but seem to wind down lately. Report with short term and long term follow up have demonstrated both equivalent and favourable clinical result of total disc arthroplasty in comparison with lumbar arthrodesis surgery. There is a low rate of an index revision and adjacent segment degeneration surgery requiring second surgical intervention. Careful patient selection, meticulous end plate preparation, careful selection and sizing of the implant are among the few most important factors in determining the good clinical outcome of the TDR procedures. Post operation rehabilitation program is as important in ensuring the good clinical outcome of these patients. Cost and unfamiliarity to the approach seems to be few factors that contribute to the declining interest for this procedure in Malaysia. Many poor clinical outcomes can be attributed to the poor patient selection and unfamiliarity with the good requirement of the surgical technique. Relook in to some of the important aspect and basic concept in LDR and review of some of the related clinical papers may rekindle the interest in these procedures. SS05 Video Assisted Thoracoscopic Decompression In Caries Spine Of Dorsal Area

Sudhir Kapoor ESI Hospital, India

Tuberculosis (TB) is the most common infectious disease worldwide, with spine being one of the most common sites of extra pulmonary involvement. Although TB chemotherapy is the mainstay of treatment for spinal TB, it may not be applicable to all patients such as those with worsening neurological deficit, where surgery would be required in addition. In the absence of major deformity, the primary goal of surgery in these cases is debridement of dead and necrotic tissue to achieve adequate cord decompression and good healing with fusion. Anterior radical debridement and bone grafting has good results and is a valuable surgical option in dorsal spinal TB, but thoracotomy is associated with high morbidity of 10–50% and prolonged hospital stay. Video assisted endoscopic decompression of caries spine presents a good alternative to open thoractomy.

There were 30 patients with mid-dorsal tubercular spondylitis with paraplegia/paraparesis requiring surgery who were included in the study. Every patient had a recent paradiscal disease at a single level. A soft tissue shadow was visible on plain radiographs of the spine, and conservative treatment for at least 3 weeks had shown no recovery. Patients with obvious respiratory insufficiency and likely to have significant pleural adhesions were excluded from the study. Single lung anesthesia and ipsilateral lung collapse using a double-lumen tube were administered. A 3-portal thoracoscopy approach was used, and conventional but long spinal instruments were used through an open port to decompress the spine. Patients were assessed for blood loss, duration of surgery, postoperative incision pain, duration of chest tube insertion, ICU and hospital stay, and neurologic recovery.

The mean duration of surgery was 158.8 minutes with mean blood loss of 296.7 ml, the mean duration of chest tube insertion was 4.25 days. Based on the frankel grading, all the patients improved neurologically. For subjective outcomes, excellent results were obtained in 24 patients, good in 4 and fair in 2. Complications included superficial wound infection in two and pulmonary complications in six (pulmonary atelectasis, pleural effusion, and pneumonia in one each). There was air leak in one patient and parenchymal lung injury in one patient.

In conclusion one can say that in properly selected cases, endoscopic decompression of caries spine gives good result.

SS06 Tuberculosis Of The Spine

Shaharuddin Abdul Rhani National University of Malaysia, Kuala Lumpur, Malaysia

Tuberculosis of the spine is a challenging disease to treat because of the prolonged time of conservative treatment and the technical difficulties of surgical intervention. The disease remains an important public health issue in developing countries, but is also returning in developed countries due to immigration and especially in the immune compromised patients. The most common symptom reported is back pain and the most frequent segment involved is the thoracic spine. The early diagnosis and treatment is mandatory in order to avoid neurological complications and to prevent progressive spinal deformity. Conservative treatment with a combination of anti- TB drugs yields similar long term results when compared to surgery in patients with no neurological deficit or instability. The radical debridement, instrumentation and spinal deformity correction will give good neurological recovery with favorable cosmetic outcome in an indicated patient.

SS07 Appropriate Choice Of Plate For Posterior Malleolus - CT Study Of 122 Chinese Adult Subjects

Churk Hang Charles Li North District Hospital, Hong Kong

Background:

Plating of posterior malleolus (PM) is a common procedure for treatment of PM fracture but its osteology was seldom mentioned. In this study, we evaluated the anatomy of the PM in relation to the choice of plate.

Method:

122 adult patients with normal distal tibia CT films were recruited. The width available for PM plating, total width of PM, the inclination angle of groove for PTT and the proportions of the width available for plating with reference to the total width were obtained.

Results:

Presence of groove was found in 98.4% of the patients (n=120). The mean width available for plating was 20.4mm for male and 18.4mm for female (p<0.05). The mean inclination angle for was 36.9o for male and 28.9o for female (p<0.05). The ratio comparing the width available for plating to total width of PM was 0.59 for both genders.

Conclusion:

Our study demonstrated the importance in understanding the anatomy for effective plating of PM. It provided estimations for appropriate width of plate and the method to evaluate the correctness by comparing with the width of the tibia.

SR01 Recessive Osteogenesis Imperfecta Resulting From Mutation Of BMP1 And Insights From Modelling

Tom Carney Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore

Osteogenesis Imperfecta (OI) is a collagenopathy resulting in bone fragility and skeletal malformation, presenting with a range of severities. Recessive forms of OI are due to mutations in a number of genes involved in collagen processing. Through analysis of patients presenting with a mild form of OI, we implicated the metalloprotease BMP1 as an OI causative gene. To understand pathomechanism, we established BMP1 mutations in zebrafish, a system increasingly employed to model human disease. We determined that zebrafish BMP1 mutants show skeletal deformities and bone fragility, with hallmarks of the human patients. Deep proteomic analysis of these mutants has identified critical targets of BMP1 processing. We have utilised these mutant fish to functionally assess human BMP1 variants in OI cases, and now have developed a model to examine the repair process in OI and upon bisphosphonate treatment.

SR02 May The Fluorophores Be With You

Anwar Norazit Department of Biomedical Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

There may come a time when we can build Luke Skywalker a new hand, but such enhanced limb engraftment is not yet within our grasp. To work towards this outcome, imaging is an integral tool. The underlying idea is that through imaging, we can peek into cellular processes and progress. With fluorescence microscopy, spatial and functional information can be obtained from labelled molecules and structures. Current fluorescence imaging allows for the use of both live cells and fixed specimens. However, all imaging modalities come with compromises, be it resolution, image acquisition speed, or noise to signal ratio. I will talk about some of the latest fluorescence imaging modalities. The Fluorophores are strong in orthopaedic research.

SR03 Targeting Angiogenesis In Osteoarthritis

Dharmani Devi Murugan Drug Discovery and Cell Biology Lab, Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

Osteoarthritis is associated with articular cartilage loss, synovial inflammation, fibrosis, subchondral bone remodeling and osteophyte formation. Angiogenesis, the growth of new blood vessels from old, may contribute to each of these features. In the healthy adult, angiogenic processes mainly represent a repair system (e.g. fracture healing), thus the ingrowth of blood vessels into articular cartilage can be viewed as a failed repair process. Blood vessels from the subchondral bone invade the articular cartilage facilitating the progression of osteoarthritis and forming osteophytes in the process. In osteoarthritis, inflammation induced angiogenesis has evolved as an important contributor to the disease progression in a more exacerbated manner. Hypoxia at sites of inflammation and inflammatory cells such as macrophages, which are abundant in the osteoarthritic synovial membrane, produce pro-angiogenic mediators like vascular endothelial growth factor (VEGF). Understanding the signaling pathway and the role of pro- angiogenic factors in osteoarthritis, may provide possible target in the hope of treating the disease.

SR04 Osteoarthritic Cartilage: The Maturity Paradox

Ilyas Khan Swansea University Medical School, Swansea, Wales, UK

Osteoarthritis is primarily a disease of aging, and yet, when we examine degenerating cartilage we find the genetic and protein signature of young immature cartilage. Understanding and resolving this paradox is the key to unlocking new therapies for patients with joint disease.

The presence of an immature-like cartilage in adult tissue is thought to be a consequence of cellular dedifferentiation in response to injury. Following the early phases of repair, the tissue needs to mature in order to generate adult-like cartilage, and it’s a deficiency in this process we believe that is major reason for the lack of durable repair. Maturation is the adaptation of a relatively unstructured and soft cartilage to a changing biomechanical environment, a process of remodeling that leads to a highly structured, anisotropic and much stiffer tissue that in many cases lasts the lifetime of the host. At the heart of the paradox is the seeming inability of cells in repair tissue to induce maturation of cartilage. Our work has shown that fibroblast growth factor-2 and transforming growth factor 1 can induce precocious in vitro maturation of articular cartilage. An understanding gained from examining this highly reproducible in vitro model has helped us to develop new ideas on how to treat articular cartilage lesions. One of these ideas is using platelet- rich plasma to aid regeneration of articular cartilage lesions following a new understanding of its mechanism of action.

The maturity paradox runs much deeper than previously thought. The critical drivers of most processes of repair and regeneration are stem cells, the closest parallel for us working with cartilage are chondroprogenitors. If chondroprogenitors are not receptive to signalling cues for chondrogenesis or maturation then tissue failure may be inevitable due to a lack of maintenance of residual tissue. Our new data suggests that immature and mature chondroprogenitors are fundamentally different cells, begging the question, which I will address, of which cell type should be used for cartilage repair.

cartilage lesions.

SR05 Bone Infection

T Fintan Moriarty AO Research Institute Davos, Davos, Switzerland

Orthopaedic surgeons and scientists recognize infection as one of the most serious and distressing complications of orthopaedic procedures. While the incidence of infection is relatively low in elective procedures at 1-2%, the costs and risks of the two-stage revision process are high. Approximately 112,000 orthopaedic device-related infections occur every year in the US alone with an estimated increase in hospital costs of $15,000-30,000 per incident. For traumatic procedures, the risk of infection increases dramatically, with an estimated 27% incidence in civilians and 40% incidence in war injuries. In total joint arthroplasty, infection problems typically require a very costly and complicated two-stage reconstruction technique to first remove the bacteria-colonized infected implants and tissues and to control the infection using antibiotic-laden cement spacers or beads, before attempting to replace the hardware. Moreover, this two-stage approach is associated with failure rates as high as 50% with catastrophic results that could lead to arthrodesis, amputation or death. In the past, this problem has been addressed through improved sterile technique and use of long term antibiotics. To date we have failed to eliminate costly bone infection, and rising rates of drug-resistant pathogens infection signal a new obstacle. As we approach the limit of the effectiveness of current techniques, novel approaches to infection management must be developed. This presentation will outline the pathophysiology of bone infection, and the current and future approaches aimed at solving this persistent clinical problem.

SR06 Antibacterial Nanoparticles: Is It Potentially Useful For Orthopaedic Implants Of The Future?

Tunku Kamarul Zaman Tissue Engineering Group (TEG) National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL) Faculty of Medicine, University of Malaya, Malaysia

Implant infection pose a major problem in orthopaedic surgery. Infection of this nature can be difficult to treat since the bone healing capacity may be significantly compromised due to the large defects created by the active bacterial disease as well as the continuous destruction of the bone architecture and vascular supply. It has been reported that several repeat surgical procedures and the use of highly potent antimicrobial for long periods may be required to treat these patients. This leads to prolonged recovery period and long-term morbidity to patients. It is therefore important that a new approach to prevent infection must be explored. A novel biomaterial that confers antibacterial properties may be an alternative method to reduce the risk of developing implant related infection. This is achieved by sanitizing implant surfaces before it is introduced into the patient and thus preventing bacterial contamination and colonization, or more commonly referred to as bio-burden prevention. In the past two decades, several advances in this area have been made. Among which, the use of technologies that employ the modification of composites, the use of nano-particle carriers with slow drug release or as ionic heavy metals such as silver have been shown to be promising. However, the commercialization of these products for the field of orthopaedics have not been seen although many studies have suggested that there is great potential for these types of implants to be extensively used in patients. In the present lecture, several of these potential technologies will be highlighted, and the potential future of these technologies to be seen in orthopaedic implants will be discussed.

SR07 Electroanalgesia For The Management Of Nociceptive And Neuropathic Pain.

Marzida Mansor Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.

Electroanalgesia or the practice of using electrical stimulation for pain control began centuries ago. Electrical stimulation has been applied directly to the spinal cord, deep brain centers, peripheral nerves, and to the traditional Chinese acupoints, in an effort to improve the management of acute and chronic pain.

The techniques range from noninvasive (e.g., Transcutaneous Electrical Nerve Stimulation), to minimally invasive (e.g., Percutaneous Electrical Nerve Stimulation), to highly invasive (e.g., Deep Brain Stimulation, Spinal Cord Stimulation). Recent modifications in the pattern of the electrical stimulus may further improve the analgesic efficacy of electroanalgesic techniques like TENS. A more “in depth” understanding of the effect of different electrical stimulation patterns on the pain response may lead to further long-term benefits with electroanalgesic therapy. (1)

TENS has been developed and used since 1960s and currently is one of the most commonly used forms of electroanalgesia intended to reduce both acute and chronic pain. TENS stood the test of time despite numerous conflicting studies on its efficacy. (2) Some of the indications for the use of electroanalgesia include Neurogenic pain, Musculoskeletal pain, Visceral pain and dysmenorrhea , Diabetic neuropathy, angina pectoris, urge incontinence and in patients requiring dental anesthesia. There are reports discussing the use of TENS to assist patients in regaining motor function following stroke, to control nausea in patients undergoing chemotherapy, as an opioid -sparing modality in postoperative recovery and in post-fracture pain.

The use of electroanalgesia is contraindicated in patients with a pacemaker (especially of the demand type),during pregnancy, because it may induce premature labor. The electrodes should not be applied over the carotid sinuses due to the risk of acute hypotension through a vasovagal reflex, should not be placed over the anterior neck, because laryngospasm due to laryngeal muscle contraction may occur, should not be placed in an area of sensory impairment (eg, in cases of nerve lesions, neuropathies), where the possibility of burns exists and an electroanalgesia unit should be used cautiously in patients with a spinal cord stimulator or an intrathecal pump. References: 1. Paul F White et. al,(2001) Electroanalgesia: Its role in acute and chronic pain management. Anest Analg. 2. Johnson, M.; Martinson, (2007) PAIN,130 (1–2): 157–165.

ST01 Antibiotic Coated Implants In The Prevention Of Implant Related Osteomyelitis

T Fintan Moriarty AO Research Institute Davos, Davos, Switzerland

The application of antibiotics through an implant coating is an attractive option for prevention of infection. Antibiotic coated implants such as intramedullary nails do not necessitate additional removal surgeries or delay wound closure, furthermore the release profiles from coatings seem superior to that of PMMA due to the absence of prolonged release of antibiotics at a sub- therapeutic level. The only trauma related implant that has been available on the European market has been the gentamicin-loaded PROtect tibia nail (DepuySynthes, Johnson/Johnson company, Inc New Jersey, USA). The emergence of resistance against gentamicin, due to exposure in local delivery vehicles, however, is a concern. Recently, we have investigated the efficacy of a biodegradable coating loaded with the antibiotic doxycycline as a local prophylactic strategy against implant-related infection. While the previously mentioned gentamicin coating releases 80% of the antibiotic in 48 h, this newer coating shows a burst release of 25% the first day followed by a daily sustained release of 3% up to 28 days. An advantage of using doxycycline is that resistance is still very low. The coating loaded with doxycycline protected against implant-related infection caused by doxycycline-sensitive, methicillin-sensitive S. aureus in a non-fracture rabbit model. Even when rabbits were challenged with a doxycycline-resistant, methicillin-resistant S. aureus (MRSA) strain, the newer coating significantly reduced the proportion of culture-positive samples. Such antibiotic coated implants seem a potential option for the prevention and treatment of infection in trauma patients with open fractures and in septic revision cases.

ST02 Rationale Of LCP Selection In Tibial Plafond Fractures

Jamal Ashraf Department of Orthopedics, UM&TC, Lucknow, India

Introduction: These fractures are difficult to treat. Controversies exist regarding different surgical procedures. This study presents a comparative analysis of distal tibial fractures treated with medial and antero lateral locking compression plates. The aim was to assess the outcome of LCP fixation and evaluate which surgical approach and method of plate fixation is related to better functional result and lower complication rate

Methods: The management of unstable distal metaphyseal fractures of the tibia remains challenging. A retrospective analysis of 92 patients was made. Patients were divided in two groups depending on surgical approach and plating method: medial vs anter-lateral. Selection criteria included, valgus / varus strain, fracture geometery and location of the anterior fracture line. The other parameters considered were time from injury to bony union, range of motion and clinical outcome.

Results: All fractures eventually united. Complications encountered were infection (3%), non union (9%) delayed union (13%) ankle stiffness (12%) and persistant swelling (21%). Secondary procedures required were debridment, secondary bone grafting, & removal of hardware. Results were similar in both groups with the exception of implant irritation which was higher in the medial plating group.

Conclusion: It is difficult to achieve an anatomical reduction by closed or minimal invasive techniques. However these techniques preserve the blood supply of the fractured fragments. The objective should be to achieve fracture fixation by any technique which assists physiological process of bone healing with minimal surgical trauma. Although these fractures have an intermediate-term negative effect on ankle function and pain and on general health, few patients require secondary reconstructive procedures and symptoms tend to decrease for a long time after fracture healing

FT01 Minimally Invasive Plate Osteosynthesis Of Distal Fibula Fractures Versus Open Reduction And Internal Fixation: A Retrospective Study

Jade PY Ho; Chesvin Singh; Suhaeb AM; Simmrat Singh Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

INTRODUCTION: tissue in an area like the distal fibula where Open reduction and internal fixation (ORIF) only thin skin covers it. Few have studied the has been the gold standard for surgical outcome of MIPO fixation for such fractures, treatment of distal fibula fractures. However, but results1,2,3,5 have been very encouraging. wound complications have been reported to be One must take extra precaution when using as high as 28%1 when locking plates are used. this technique as the superficial peroneal nerve With the advent of the minimally invasive is at risk. In one cadaveric study4, the nerve plate osteosynthesis (MIPO) technique, there has been found to be in direct contact with the appears to be an alternative, especially for plate (55%) when a long one is used. diabetics, patients with poor vascularity, poor tissue condition or smokers. We set out to CONCLUSION: compare two groups of patients who were The MIPO technique is a viable alternative for treated at our centre with either ORIF or fixation of distal fibula fractures, especially in MIPO. patients with a high risk of wound complications. METHODS: This is a retrospective study of patients who REFERENCES: underwent surgical treatment for distal fibula 1. C Iacobellis et al. Minimally invasive fractures at our centre from January 2015 to plate osteosynthesis in type B fibular December 2015. Patients who sustained fractures versus open surgery. Orthopaedic Trauma Association (OTA) 42, Musculoskelet Surg 2013; 97:229-235 43, 44 fractures, requiring plating of the distal 2. R E S Pires et al. Minimally invasive fibula were included. All patients were percutaneous plate osteosynthesis for followed-up for a minimum of 6 months post- ankle fractures: a prospective surgery. Co-morbities, trauma mechanism, observational cohort study. Eur J Orthop fracture classification, trauma-surgery interval, Surg Tramatol 2014; 24:1297-1303 duration of surgery, type of implant, 3. F Hess et al. Minimally invasive plate complications and functional score (American osteosynthesis of the distal fibula with the Orthopaedics Foot and Ankle Society, locking compression plate: first AOFAS ankle-hindfoot score) were compared. experience of 20 cases. J Orthop Trauma 2011; 25: 110-115 RESULTS: 4. D E Krenk et al. Results of minimally 22 patients were recruited of which 13 invasive distal fibular plate osteosynthesis. underwent ORIF and 9 received plates applied J Trauma 2009; 66: 570-575 with the MIPO technique. The ORIF group 5. T Neubauer et al. The risk of nerve injury achieved union in an average of 7.67 weeks, with minimally invasive plate whereas union was achieved in 6.67 weeks in osteosynthesis of distal fibula fractures: the MIPO group. Wound complications were an anatomic study. Arch Orthop Trauma seen in 23.08% of patients in the ORIF group Surg 2011; 131:1409-1412 and 22.22% in the MIPO group.

DISCUSSION: MIPO is not an easy technique for beginners, especially if applied to a small bone like the fibula. This technique aims to preserve soft FT02 Post Traumatic Osteomyelitis Of The Femur Or Tibia: An Evaluation Of The Clinical Outcome, Functional Outcome, And Quality Of Life

1Zayzan R; 1Yusof NM; 2Ab Rahman J 1Department of Orthopaedic, Traumatology, and Rehabilitation, International Islamic University Malaysia, Pesiaran Sultan Ahmad Shah, Bandar Indera Mahkota 25200 Kuantan, , Malaysia. 2Department of Community Medicine, International Islamic University Malaysia, Pesiaran Sultan Ahmad Shah, Bandar Indera Mahkota 25200 Kuantan, Pahang, Malaysia.

INTRODUCTION: population. Concurrent medical problem and This study was conducted to evaluate the CM-B(Systemic) hosts significantly clinical outcome, functional outcome, and contributed to poorer functional outcome, and quality of life of patients treated for post lower quality of life score especially the traumatic osteomyelitis (PTO) of femur or Physical Component domain. tibia in Hospital Tengku Ampuan Afzan, Kuantan, Malaysia. DISCUSSIONS: The clinical outcome in our study population METHODS: was comparatively better than other study A total of 57 patients that fulfilled the cohort. Campbell et al (2011) describes that inclusion and exclusion criteria were identified the failure of treatment rate was as high as 10- from the operating records from June 2007 30%. In addition, the SF-36v2 is a sensitive until June 2014. 10 patients were not able to tool to evaluate the quality of life of PTO. participate. Eventually 47 patients consented This is consistent with the study by Azman et and participated in this study. The median age al (2003) that described the quality of life by of participants was 44 years old, and ranges age group in the Malaysian general from 16 to 80 years old. There were 26 tibia population. On the other hand, Siegel et al and 21 femur osteomyelitis and 38 participants (2000) found similar finding with our study (80.9%) had implants inserted. They were that individuals with CM-B hosts had poor follow up for a mean duration of 4.4 years functional outcome score. (range 1.7-9.5 years). Interviews were then conducted and clinical assessments were CONCLUSION: performed to evaluate the clinical outcome. Most patients with post traumatic Their functional outcome was evaluated using osteomyelitis had successful treatment. the Lower Extremity Functional Score (LEFS) However their quality of life were poorer in and the quality of life was evaluated using the comparison to the Malaysian general SF-36v2 (validated and translated into Malay population. Concurrent medical problem and Language). CM-B(Systemic) hosts had significantly poorer functional outcome and quality of life RESULTS: than healthy patients. 93.6% of participants had a successful treatment and achieved union without REFERENCES: recurrence of infection. 3 (6.4%) participants 1. Azman AB et. al. Medical Journal of had failure of treatment were from CM-IIIA, Malaysia 2003, 58 (5), 694-711. CM-IVA, and CM-IVB. Staphylococcus 2. Cierny GM et. al. Clinical Orthopaedics and aureus and MRSA were the 2 commonest Related Research 2003, 7–24. microorganisms isolated from the culture. The 3. Siegel, H. J. et. al. The Journal of Trauma mean scores of SF-36v2 of participants with 2000, 48(3), 484–489. PTO were significantly lower compared to the 4. Campbell, R. et. al. Eplasty 2011, 11, e3. Malaysian general population. However with 5. Patzakis MJ et. al. The Journal of the increasing age, the general health and vitality American Academy of Orthopaedic Surgeons were similar with the Malaysian general 2005, 13(6), 417–427.

ABSTRACT TRUNCATED FT03 Reemergence Of Double Plating In Bicondylar Tibial Plateau Fracture Fixation. A Retrospective 5 Year Review Of Tibial Plateau Fracture Fixation Outcomes In Tertiary Hospital

1Rampal S; 2Wong YJ; 2Prasad N; 2 Silvaraju M; 3Rampal R 1 Department Orthopaedic,Faculty of Medicine,University Putra Malaysia,Serdang 43400 Selangor 2Hospital Serdang,Ministry of Health Malaysia,43400Serdang 3 Department of Orthopaedic ,Hospital ATM Tuanku Mizan,Ministry Defense,53300 Kuala Lumpur

INTRODUCTION: infection which was successfully treated with Displaced bicondylar fractures possess a wound debridement and antibiotics. modern day challenge to surgeons. The Bar chart 1 shows the HSS knee scores of both emergence of better understanding of groups. biomechanics and implant designs has caused HSS Knee Score

a paradigm shift towards biological fixation with single lateral lock plate. Aim of our study Sing… was to outline perioperative complications and functional outcomes when comparing single Scores Numbers incision to dual incision plate fixation. METHODS: Days of Hospital Stay

A total of 60 subjects (50 males and 10 females) with bicondylar fracture of tibia who S… were treated at our center from duration 2010 Days to 2014 was included in the study. Subjects Numbers age varied from 17 to 69 years old ( mean age Line graph 2 demonstrates length of hospital of 41.1 years old) year old.All subjects (98 stay of the two groups. percent had closed fractures) had intial DISCUSSIONS: stabilisation and definitively fixed laterally or Our retrospective review showed that current dual plate by resident surgeons. Peri-operative surgeons prefer to use single lateral lock plate factors included were operation time(minutes), to dual plating. Better understanding of infection and presence of compartment surgical techniques and implants designs could syndrome, length of hospital stay(days) be contributory factors. Our study also ,presence of non union and post operative outlines the comparable HSS scores for both range of movement(Hospital Special Surgery groups without need of bone graft use. This Knee Score) at 3months, 6months and 1 year would contribute to a more cost effective way duration were assessed retrospectively. The of treating this problem. statistical analyses were conducted using CONCLUSION: Statistical Package of the Social Sciences Our study suggest single lateral plating is a (SPSS) version 22.0 for Windows (SPSS Inc, viable definitive surgical option for displaced Chicago, IL). bicondylar tibial plateau fractures. RESULTS: The current trend of treating these fractures is REFERENCES: by single lateral lock plate (58 subjects). The 1. Devdatta SN, Vivek T et. Al. Indian J operation time and length of hospital stay was Orthop. 2015 Mar-Apr; 49(2): 193–198. significantly lower in single plating group(Figure2). Post operative range of motion was comparable in both groups at 6 months duration (Figure 1). Furthermore there was no reported case of non union at 1 year follow up. We report single case of superficial FO01 The Recycling Of Autoclaved Autografts In Proximal Tibia And Distal Femur Reconstruction: Case Series

E Tan; Loi KW; Singh VA Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia.

INTRODUCTION: biopsy reported degenerated secondary Limb salvage surgery has become the standard neoplastic deposits. treatment for malignant primary bone tumours Both patients underwent epiphyseal sparing of the extremities with the supplementation of wide resection of diseased bone and neo-adjuvant and adjuvant chemotherapy. reconstruction with recycled autoclaved Large bone surgical defects are usually autograft and vascularised fibular grafting, expected in which reconstruction is needed. with the addition of neo-adjuvant and adjuvant Limb salvage surgery represents a challenge in chemotherapy. The first patient achieved bony skeletally immature patients as further growth union six months post operatively with the is anticipated posing a need to address bone ability to weight bear on the affected limb. The loss and possible limb length discrepancy at second patient however is still under follow skeletal maturity3. We report two cases of up, awaiting bony union. epiphyseal sparing and reconstruction with recycled autoclaved autografts and DISCUSSIONS: vascularised fibular grafting. Limb salvage surgery for malignant bone tumours often results in large bone defects CASE REPORT: requiring reconstruction. Various methods of Case 1: A 5-year-old girl presented with a reconstruction have been described namely: complaint of worsening left leg swelling and endoprosthesis replacement, allograft pain for the past 6 months. The pain was replacement, alloprosthetic composite, described as a continuous throbbing pain that , , was worse in the morning and night, which arthrodesis and autograft. The use of bone in significantly reduced ambulatory activities. limb salvage reconstruction has become more There were no significant constitutional appealing due the potential of bone remodeling symptoms. Examination revealed an immobile and its incorporation with host bone. There has bony swelling over the anteromedial aspect of been a great interest in recycling the tumour the proximal left shin that was hard in bone itself by various methods of sterilization consistency, irregular with no skin changes. (eg.: boiling, autoclaving, irradiation, alcohol Radiograph of the left tibia showed immersion, pasteurization, liquid nitrogen) and radiographic changes consistent with reimplantation1. Singh and Pan in separate osteosarcoma with sparing of the growth plate accounts reported the success of eradicating and epiphysis. Core needle biopsy confirmed tumour cells by autoclaving while preserving the diagnosis of osteosarcoma of the proximal bone stock 1,2. left tibia. It is imperative to develop a technique that Case 2: A 2-year-old boy with a history of reduces morbidity and increases functional and testicular yolk sac tumour presented with a aesthetic outcome. The use of native bone post right thigh swelling which was rapidly pathological cells eradication has become an enlarging and limiting knee range of motion. attractive possibility. Long-term follow up will Examination showed a right distal thigh be required to assess function, growth and immobile bony swelling that was hard and development. irregular, causing patella lateral displacement and knee flexion deformity. Radiograph REFERENCES: showed features of metastatic bone tumour 1. Singh VA, Nagalingam J, Saad M, Pailoor involving the right distal femur with sparing of Jayalakshmi: Which is the best method of the growth plate and epiphysis. Core needle

ABSTRACT TRUNCATED FO04 Evaluation Prognostic Factors And Survival Range In Patients With Metastatic Bone Disease

1Abumarzouq Mahmoud; 1Wan Faisham Nu’man Wan Ismail Department of Orthopaedic Surgery, Faculty of Medicine, University Sains Malaysia, Kubang Kerian, 16150 Kelantan, Malaysia.

INTRODUCTION: groups the survival rate was statistically Management of bone metastatic disease still significant p value (0.028). challenging, along with the improvement in Other prognostic factors including managing primary solid tumours, patients chemotherapy administration and side of bone survive longer and they become potential to metastasis (appendicular, axial bone or both have metastatic lesions of bone more than they together) were also significantly correlated had before. with the survival p value (0.003, 0.021) A variety of treatment options could possibly respectively. give to those patients includes medical Concerning type of the surgery as significant treatment, radiation, chemotherapy and factor associated with the survival rate (p- surgical intervention. value 0.038), resection and endoprosthesis The surgical intervention for metastatic bone surgery was the most procedure has been lesions gives satisfactory outcome, however performed in our center for (hip, proximal there are few factors affecting the survival of femur, shoulder and around knee joint patients with bone metastatic disease such as lesions) 58.97% (n=24), followed by performance status, type of primary tumor, Harrington procedure for pelvic involvement neurology deficit, pathologic fracture, visceral which was 17.95% (table 1). organ metastasis last but not least is the DISCUSSIONS: chemotherapy administration(Harrington, As the surgery was a significant prognostic 1981). Accordingly this study was conducted factor affecting survival rate; patients with to evaluate the prognostic factors affecting the short life expectancies may require less median survival and the patient’s quality of invasive surgery including intramedullary life. nailing or other fixation techniques. In METHODS: contrast, patients with longer survival Retrospective and cross sectional study estimates are generally thought to require including a total of 40 patients with bone more durable reconstructive and extensive metastatic disease treated surgically between surgery, which it may improve patient’s 2008 to 2015 at orthopaedic department quality of life and survival. However, it can oncology unit, Hospital Universiti Sains increase both the perioperative risk and the Malaysia, prognostic factors affecting the duration of rehabilitation. median survival were evaluated, while the Based on the ECOG results, patients was performance status questioner of ECOG grouped in to ECOG 0-2 and ECOG 3-5, the (Eastern Cooperative Oncology Group) was ECOG results in both groups were significant used to assess the patient’s quality of life at correlated with the patient’s survival at 3, 6 three, six and twelve month after the surgery. and 12 month after operation. in consistent Moreover, rates of survival were calculated by with (Katagiri et al., 2014) performance status the Kaplan-Meier method. 3 or 4 had a 50% higher risk of dying than RESULTS: those with more favorable performance status Fourteen (37.8%) patients survived, while ECOG grad 0-2. 23(62.16%) patients died, and the median The performance status (ECOG) was survival was 36 month. significantly affected by few factors like the Mean age at presentation was 54.43 years, type of surgery and age, in contrary there were there were 30% (12/40) above 60 years and no correlation with other factors such as spine 70% (28/40) below 60 years, based on the age metastasis and site of primary tumor.

ABSTRACT TRUNCATED FO05 Surgical Management Of Pelvic Tumor: 10 Years UMMC Experience

Salim Al-busaidi, Azura Mansor, Vivek Ajit Singh Department of , Faculty of Medicine, University of Malaya, Jalan Universiti, 50603 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia

INTRODUCTION: is a developing country and that the results are The procedures of pelvic tumor are a surgical comparable to developed nations, UMMC has challenge due to its complex anatomy and the potential to achieve better outcomes. limited reconstruction options. University Malaya Medical Centre (UMMC) is one of CONCLUSION: few centers that manages such tumors The overall survival rate of the pelvic tumors surgically. The purpose of this study is to procedures performed in UMMC was 72%. evaluate the surgical and functional outcomes The recurrence rate and the type of procedures of pelvic tumor resections conducted in were only factors found to be significantly UMMC in the past 10 years (2005-2015). We associated with the survival rate and also wish to determine the variables that may functional outcome respectively. predict both outcomes. REFERENCES: METHODS: 1 .Factors predicting functional outcome after A Cross-sectional retrospective study was malignant pelvic tumor resection ,S. Iwata, F. conducted on 64 patients. The surgical Giardina, S.R. Carter, R.M. Tillman, A. outcome and clinic-pathological variables Abudu, L.M. Jeys, R.J. Grimer ,Royal (patients demographic, staging, tumor details, Orthopaedic Hospital, Birmingham, United procedures and complications) were obtained Kingdom from medical archives. The functional outcome was assessed through interview using 2. Biological Reconstruction Following the two established functional scores (MSTS & Resection of MalignantBone Tumors of the TESS). Pelvis,Frank Traub, Dimosthenis Andreou, Maya Niethard,1 Carmen Tiedke,1 RESULTS: MathiasWerner, and Per-Ulf Tunn1 Out of 64, fifty patients have complete records. There were 23 males and 27 females. 24% had Hindquarter amputation and 76% had Internal hemipelvectomy. 76% were primary and 24% were secondary tumors. The overall 5-years survival rate was 72%. Recurrence (36%) and Infection (20%) were most common complications. The recurrence rate was the only factor found to be significantly associated with the survival rate. The overall result of MSTS & TESS scores of survivals were (70%) & (65%) respectively. The type of procedures done was significantly associated with the final functional outcome.

DISCUSSIONS: The present study demonstrates that the procedures for pelvic tumors conducted in UMMC is comparable and some even better than those reported elsewhere around the world (1,2). However, considering that Malaysia FO06 Reconstruction In Ankle Sarcoma

SahranYahya; WI Faisham; WS Azman; AZ Mat Saad; AS Halim; MZ Nor Azman; W Zulmi Orthopaedic oncology & Reconstructive Science School of Medical Sciences, Universiti Sains Malaysia, 11800 Gelugor, , Malaysia.

INTRODUCTION: Reconstruction with combination of allograft Reconstruction of bony defect following and biological incorporation for long-term sarcoma resection around ankle poses result. Furthermore cutaneous component of challenges to musculoskeletal oncology osteocutaneous fibula is important to cover surgeon. Options include allograft, skin defect and minimized early complication endoprosthesis or bone transport always complicated with high complication

METHODS: We describe 6 cases of distal tibia and 3 cases of talus sarcoma managed by resection and reconstruction by composites allograft and vascularised fibula graf. All talus defect were reconstructed with double barrel fibula to bridge tibio-calcaneum and tibio-navicular to achieve hind foot stability for walking

RESULTS:

Outcome allograft fibular composite distal tibia b c

CONCLUSION: Resection is possible – Sarcoma with good chemo-response Outcome vfg for talus sarcoma – Aggressive benign Vascularized fibula for long term results – is an option with reasonable function

REFERENCES: 1. Long term outcome of free fibula osteocutaneous flap and massive allograft for reconstruction bone defect. AS Halim et al JpLastic Recons Sci 2015 2. High grade OS of talus Case report. DISCUSSIONS: Jon R Goldsmith eta al 2008 This biological reconstruction preferred method especially in younger patients to achieve long-term favourable outcome. SP01 Paediatric Orthopaedic Training In ASEAN – Current And Future Challenges

LEE Eng Hin Department of Orthopaedic Surgery, National University of Singapore, Singapore

ASEAN countries are in different stages of economic and social development. Many countries have relatively young populations with high birth rates. As a result there are large numbers of children who require medical care. Although in principle health care should be universally available to all citizens and residents of each country, children in the rural areas have less access to good healthcare. This has led to many neglected cases of trauma and congenital deformities in children. Trauma is often treated by traditional bone setters leading in many instances to poor outcomes. Inadequate treatment of infections in and joints result in residual deformities.

Currently there are few trained full time paediatric orthopaedic surgeons in ASEAN countries. How can we bridge the gap? Firstly, national healthcare policies should aim to provide more effective services and train more healthcare workers especially to service the rural areas. Orthopaedic training programs should provide adequate coverage of common paediatric conditions and trauma so that general orthopaedic surgeons can manage the more simple problems. Complex problems can then be referred to major centres with paediatric orthopaedic units. Major orthopaedic training centres should provide training in paediatric orthopaedics and we should encourage more orthopaedic trainees to take up paediatric orthopaedics as a subspecialty even though it is not seen as a lucrative subspecialty area.

How can we work together to make this happen? In the ASEAN community, we can offer more paediatric orthopaedic fellowships as well as paediatric orthopaedic electives during residency training. Through more exchanges we can move towards the adoption of best practices which will enable us to define standards of care. Research collaborations in common children’s orthopaedic problems in the region will also be useful.

SP02 Challenges In Managing Congenital Talipes Equinovarus In Malaysia

Kamariah Nor Mohd Daud Department of Orthopaedic, Hospital Tengku Ampuan Afzan, Kuantan Pahang, Malaysia

Introduction:

Congenital Talipes Equinovarus(CTEV) is common presentation in young pediatric age group in orthopaedic clinic at any hospital in this country. CTEV is very easy to diagnose as the clinical presentation is straight forward. For idiopathic CTEV, management can be straight forward or may end up with difficulty. Ponseti method of casting is the commonest method using in treating CTEV.

The outcome or successful treatment of CTEV also depend on various factor like Patients and parents factors Surgeon’s factors Socioeconomic factor Geographical distribution

Challenges present in many ways, some of the challenges is very easy to tackle but certain issue need an input from other units or departments. The challenges can occur in the early part of treatment, in the middle and towards end of treatments. Various strategies applied by the hospitals in order to reduce the challenges and make the treatment successful.

SP04 Economic Impact Of Managing Late Presentation Of Developmental Dysplasia Of Hip (DDH)

Mohd Anuar Ramdhan Ibrahim1, Mohd Hisyamudin Haris Padilah2, Ahmad Munir Hashim2, Zulkiflee Osman2 1Paediatric Institute, , Malaysia 2Penang Hospital, Penang, Malaysia

Delayed presentation of Developmental Dysplasia of Hip (DDH) comes with challenge in treatment as well as high surgical cost. Therefore the objective of this study is to quantify the economic impact of management of late presentation of DDH in the last 3 years. We conducted a retrospective study with analysis of DDH cases managed in year 2012 to 2014. Early and late presentation of DDH was identified and cost management for both was estimated. Out of twenty- four DDH cases, thirteen cases were fulfilled the inclusion criteria. All were female with majority of them presented with unilateral DDH with left hip predominant. Most patients presented after six month old and the principal complaint was abnormal or limping gait. The grand total cost for managing DDH for the three years period was USD 12,385.51, with 86% of the amount was used to manage late presentation of DDH that mostly contributed by cost of surgery. We concluded that delayed presentation of DDH gives strong financial impact to country. Early detection of DDH cases with systematic neonatal screening may help to minimize the incidence of the late presenting DDH and subsequently reduce the economic burden to our government.

SL01 Management Of Traumatic Bone Loss

Suheal Ali Khan KTP Hospital, Yishun NUH, Singapore

A traumatic fracture is a severe soft tissue injury with discontinuity of the bony elements. If one respects the soft tissue, address the stability of the bony elements, the patient should have a favourable outcome with restoration of function, bony union without infection. Fractures of the tibial diaphysis are common with an annual incidence of 20 per 100,000 population. Due to the subcutaneous position of the tibia, approximately 25% of these fractures are open of which 11% are associated with bone loss (2). Historically, significant bone loss was treated by primary amputation. Modern techniques of fracture stabilisation and soft-tissue reconstruction mean that many more severely injured limbs with bone defects can now be salvaged in the acute phase of treatment. However, the problems involved in subsequently bridging and regenerating areas of skeletal loss with viable bone, while maintaining limb length and alignment commensurate with satisfactory function remains a substantial challenge. Attempting limb reconstruction in the presence of significant bone loss usually involves surgery which is technically difficult, time-consuming, physically and psychologically demanding for the patient, and with no guarantee of a satisfactory outcome. The function of the salvaged limb may be disappointing due to residual pain, joint stiffness and neurovascular deficit. The patient may require a secondary amputation due to refractory infection or non-union. Thus, the correct initial decision as to whether to embark upon limb reconstruction or to perform a primary amputation is important, but difficult. Unfortunately, the relative rarity of these injuries and the considerable variation in their configuration dictate that prescriptive management based on established protocol is not possible. A flexible and individualised approach to management for these injuries is required. Some methods to address this rare event are discussed using Masquelet and Ilizarov techniques.

SL02 Acute Correction For Limb Deformities

Aik Saw NOCERAL, Department of Orthopaedic Surgery, University of Malaya, Kuala Lumpur, Malaysia

The main purpose for correcting limb deformities is to improve the limb function and to prevent premature osteoarthritis especially for the weight bearing joints. Causes for the deformities can be congenital, developmental, or acquired (infection or trauma). The main components of limb deformity are angulation, translation, rotation and length difference.

Acute correction with osteotomy is the most common method of treatment. Opening wedge osteotomy may result in slight increase in bone length, while closing wedge is associated with lower risk of neurovascular injury and nonunion. Intra-medullary nail is commonly used for fixation of diaphyseal osteotomy (Rickets), while plate is more commonly for fixation of metaphyseal osteotomy (Blount disease). With the introduction of fixed angle locking plate and minimally invasive osteosynthesis (MIO), the use of plate is becoming more popular.

Outcome of limb deformity correction will also depend on status of the soft tissue, and integrity of neurovascular structures. When the angulation is more than 30o, risk of compartment syndrome and neurovascular injury is significantly higher. The risk can be reduced by performing gradual correction or by shortening the bone. For bilateral deformities, acute correction with shortening of both bones can be considered for severe deformities.

Multiple factors should be considered in the management of limb deformities. In addition to improving radiological outcome, we should also evaluate the soft tissue conditions, risk of potential complications, and patient / family expectation. Restoration of anatomical and mechanical axes to prevent premature osteoarthritis should be one of the considerations for lower limb deformity correction.

(250 words)

SL03 Pilon Fractures: Current Update

Hemant K Sharma Hull & East Yorkshire University Hospital, United Kingdom

Pilon fractures, although relatively uncommon (5 – 7% of tibial fractures), are severe ankle injuries with significant long-term economic, social and physical consequences. This fracture typically occurs in young patient population, resulting in substantial working days loss.

Complications are common, burdening the health services across the world. Direct costs of readmission for failed treatment are between £18,335-£30,000 and can take four times longer than successful treatment. These estimates do not take into account hospital and infrastructure costs, the wider personal and societal costs of morbidity and loss of earnings for the individual nor long-term health burden. Life time cost of amputation can exceed £320,000. Societal impact, due to financial and emotional burden, is far wider: only 28% of patients return to work within 20 months.

In absence of robust literature, management of Pilon fractures remains controversial, usually dependent of surgeons training, expertise and strong preference for a particular treatment. There is limited evidence in the literature comparing the relative effectiveness of these treatments and that, which exists, is of poor quality. Evidence, although weak and limited, suggest that internal fixation may lead to increased unplanned surgery and deep infection.

There is urgent need to identify the most clinical and cost effective treatment of Pilon fractures: internal or ? Management of Pilon fractures, until then, should be rationalized, respecting basic surgical principles & surgeons expertise and patient factors. SL04 Turning A New Leaf. Fidelity – 8D By Ilizarov Technique

Md. Mofakhkharul Bari Bari-Ilizarov Orthopaedic Centre, Dhaka, Bangladesh

Surgery for anthropometric corrections to correct the form of extremities is called “Cosmetic Orthopaedics” Cosmetic orthopaedics is that branch of medical science that makes a person beautiful through changing his limb form, improvement in the appearance of physical feature and defects. Ilizarov is the most natural way of treating all bones and joint problems.

During my long period of Ilizarov surgery since 1983 (from home and abroad) till today I faced lot of problems and difficulties with very interesting and complex cases. Today I would like to share my bitter experiences with these following diseases— 1. Popliteal pterygium syndrome with 8 cm shortening 2. Post traumatic right disorganized knee, bad scar in the leg with ankle valgus, 14 cm LLD 3. Reconstruction vs. Amputation 4. Bilateral relapse CTEV with Bilateral genu valgum 5. AMC total body involvement 6. Sequalae of meningo myocele and so on.

SL05 Role Of Ilizarov Surgery In Infection Following Internal Fixation.

Thirumal Manickam. Department of Orthopaedics, Hospital TAR Klang, Malaysia.

Treatment of fractures by internal fixation is o the rise. Risk of infection however remains resulting in an increased volume of patients presenting with this complication. There is no standard treatment protocol for acute osteomyelitis today.

Between July 2014 and December 2015, we treated 24 cases of acute osteomyelitis. Of these 5 cases had infection in the diaphysis of femur, 4 in supracondylar femur and one patient in both supracondylar femur and diaphysis of tibia. Three cases were infected in the tibial plateau, 6 in the diaphysis of tibia, 3 in the ankle and 2 in the tallus.

Conventional treatment may be done using Intramedullary nail coated with cement impregnated with antibiotics, Macquet’s technique or other local antibiotic delivery agents such as gentamicin beads. All these methods are associated with variable success and failure rates. In our hospital, we have introduced our own treatment classification depending on the extent and severity of the osteomyelitis into four types.

Of these 24 cases, infection was eradicated and union achieved in all except one (supracondylar fracture of femur).

SL06 The Use Of Ring Fixators For Treatment Of Complications Of Trauma

Diarmuid Murphy National University Hospital, Singapore

Ring fixators have been used for many years for the treatment of infection and bone loss with great success. One of the other more serious complications for a patient is joint stiffness and contracture. This can occur in patients following polytrauma or with severely comminuted intraarticular fractures where they are unable to commence early mobilization. This paper will discuss the use of ring fixators in treating these recalcitrant problems, will discuss the literature regarding the use of fixators for contracture as well as illustrate it’s use with some case presentations.

SL07 TKR In Presence Of Deformity

Hemant K Sharma Hull & East Yorkshire University Hospital, United Kingdom

The long-term success of total knee replacement (TKR) is dependent on the proper positioning of the prosthesis and accurate soft tissue balancing to restore mechanical alignment of the limb. In the presence deformities affecting the lower limb, successful TKR becomes much more challenging and outcomes less predictable. Degree of mal-alignment and TKR wear remains a topic of considerable debate. It is generally accepted that mal-aligned components: > 8° valgus, >5° of Varus and when one component was introduced in such a way as to compensate for mal-alignment of the other component, resulting in neutral alignment, leads to increased failure rate of TKR.

Deformity analysis is complex and often inadequately appreciated. Deformities can be bony or soft tissue or can be intra or extra articular. Coronal plane alignment is easy to identify and manage. Sagittal and axial plane alignment is poorly understood and difficult to manage or measure reproducibly.

Long term outcomes of TKR in this patient group are unknown, and therefore, surgeons preference and expertise is the primary factor in managing these patients. Single stage TKR with asymmetric resection is restrained by collateral ligament attachment on tibia and femur. Up to 20 of tibial and 10 of femoral extra articular deformities can be corrected by intra articular resection. Asymmetric femoral resection affects extension and flexion gap differently, and therefore, femoral deformities are complex and more difficult to manage.

Young patients, large complex, multi apical, sagittal, axial and multi planar deformities should be managed by two stage procedure: deformity correction first followed by TKR as 2nd stage procedure. Navigated TKR has significant advantages over conventional instrumented TKR, and should be the standard of care in these patients.

SA01 Patient Selection And Preparation For Arthroplasty

Ahmad Hisham Abd Rashid Sunway Medical Centre

Arthroplasty is one of the orthopaedic surgery that has been shown to give good outcome worldwide. However good patient selection criteria and preparation of the patient for the surgery is very important to minimize the risk and maximize the outcome

SA02 Infection Prevention In Arthroplasty

Pruk Chaiyakit Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand

Periprosthetic joint infection (PJI) is one of the most devastating complications and the leading causes of morbidity following total joint arthroplasty with the average incidence of 0.5-2% in primary arthroplasty surgery. Several perioperative strategies are used to decrease the incidence of infection, some of which are supported by the literature whereas others remain unproven. These strategies developed with the concept of improving the host response and decreasing the chance of bacterial contamination in the preoperative, intraoperative, and postoperative periods. Our data from Vajira hospital showed the average infection rate in primary knee arthroplasty of less than 0.5%, which comparable to various report around the world. However, unlike most advanced institute, we did not utilize ultraclean air system, laminar air flow operating room, or body exhaust suits. The present report will discuss the commonly used methods to decrease the rate of periprosthetic joint infection and present the current protocol in our institution.

SA03 Thromboprophylaxis In Arthroplasty – Does One Size Fit All Populations?

Diarmuid Murphy National University Hospital, 21 Lower Kent Ridge Rd, Singapore 119077

Thromboprophylaxis after lower limb arthroplasty still remains a point of discussion among orthopaedic surgeons. LMWH, factor Xa inhibitors, direct-thrombin inhibitors, aspirin or pneumatic compression devices have all been advocated in DVT prevention. Guidelines on prevention of VTE have been advocated by orthopaedic bodies throughout the world which try to balance the benefits of pharmacological thromboprophylaxis with the risk of post-operative haemorrhage and wound complications. However, there are bones of contention even between the various VTE guidelines developed for the Western population. This paper will look at the current evidence for the efficacy of the various modalities commonly used to reduce DVT and PE rates following arthroplasty and how this may be applied to a local population.

SA05 Levels Of Evidence In Knee Arthroplasty

David S K Choon Department of Orthopaedics University Malaya, Kuala Lumpur, Malaysia

Evidence based medicine is used both by doctors and the public to judge the validity of a particular procedure or treatment and compare it against existing or competitive product.

It is accepted that the randomised blinded trial is the best guide to results in medical practice. However it is not without pitfalls, particularly if a major component of the trial is surgical skill and aptitude. In this circumstance are we testing the strength of the technique or its application by a single surgeon or a group of surgeons? Meta-analysis may help to eliminate surgeon factors but the conditions of surgery may differ in each study.

Observational studies are useful in order to be able to give the patient an idea of possible longevity or complications of a particular procedure. Again, this may be surgeon and circumstance dependent. Larger studies such a joint registry may provide crude revision rates and compare different technologies and implants. However, even these statistics may be skewed by circumstances, such as revision rates in patella retention and unicondylar knee replacement.

In conclusion, much data is now available to surgeons and patients regarding knee replacement. It is the duty of the surgeon to review the data and to guide the patient in its interpretation.

SA06 The Learning Curve: How I Improve My Outcome

Christopher S. Mow Department of Orthopaedic Surgery, Stanford University Medical Center, 300 Pasteur Dr, Stanford, CA 94305, United States As physicians and surgeons, our utmost responsibility is to protect and safeguard our patient’s well being. We as surgeons have a particular issue concerning the constant, relentless introduction of new medical devices and techniques. It is our responsibility to adequately evaluate and properly implement these new implants and technologies for the best possible outcomes for our patients. The ongoing education and training of practicing orthopaedic surgeons is an area of intense interest worldwide, as we come under greater and greater scrutiny and become more and more accountable for the care that we provide. As the techniques and implants we use rapidly become more complex and demanding, orthopaedic leadership worldwide (and in our profession as a whole) have come to realize that 5 to 6 year residency programs and the “master / apprentice” historical model are is no longer adequate for today’s physicians, including and especially specialties such as ours. There is clear evidence in not only the orthopaedic literature but also nonmedical literature show that mastery of complex procedure (like surgery) requires at least 30-50 occurrences of that procedure. How to achieve that in an active, ongoing surgical practice is a major challenge. The currently best available opportunities to meet this challenge are enrolling in fellowships after residency and technique based education opportunities post fellowship (such as cadaver courses and simulated surgery training centers). It is often stated in National level and International level meetings that Continuing Medical Education (CME) is at a crossroads in all specialties, especially surgical, as we are highly technique dependent. Future CME will need to meet this challenge, and we must do so in a way that maximizes learning and training in the least possible amount of time. Romeo AA: Surgical Skills Education: Deficiency in Learning Curve Has to Change. Orthopedics Today, Feb. 2016. http://www.healio.com/orthopedics/business-of- orthopedics/news/print/orthopedics-today/%7B709dd208-2619-40ae-811c- 7f52f61d0338%7D/surgical-skill-education-deficiency-in-the-learning-curve-has-to-change

Romeo AA: An evolution of surgeon education is clearly underway. Orthopedics Today, May 2015. http://www.healio.com/orthopedics/business-of-orthopedics/news/print/orthopedics- today/%7Be2544799-4b17-41ce-9345-514197aa2b40%7D/an-evolution-of-surgeon-education-is- clearly-underway

SA07 Knee Implant Choice – How Do I Decide

Sureshan Sivananthan Siva Orthopaedic Clinic, Hospital Fatimah, Ipoh, Malaysia

As the number of knee replacement surgeries continues to increase, so does the number of new knee replacement implants being introduced into the market. Implant manufacturers have seen that even with a limited number of surgeon users, they can still make a profit and this has resulted in a plethora of implant choices for the knee surgeon. This talk will focus on the key points and registry data that will help the surgeon make an informed decision on the best implant type for a given patient population.

SA08 Perioperative Blood Management In Total Knee Arthroplasty

Rizki Rahmadian Indonesian Hip and Knee Society, Department of Surgery, Andalas University, Jl. Universitas Andalas, Limau Manis, Pauh, Limau Manis, Pauh, Kota Padang, Sumatera Barat, Indonesia

Orthopaedic surgery is one of most consuming surgical specialties associated with a significant preoperative hemorrhage requiring frequent blood transfusion. A special consideration need to be done to Total Knee Arthroplasty (TKA) procedures. The prevalence of TKA has increased dramatically due to both and aging population and a rise in capita utilization. Perioperative blood loss during TKA can be significant, approximately from 300 mL to 1 L, and sometimes more. Anemia cause by perioperative hemorrhage can be lead to severe complication such as post operative infection, slower physical recovery, increase hospital length of stay, and increase morbidity and mortality. These complications may be magnified in patients with preexisting medical comorbidities, including cardiac, pulmonary, and renal disease. Allogeneic blood transfusion is the standard approach to increase hemoglobin level. However, it can cause some complication such as transfusion reaction, transmission of infectious disease, patient’s wrong identification, and immunologic reaction. Reducing the need for blood transfusion become a major concern for orthopaedic surgeon. Perioperative blood management refers to perioperative blood transfusion and adjuvant therapies. Perioperative blood transfusion addresses the preoperative, intraoperative, and postoperative administration of blood and blood component (e.g. allogenic or autogenic, and plasma products, fresh frozen plasma, PF24, or Thawed Plasma). Adjuvant therapies refer to drugs and technique to reduce or prevent blood loss and the need for transfusion of allogenic blood.

Keywords : Perioperative blood management, Total Knee Arthroplasty,

SA09 Addressing The Varus Deformed Knee

Aree Tanavalee Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University 1873 Rama IV Road, Bangkok 10330, Thailand

The integrity to the medial collateral ligament (MCL) is crucial for the proper knee function and implant longevity in total knee arthroplasty (TKA). In Asia, TKA performed in those knees with moderate to severe fixed varus arthritis are common. However, most surgeons avoid performing a complete release of the MCL due to concern of later knee instability. In routine our practice for TKA in varus arthritic knee, we use less invasive-midvastus approach. With the knee in 60° flexion and visualization is adequate, medial osteophytes were removed from both the femoral and tibial sides. Exposure of the medial tibia toward the posteromedial corner was made subperiosteally using a small curved osteotome. The exposure toward the distal tibia was limited at 1 cm at mid medial plateau and 0.5 cm at the posterolateral tibial corner. Sequential bone cuts were made and the provisional gap balancing in flexion and extension was evaluated. The fine-tuning of gap balancing was again evaluated after trial components are in place. With the knee in full extension, knees which had tight medial gap and > 2 mm lateral gap were indicated for complete MCL release. The technique was as described by Insall et al1, including subperiosteal MCL release using a slim osteotome. The release was made from tibial attachment along the anteromedial part of the tibia cortex, without violation of pes ancerinous insertion, until there is we feel no soft tissue resistance. In contrary, the MCL release was not indicated for those who had lateral gap of ≤ 2mm. No additional external knee splint was used at postoperative period in all patients. Early postoperative ambulation was started in the morning of the postoperative day 1, including voluntary upright sitting, knee straightening, feet dangling, and full-weight walking with a walker under the supervision of orthopedic fellows2. The discharge criteria included ability to flex the operated knee to 90° and to walk independently with walking aid. With this release technique, our 6- to 9-year follow-up in 35 patients is still satisfactory with intact for medial soft tissue tension. References 1. Insall JN, Binazzi R, Soudry M, Mestriner LA. Total knee arthroplasty. Clin Orthop Relat Res. 1985;192:13-22. 2. Nophakhun P, Yindee A, Amornpiyakij P, Hlekmon N, Tanavalee A.The efficiency of the patient care team on 3-day protocol for early ambulation after MIS-TKA. J Med Assoc Thai. 2012;95:537-4

SA10 Addressing The Valgus Deformed Knee

Azhar M Merican University of Malaya Medical Centre, Kuala Lumpur, Malaysia

TKR in valgus deformity is complex because of variable pathoanatomy, less familiarity, the risk of overrelease and instability. Assessment of bone defects, laxity of the MCL and contracted lateral structures guides appropriateness and extent of release. A rheumatoid knee with contracture be- haves differently from one with laxity. Significant medial opening on radiographs may require proximal advancement of the MCL femoral attachment, or in the elderly, a constrained implant. A rotating hinge should be available with severe valgus deformities with limited flexion and gross recurvatum. A lateral approach is preferable if the deformity does not correct when the knee flexes or with varus stress or in the presence of patellar subluxation. It allows direct access to lateral structures without further MCL compromise and lengthening of the lateral patellar retinaculum is possible. A gap balancing technique with tibial resection followed by a conservative distal femur resection is used. This is followed by sequential release of lateral structures, then by reassessment of balance using blocks or laminar spreaders and palpation intraoperatively of tight fibres. Pie crusting the posterolateral structures allows controlled release. As part of the lateral approach, the iliotibial band is already released off the tibia. The ITB is tight in extension and does not contrib- ute to lateral tightness in flexion.The femoral attachment of the ITB above the condyle and to the linea aspera can also be released.Next, the posterior capsule is released by pie crusting or directly off the femur. Releasing the LCL and popliteus in particular, may establish a rectangular gap in extension but may inadvertently cause postero-lateral instability in flexion. Thus, the femoral component may need to be more externally rotated. Rarely, the lateral head of gastrocnemius or biceps require release especially with a coexisting fixed flexion deformity.

SA12 Rehabilitation Protocols Pre And Post TKA

Dilbert A. Monicit Department of Orthopaedics, Chong Hua Hospital, Don Mariano Cui, Cebu City, 6000 Cebu, Philippines Cebu Orthopaedic Institute, Room 401, 4th Floor, Robinson's Cybergate, Don Gil Garcia St, Cebu City, 6000 Cebu, Philippines

The goal of total knee replacement is pain relief and improvement of knee and overall function, but restoration of full motion is uncommon. The pre operative range of motion and knee muscle strength can predict the motion and function of knee replacement after surgery. While most patients can expect to be able to almost fully straighten the replaced knee and to bend the knee sufficiently to manage the activities of daily living. Physical therapy after total knee arthroplasty (TKA) is standard care for all patients. Physical therapy before surgery (prehabilitation) can diminish the need for postoperative care according to some studies. The efficacy of rehabilitation before surgery followed up immediately after surgery may produce better results. It may be important to have an opportunity to preempt postoperative outcome variances by implementing preoperative physical therapy along with management of comorbidities before and during surgery to produce an overall good result.

SA13

Tibial Plateau Fractures : Internal Fixation Vs TKA

Faesal RSUD Dr. R. Sosodoro Djatikoesoemo Government Hospital, Jalan Doktor Wahidin No.40, Kec. Bojonegoro, Jawa Timur, Indonesia

Proximal tibial fractures are relatively common in orthopedic injuries, which can eventually contribute to development of post-traumatic osteoarthritis (POA) of the knee. The major risk factors for POA are complex intra-articular fractures including cartilage damage, meniscal tear and ligament rupture during trauma. Inadequate reduction, residual malalignment, pre-existing osteoarthritis and porotic bone in advanced age at the time of the fracture are some of the most important contributing factors

Intra-articular chondro-osseous defects, malunion fracture, joint instability, knee stiffness and previous occult infection may in turn compromise the outcome of total knee arthroplasty and can be technically challenging to the surgeon. However published reports showed a poorer outcome and higher complication rate in patients with POA treated with TKA.

Therefore, one-stage TKA for a complex proximal tibia fracture seems to be a promising alternative to restore limb alignment and facilitate fracture healing. Unfortunately there are not many publications dealing with the primary arthroplasty for treating the complex tibia plateau fractures. SA14

Managing Patella In Primary TKA

Lê Phúc HoChiMinh City Arthroplasty Association, Vietnam

My first 50 TKAs were all patella resurfaced. No complications (fractures, loosening.etc..) registered, however, technically there were some worries ( it took more time, higher infection risk, technical problems of patellar replacement etc..). In 1999, I finished a review 371 TKAs performed at SGH & followed- up in average 3,5 years: 20 TKAs were reoperated, in which 18 by patellar loosening. Since then I ‘ve only patella resurfaced if the cartilage severely destructive. No patella resurfacing, the surgery time is shorter, no worry on patellar fractures and/or malplacement of patellar component. Postoperative anterior knee pain were not much and well controlled by medical measures. SA15 When Do I Decide To Perform High Tibial Osteotomy (HTO)

Saw Khay Yong Kuala Lumpur Sports Medicine Centre, Malaysia

Medial compartment osteoarthritis (OA) secondary to varus deformity of the knee joint is a common orthopedic presentation. Due to varus mal-alignment, accelerated degeneration of the medial compartment is seen. Left untreated, varus deformity progresses and leads to significant clinical symptoms and deformity that warrants surgical intervention. Recently advancement in stem cell therapy has made it possible to regenerate repair cartilage that closely resembles that of native articular cartilage in combination with high tibial osteotomy (HTO). Informed consented second-look arthroscopy and chondral biopsy revealed satisfactory healing of the regenerated articular cartilage. Biopsy specimens using 14 components of the International Cartilage Repair Society Visual Assessment Scale II (ICRSII) showed results approaches 94% of normal articular cartilage score. There were no infections, delayed or non-union.

SA17 When Do I Do Patellofemoral Replacement ?

Lo Ngai Nung Duke-NUS Medical School YLL Medical School, National University of Singapore Dept of Orthopaedics, Singapore General Hospital

PFR can provide predictable pain relief in patients with isolated end-stage anterior compartment knee osteoarthritis, especially so in the younger patients where a TKR is less desirable. It is estimated that 9% of women over 40y will have isolated patellofemoral osteoarthritis (PFOA). Patient selection is critical as progression of tibia-femoral arthritis is the main cause of failure of PFR. 85% of revisions of PFR to TKR are because of tibia-femoral osteoarthritris. Selection criteria : Patients for PFR should have radiological evidence of PFOA, neutral tibia- femoral alignment, full range of motion, no ligamentous laxity and have failed conservative treatment. The 2 classical diagnosis presenting will be PFOA from troclear dysplasia and from patella fracture malunion. PFR can also be carried out with a medial or lateral unicompartment replacement ( “bicompartmental replacement” ) in knee osteoarthritis patients who prefer the more normal kinematics associated with preservation of the 4-bar linkage as opposed to doing a TKR. Successful PFR will require good patient selection, use of a modern PF implant with good geometric features, accurate prosthesis placement (through good instrumentation), and attention to soft tissue balance.

SPL01 How I Face The Complications In Total Hip Arthroplasty?

Taek Rim Yoon; Young Jun Seol Chonnam National University Hospital, Gwangju, Korea

Total hip arthroplasty is a highly successful treatment for advanced arthritis. Unfortunately, complications during and after surgery are inevitable, even in surgeries performed by experienced surgeons.

The complications include bleeding, wound complication, thromboembolic disease, neural deficit, vascular injury, dislocation/instability, periprosthetic fracture, abductor muscle disruption, deep periprosthetic joint infection, heterotopic ossification, bearing surface wear, osteolysis, implant loosening, cup-liner dissociation, implant fracture, reoperation, revision, readmission, death and etc.

Among these, current strategies to prevent and effectively manage the most common early important complications including leg length inequality, dislocation/instability, periprosthetic fracture, and periprosthetic joint infection will be discussed in this presentation.

Leg length discrepancy (LLD) is one of the most common complications of total hip arthroplasty. It may cause limping and disability to the patient and it is known as the number one reason for filing a lawsuit against the surgeon. Surgeons should keep in mind to equalize the leg length especially for developmental dysplastic arthritis patients. While no validated well recognized standard currently excists, less than 10mm of discrepancy is still generally considered acceptable for the majority and more than 30mm is agreed upon as unacceptable.

The cause of dislocation is multifactorial. Re-establishment of the anatomic centre of rotation, balancing soft tissues, avoidance of impingement around the hip and adequate position of the components are important considerations. Careful preoperative planning with templates and meticulous intraoperative assessment associated with femoral offset and acetabular version will ensure few technical errors. Minimal invasive approach using two incisions in surgical techniques has led to a decrease in the rate of dislocation. Postoperatively, limited adduction, flexion and internal rotation are allowed at the hip joint and certain motions are prohibited.

Periprosthetic hip fractures are challenging complications that have become increasingly more prevalent. Intra-operative and postoperative fractures occur much more often with uncemented stems. Female patients over 65 years of age are at highest risk. Vancouver classification is generally used to determine for management of periprosthetic femur fractures. Prosthesis stability and bone stock quality play an important role in periprosthetic fracture around implant component.

Periprosthetic joint infection is among the most common modes of failure of a total hip arthroplasty. The initial evaluation for periprosthetic joint infection including a history and physical examination, followed by radiographs, and laboratory tests such as serum ESR and CRP testing. The use of pre- incisional antibiotics is probably the most important factor in preventing periprosthetic joint infection. The most common treatment for acute post-operative infection is irrigation and debridement with exchange of the modular bearing surface. Debridement with component retention has a dismal failure rate for late chronic infections and should not be performed. Late chronic infections are most commonly treated by a two-stage operation.

Careful surgical procedure to prevent the perioperative complications is key to the success of the total hip arthroplasty.

MMA02 Effects Of Exercise Training On The Cartilage Of Young & Older Rats: A Preliminary Study

Tan, KT; Baigh S; Naveen S; Tunku Zainol Abidin TKZ Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

INTRODUCTION: significantly lower (+22.48% ± 2.36) than that It has been shown that vigorous exercises may in the older rats. From T2 to T8, GAG:TP in the be harmful to the adult articular cartilage (AC), older rats was significantly higher (+13.63% ± whilst moderate exercises have been shown to 3.96), than that in the young rats. From S2 to benefit cartilage homeostasis, the effects of S8, the young rats showed less reduction in physical activity on ageing AC are still largely Col2a1 and more increase in Sox9 expressions unknown. (-15.52% and +123.97%, respectively) than MATERIALS & METHODS: older rats. From T2 to T8, old rats showed an This study compared changes in AC of the increase in Col2a1 expression (+103.73%) and older rats over the duration of 2 and 8 weeks of Sox9 expressions (+81.5%), higher than young sedentary activity, with those of young rats rats. subjected to the same protocol. The second DISCUSSIONS: objective was to compare changes in AC of Following 8 weeks of treadmill training, the older rats over 2 and 8 weeks of treadmill older rats responded with higher Col2a1 training, with those of the young rats subjected expression. This could be the homeostatic to the similar protocol. Thirty young (8 to 12 response to high cartilage matrix degradation in weeks old) and 30 old (12 months) Sprague- response to excessive exercise (1). Cartilage of Dawley rats were divided evenly for different the older rats responded positively in Sox9 activities, including non-exercising (W0), 2 expression following 8 weeks of treadmill weeks sedentary (S2), 8 weeks sedentary (S8), training compared to that of the young rats, 2 weeks training (T2), and 8 weeks training which was consistent with that of degenerated (T8). Sedentary regime involves 10 minutes of cartilage (2). GAG production as the present 0.3 km/hr treadmill exercise once a week. results showed there was no significant changes Exercise training regime involves 1 hour of in GAG:TP after 2 and 8 weeks of treadmill treadmill exercise at the intensity of 50-60% of exercise in both young and older groups of rats. the maximal exercise capacity, 5 days a week. Significant reduction of GAG:TP was observed Rats were euthanised immediately after the end in young sedentary rats, suggesting that GAG of experiments and knee cartilage were of young AC is more susceptible to reduction harvested for histological description (n=1), in the absence of regular physical training. glycosaminoglycan (GAG) & total protein (TP) CONCLUSION: assays, Col2a1 and Sox9 expression analyses Whilst sedentary activity did not benefit the AC (n=5). of all rats, it was shown to be detrimental to the RESULTS: maintenance of cartilage thickness and Areas of increased cartilage thickness (CT) GAG:TP in young rats. Treadmill training were observed more in older rats from S2 to S8, benefitted cartilage thickness and Col2a1 compared to those from W0 to S2. Areas of expression in young rats. increased CT were observed more in young rats REFERENCES: from T2 to T8, compared to those from W0 to T2. Areas of increased chondrocyte density 1. Franciozi CE, Tarini VA, Reginato RD, (CD) were observed more in young rats from Goncalves PR, Medeiros VP, Ferretti M, et al. S2 to S8, compared to those from W0 to S2. Gradual strenuous running regimen Areas of increased CD were observed more in predisposes to osteoarthritis due to cartilage older rats from T2 to T8, compared to those cell death and altered levels of from W0 to T2. From S2 to S8, GAG to TP glycosaminoglycans. Osteoarthritis Cartilage. ratio (GAG:TP) in the young rats was 2013;21(7):965-72.

ABSTRACT TRUNCATED FSS01 Peri-Operative Outcome In Posterior Spinal Fusion For Adolescent Idiopathic Scoliosis: A Prospective Study Comparing Single Versus Two Attending Surgeons Strategy.

Chris Yin Wei Chan, Mun Keong Kwan Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

INTRODUCTION: DISCUSSIONS: The complication rate for surgical correction Surgical correction for AIS carries significant in AIS is significant. There are no prospective risks. Operative morbidity has been shown to studies that investigate dual attending surgeon be associated with prolonged operative time strategy for posterior spinal fusion in AIS. and massive blood loss. This would affect the This study was designed to evaluate the peri- perioperative recovery of patients. To date, operative outcome of posterior spinal fusion in there are no published literature comparing the Adolescent Idiopathic Scoliosis (AIS) patients outcome of single versus two attending comparing a single attending surgeon strategy surgeon strategy for AiS. The result of this (G1) versus a dual attending surgeon strategy study showed that two attending surgeon (G2). strategy significantly reduce the operative time and blood loss. This lead to less post- METHODS: operative pain and faster recovery in our 60 patients (30 patients in each arm) were cohort of patients. The limitations in this study recruited. The patients were comparable for includes non-randomisation of patients into age, gender, Lenke classification, major Cobb the two groups which could lead to angle magnitude and number of fusion levels. recruitment bias. A two attending surgeon The anesthetic, surgical and post-operative strategy has a learning curve and the results protocol was standardized. The outcome reported here might not be attainable at the measures included the operative duration, beginning of the learning curve. A bigger blood loss, post-operative hemoglobin, need sample size would also increase the reliability for transfusion, morphine usage, the duration and accuracy of the study results. of hospital stay, intra-operative lactate levels and pH. The timing of the operation at 6 CONCLUSION: critical stages of the operation was recorded. The involvement of two attending surgeons significantly reduced operative time, blood RESULTS: loss, need for allogenic blood transfusion, The mean operative time for G2 was 173.6 ± PCA morphine requirement and led to faster 27.0 minutes vs. 248.0 ± 49.9 minutes in G1 patient recovery during the peri-operative (p<0.000). Mean blood loss in G2 was 0.92 ± period. 0.4 L and 1.25 ± 0.6 L in G1 (p<0.05). None of the patients in G2 required any allogenic transfusion. Four patients in G1 (13.3%) required allogenic blood product transfusion. The day 2 post-operative hemoglobin levels in both groups were similar but this was taken after blood product transfusion in G1. The amount of morphine usage was 20.4 ± 11.5mg in G2 and 42.5 ± 24.0mg in G1 (p<0.000). G2 patients had a shorter hospital stay. One patient in G1 had superficial wound infection. G2 was faster than G1 during exposure, instrumentation, and bone grafting. FPB01 Comparison Between Percutaneous Fluoroscopic-Guided And Conventional Open Pedicle Screw Placement Techniques For The Thoracic Spine: A Safety Evaluation In Human Cadavers.

Mun Keong Kwan, Chee Kidd Chiu, Chee Kean Lee, Chris Yin Wei Chan. Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

INTRODUCTION: offers the advantage, when accurately inserted. Minimally invasive spinal surgery using Percutaneous pedicle screw fixation has been percutaneous pedicle screw technique has reported to have a perforation rates of 0.4- revolutionalized the treatment of many spinal 13.0% in thoracolumbosacral spine. To the pathologies. This study is designed to compare best of our knowledge, this is the first study the accuracy and safety of pedicle screw that compares the accuracy and safety profile placement in the thoracic spine (T4-T12) between percutaneous and conventional open between percutaneous fluoroscopy-guided and techniques in the thoracic spine (T4-T12). In conventional open techniques using cadaveric this study, the overall perforation rate for the model. percutaneous group was 11.1% (10.1% grade METHODS: 1 and 0.7% grade 2 perforations) and A total of 288 screws were inserted in 16 conventional open group was 8.3% (all grade cadavers: Percutaneous Group - eight 1 perforation). There was one grade 2 ‘lateral cadavers with 144 screws and Conventional perforation’ in the percutaneous group and Open Group - eight cadavers with 144 screws. although potentially dangerous, this lateral Pedicle screws were inserted in both pedicles perforation was unlikely to cause any clinical from T4 to T12 in every cadaver. T1 to T3 problems owing to the interposing levels were not included in this study because costovertebral joint which would confer a of the difficulty in obtaining lateral barrier from injury to the lung. fluoroscopic views at these levels. The pedicle The incidence of pedicle fractures in this study screws were of diameter 5.0 mm from T4 to is harder to place in context as the pedicle T6 and 6.0 mm between T7 and T12. Pedicle fracture rates have not often been reported in perforations and fractures were documented literature. The incidence is hard to assess in subsequent to wide laminectomy followed by vivo as they are not readily amenable to skeletalisation of the vertebrae. The demonstration by CT because of the artefact perforations were classified as grade 0: no created by the implant. The fractures occurring perforation, grade 1: < 2 mm perforation, in our series were mainly split fractures of the grade 2: 2 mm to 4 mm perforation and grade pedicle and did not encroach into the spinal 3: > 4 mm perforation. canal or adjacent structures. There were 19 RESULTS: (13.2%) pedicle fractures in the percutaneous The mean age of the cadavers was 41.7 years group and 21 (14.6%) in the conventional (25 to 67; 12 males and four females). In the open group (p = 0.73). Although generally not percutaneous group, the perforation rate was dangerous, such disruption does compromise 11.1% with 15 (10.4%) grade 1 and one (0.7%) the pull-out strength of the screw. One fracture grade 2 perforations. In the conventional open resulted in a medial pedicular wall flap; this is group, the perforation rate was 8.3% (12 rare but may cause irritation to the nearby screws) and all were grade 1. This difference nerve root, or even injury to the spinal cord was not significant (p = 0.45). There was no with greater displacement. grade 3 perforation documented in all the 288 CONCLUSION: screws. There were 19 (13.2%) pedicle Fluoroscopy guided percutaneous pedicle fractures in the percutaneous group and 21 screw placement in a cadaver model in the (14.6%) in the conventional open group (p = absence of deformity has a similar safety 0.73). profile to a conventional open technique DISCUSSION: between T4 and T12 in the thoracic spine. The use of pedicle screws for posterior spinal stabilisation had been well established and

BBS01 Cooling Material Composite For Cost-Effective Transportation Of Bone Allografts

Saravana Ramalingam; Nurhafizatul Nadia Hanafi; Sharifah Mazni Samsuddin; Suhaili Mohd; Norimah Yusof; Azura Mansor UMMC Bone Bank, NOCERAL, Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia

Introduction Discussion UMMC Bone Bank supplies sterile frozen All DI & GI composites recorded minimum bone allografts for orthopaedic surgeries. The temperature below -40oC as AATB bone allografts must be maintained frozen recommendation and maintained from 76.4h below -40oC as recommended by AATB (DI alone) to 6.3h (GI alone). Time taken to Standards to retain highest level of safety and despatch bones from Bone Bank to in-house quality.1, Dry ice (DI) slab is deemed to be a OT is usually 30 min and up to 5 h before the reliable cooling material2,3 but it is expensive bone is transplanted therefore all GI can be and some banks have used gel ice (GI) instead. used as cooling material. The process for Thus the study was conducted to identify a radiation sterilization takes normally 2 days cheaper cooling material by using composite of including transportation therefore composite of dry ice (DI) and gel ice (GI) and validated the 15kg DI:9 packs GI is suitable. GI alone can be frozen state in-situ for use of our bank. used to transport procured bones below -20oC if the trip less than 12h. The cost of 20kg DI at Materials & Methods RM 6.15 per kg (slab) can be reduced from Five composites of DI & GI as cooling RM123.00 to only RM 30.00 when only GI materials were used: 20kg (DI alone ), 15kg DI (RM 1.00 including freezing >48h) is used. + GI, 10kg DI + GI, 5 kg DI + GI and 0kg DI (GI alone). Five frozen and dummy bones Conclusion individually packed in triple plastic bags were Different DI & GI composites can be used to put in the middle of a polystyrene box (49.5cm maintain the frozen bones below -40oC for x 36.5cm x 33.5cm). Bones were surrounded despatch and sterilization process, and below - by the cooling materials and insulated by 20oC for transporting procured bones. This bubble wraps covering the internal walls. approach can reduce the amount of DI used Probe of calibrated thermocouple thermometer hence cost saving especially when the price was placed in between the bones and the box keeps escalating. was sealed with masking tape. The boxes were placed in non air-conditioner storeroom. The References boxes were weighed before and after the [1] AATB (2008) Standards for Tissue experiment for density calculation. Data were Banking, American Association of Tissue retrieved from the logger of thermocouple Banks, Maryland. thermometer for analysis. [2] Rooney P, Eagle MJ & Kearney JN (2015) Validation of cold chain shipping environment Results for transport of allografts as part of a human DI: GI Min Temp -40oC -20oC 0oC tissue bank returns policy. Cell Tissue Bank, (kg: pack) ±SD (oC) (h) (h) (h) 16:553-558. 20 :0 -73.9±2.55 76.4 94.1 119.6 [3] Bryce S, Taylor F & Shaw W (2010) 15 : 9 -69.7±2.57 61.0 95.6 124.9 Packin’ Ya Eskies!. Cell Tissue Bank, 11(3): 10 : 17 -59.1±6.73 35.5 57.8 78.3 291-294. 5 : 15 -63.3 7.5 25.2 64.5 0 : 28 -68.0± 4.91 6.3 11.8 91.2

Temperature in the storeroom was 26.0-28.0oC

BBS02 Accuracy Of Ottawa Ankle Rule For Diagnosis Of Ankle Fractures In Acute Ankle Injuries

1Syed Jeffrey; 1Jamaluddin Shafie; 1Zamri Abdul Rahman; 1Ruben Jayakumar; 1Zaharul Azri; 2Abdus Syakur; 2Baskar Panirsheellam; 2Ahmad Hazani 1Department of Orthopaedic and Traumatology, Hospital Kuala Lipis, Kuala Lipis, Pahang, 27200, Malaysia 2Emergency Department, Hospital Kuala Lipis, Kuala Lipis, Pahang, 27200, Malaysia

INTRODUCTION: The Ottawa ankle rules (OAR) are a set of were male and 7 were female. The average clinical guidelines used to identify whether group age is 29 years. In our study 7 patients patients with ankle injuries need radiography were OAR positive and 16 patients were OAR to rule out , thus reducing negative. 4 patients from the OAR positive unnecessary radiography. This study was group had ankle fractures whilst all patients in conducted to assess the applicability of the the OAR negative group did not have any OAR in our setting and to examine its fractures. Furthermore, in our study the OAR accuracy for the diagnosis of fractures in acute has a sensitivity of 100%, specificity of ankle injuries. 84.2%, positive predictive value of 57.1% and MATERIALS & METHODS: negative predictive value of 100% for All patients with acute ankle injuries who met detection of ankle fractures. Based on the our study criteria and presented to our hospital OAR, 16 (69.5%) ankle x-rays in this study within 72 hours of injury from 1st to 31st would be unnecessary radiography. Overall in December 2015 were selected for this 1-month our study the OAR is 86.9% accurate at prospective study. Our inclusion criteria diagnosing ankle fractures in acute ankle included patients more than 8 years of age and injuries. close injury. Polytraumatic, unconscious or patients with open wounds were excluded from this study. The ankle area was defined as the entire malleolar area and distal 6 cm of the tibia and fibula. Eligible patients were examined by emergency and orthopedic medical officers using the OAR, and then underwent standard anteroposterior and lateral ankle x-ray. According to the OAR, ankle x- ray is required if there is pain in the malleolar zone and any one of the following: bone tenderness at tip of medial mallelolus or along the distal 6 cm posterior tibia or; tip of the lateral malleolus or along distal 6 cm posterior fibula or; inability to weight bear Figure 1: Summary of the results immediately and four steps in the emergency department. The results of examination using Type of fracture Total the OAR were compared with the radiographic Lateral malleolus 2 results Avulsion fracture tip 1 RESULTS: of lateral malleolus 28 patients were initially enrolled. However, Medial malleolus 1 only 23 patients fulfilled our study criteria. 5 Figure 2: Type of ankle fracture patients were excluded; 1 had open wound, 1 had polytrauma and 3 patients’ forms were not completed. Out of the 23 selected patients 16 ABSTRACT TRUNCATED BBS05

Incorporation Of PDGF-BB In 3D Coragraft For Differentiation Of Mesenchymal Stromal Cells In Vitro

Mohan, S; Karunanithi, P; Raghavendran, HRB; Malliga Raman Murali, Kamarul, T Tissue Engineering Group, NOCERAL, Department Of Orthopaedic Surgery, Faculty of Medicine, University Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

INTRODUCTION: Figure 1. Scanning electron microscopy & Combination of scaffold, growth factor and Confocal of cell on coragraft loaded PDGF-BB stem cells gaining more attention in tissue engineering. Growth factors such as PDGF- BB is a potent mitogen and chemotactic factors for cells of mesenchymal origin, including periodontal ligament cells and osteoblast (Lynch et al.1991) but due to short half-life which is below 4 hours in vivo resulting to encapsulation in nanoparticles such as microspheres to protect from Confocal is done to confirm the cell attachment exponential decay. This study investigated the on the coragraft embedded with microsphere The effects of sustained release of Platelet derived cell proliferation is studied through the increase growth factor (PDGF-BB) encapsulated in in reduction rate of Alamar blue and the cell mircosphere embedded on 3D coragraft on the differentiation was examined through osteocalcin proliferation and differentiation of and ALP which showed positive result compared mesenchymal stromal bone marrow cells in to coragraft with unloaded PDGF microspheres. vitro. Gene expression showed up-regulation of genes compared with control. MATERIALS & METHODS: Microspheres are fabricated through the DISCUSSIONS: double emulsion method. Characterization of Initial result shows a burst release due to the the scaffold was confirmed using SEM, AFM, protein which is present on the surface during Confocal microscopy, FTIR, Staining fabrication. The 2nd and 3rd week protein is methods, Marker assay and gene expression. released through diffusion method. Higher release was found on 4th week due to the RESULTS: degradation of microspheres. PDGF increase the Microspheres fabricated through double expression of ALP and osteocalcin. emulsion method have a mean size of 400uM. FTIR examines the functional groups present CONCLUSION: in coragraft loaded and unloaded with The sustain release of PDGF from PLGA microspheres. AFM shows the 3d positioning microspheres has showed a better proliferation of microspheres within the coragraft. BET and differentiation of MSC on coragraft calculates the pore size as unloaded coragraft embedded with PDGF loaded microspheres. has more pore size compared to loaded coragraft. SEM done on coragraft embedded REFERENCES: with microspheres confirms the cell Lynch et al. Effects of the platelet-derived attachment on the coragraft and microspheres growth factor/insulin-like growth factor-I which shows no toxicity and gene expression combination on bone regeneration around showed up-regulation of genes related to titanium dental implants. Results of a pilot study osteogenic lineage . in beagle dogs. Journal of Periodontology. 1991:62:710-716

SPJ01 Submitting Manuscripts – To Which Journal Should I Submit?

Tunku Sara Ahmad National Orthopaedic Centre of excellence in Research and Learning (NOCERAL) Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya

This presentation is a guide for new researchers on where to submit their case reports or research articles.

We wish to publish in the journal with the highest impact factor which is the most prestigious but it should be relevant with a readership that is interested in your topic and if it is not of high enough quality, it may be rejected.

Advice is given on how to select the best “fit” for your article.

SPJ03 Illustrations In Medical Writing

Sharaf Ibrahim Department of Orthopaedics & Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

A picture is worth a thousand words. Without illustrations, an article becomes less appealing. Illustrations in medical writing consist of photographs, photomicrographs, diagnostic images, diagrams, and graphs. The photographs and diagnostic images must have the highest resolution to ensure clarity. The captions for illustrations should be self-explanatory, containing information that allows readers to understand without referring to the text.

SPJ04 Open Access Journals

Lee Eng Hin Department of Orthopaedic Surgery, National University of Singapore, Singapore

The concept of “open access” publications started in the late 1980’s as free internet publications. The first open access journal was the Journal of Internet Medical Research published in 1999. In recent years there has been an explosion of open access journals leaving researchers confused as to which ones they should aim to publish in.

Open access journals can be fully open access in which all articles are freely available to the reader, hybrid in which limited number of articles are freely available or delayed in which articles become freely available after a certain time period. Publishers of these journals work on two different business models that are either fee-based or non fee-based. Fairly substantial fees are usually charged for publishing an article in the fee-based system. This is over and above the administrative fee charged by many non-open access journals today. Non fee-based journals usually get support from institutions, subscriptions, advertising or government agencies. In certain countries in Europe and in the USA there has been a move by institutions of higher learning and grant funding agencies to mandate publishing in open access journals to allow greater access to the publications.

As with non-open access journals, the quality of the publications in open access journals also vary. Some open access journals have good quality control in terms of the peer review process and good editorial and publishing practices. However, many have not. Readers and potential authors should be aware of predatory journals which usually accept any submission with no peer review and charge a substantial fee for publishing the article. These journals tend to send out emails to academics to send in their papers and serve on their editorial boards. The quality of their publications are generally low and they usually do not have impact factors (or fake impact factors).

SPJ05 Predatory Journals And Publishers

Aik Saw NOCERAL, Department of Orthopaedic Surgery, University of Malaya, Kuala Lumpur, Malaysia

Open access publishing allows readers to view, download, duplicate and distribute published material as long as the contributors are properly acknowledged. With this publishing model, we can expect significant reduction in rate of subscriptions by individuals and institutions since the journal content will be available online free of charge. For this reason, many publishers started to collect “Article Processing Charge” (APC) from the authors / contributors of articles. This will eventually become the main source of income for professional organizations or publishers that have been supporting the journals.

Over the last few years, a new group of “predatory journals” appeared through the internet and aggressively advertise themselves. Most of them carry general titles, and provide quick and usually favorable feedback on the submissions. They will request APC from the authors before the articles are being published on their homepage. Those who are organizing these activities are usually not medical professionals, and their main interest is to derive financial gain from the desperate authors. Jeffrey Beall developed a list of questionable journals based on selected criteria. The number of “potential, possible or probable” predatory journals has increased from 123 in 2013 to 882 in 2016.

Another aspect of predatory publication is the publisher. Journals under these publishers are usually formed about the same time (last 3 to 5 years). The cover designs of journals under the publishers are rather similar. Jeffrey Beall reported another list for these publishers and noted an alarming increase from 18 in 2011 to 923 in 2016.

More recently, some companies started to provide misleading journal metrics for a fee by “calculating” and publishing counterfeit impact factors. Some established journals were even “hijacked” by companies that created counterfeit websites and charging APC for submitted articles. Many researchers and clinicians are receiving regular emails from these companies and it is essential for us to be well informed and not to fall victim to these organizations. Once an article has been accepted and uploaded onto the internet, they cannot be resubmitted to other medical journals. Moreover, the content will never be indexed.

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SPJ06 How To Become A Good Peer Reviewer

Aik Saw NOCERAL, Department of Orthopaedic Surgery, University of Malaya, Kuala Lumpur, Malaysia

Strength of a scientific journal depends on the quality of its peer reviewers. Peer reviewers are a group of people who share the same knowledge and provide their opinion on new material prepared for publication by their peers.

Most journals practices pre-publication peer review, where submitted articles will be reviewed by one or more peers familiar with the field of work / research. To be a good peer reviewer for a biomedical journal, one should observe a few guidelines and they are listed below:

 Scientific content: Good reviewers should be able to understand the subject so that they can evaluate the originality and relevance of the study / reported case. Usually the author would have provided an “introduction” on the topic with a list of references, peer reviewers may occasionally need to countercheck these material with available medical literature.

 Ethical conduct: Peer reviewer must declare any conflict of interest that may introduce bias to their comments. Even with double-blinded peer review system, it may be possible that the reviewer knows the author, and this may influence the feedback to be provided. The reviewer must also not make use of the submitted material for personal benefit.

 Punctuality: Timeliness is very important in journal publication. A reviewer must provide their feedback on time. Occasionally, the editorial process may be affected by delay in the review of one single article, and the author may miss the deadline for getting the paper published in a specific journal issue.

 Other matters: Peer reviewers can comment on the quality of language of the article, but not to the extent of suggesting how to improve it. It is also helpful for reviewers to advise the authors on specific requirements of a journal including the text format, word count and format of references.

The most important quality of a peer reviewer is the willingness to contribute his or her time and effort towards progress of medical science. Studies have shown that the quality of comments provided does not necessarily correlate with the seniority of the reviewers.

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SO02 New Techniques In Achieving Better Surgical Margins In Soft Tissue Sarcoma Surgery

Vivek Ajit Singh University of Malaya, Kuala Lumpur, Malaysia

Soft tissue sarcomas are malignant tumours arising from mesenchymal soft tissue. The commonest being Pleomorphic sarcoma, followed by synovial sarcoma and liposarcoma. These group of tumours are generally managed as a group by wide resection followed by local radiotherapy to the tumour bed.

The rate of local recurrence is strongly correlated to the surgical margins and the use of adjuvant chemotherapy is not standard in the current circumstances.

This talk is to explore all the current methods that been used to improve the oncology outcome of these tumours and what standards we can expect in the future.

SO04 Risk Factors For Recurrence And Mortality In Adult Soft Tissue Sarcomas Of The Extremities

Edward HM Wang Dept of Orthopaedics, University of the Philippines-Philippine General Hospital Manila, Philippines 1000

Studies have identified different prognostic factors for soft tissue sarcomas. We attempt to define these factors in a hospital-based cohort of adult patients with soft tissue sarcoma of the extremities.

A retrospective review was made of a prospectively collected series of adult patients (>18 years old) with soft tissue sarcoma (STS) of the extremities treated by our Unit during the period January 1993 to December 2013. Included were all consecutive patients with histologically proven STS, who were M0 (nonmetastatic) on presentation, received complete treatment at our Unit, and who had follow-up of at least 2 years or until death.

Data collected included both tumor and treatment variables, including tumor size (< or > 10 cm), tumor grade, presentation (virgin or recurrent), intact skin or fungating lesion, location (proximal or distal extremity), depth (above or below fascia), surgical margins (adequate or inadequate), and adjuvant treatment (given or not). Cox regression analysis was used to determine the risk factors significant for local recurrence (LR), systemic recurrence (SR), and survival.

Variables which were significant risk factors for local recurrence included inadequate surgical margins, fungating lesions and the use of adjuvant treatment. On the other hand, a high grade histology, size over 10 cm, a fungating lesion and the use of adjuvant treatment were significant risk factors for systemic recurrence. Finally, a high grade and the presence of systemic spread were risk factors for survival. An analysis of these risk factors will be presented. 5 year survival rate for this cohort of patients is 62%.

SO05 Latissimus Dorsi Motorised Muscle Transfer For Reconstruction Of Quadriceps Femoris Following Oncological Resection Of Sarcoma

WI Faisham1 WS Azman2, AZ Mat Saad2, AS Halim2 MZ Nor Azman1, Sahran Y1, W Zulmi1 Orthopaedic oncology1Reconstructive Science2,,School of Medical Sciences, Universiti Sains Malaysia.

Extensive sarcoma in the anterior thigh compartment sometimes requires entire quadriceps resection and loss of extensor mechanism. Distal femur sarcoma with anterior extension will be manage with knee fusion for function. We describe a technique using motorised latissimus dorsi reconstruction method to improve the outcome of this problem. We described a technique reconstruction of extensor mechanism of quadriceps femoris using motorised latissimus dorsi flap. The thoraco-dorsal nerve was neurotised to remnant femoral nerve for extensor function. 14 patients underwent this procedure, 4 with extensive soft tissue sarcoma of anterior thigh and 10 patients had distal femur sarcoma with extensive anterior involvement. 12 patients ambulating without support and 2 with single stick. Average MSTS functional score was 68%. Extensor lag was noted in all patient with mean of 17 (ranged 10-40). Motorised latissimus dorsi is an alternative method for quadriceps reconstruction with reasonable good outcome

SO06 Step Closures In Soft Tissue Tumour Surgery

Wan Azman Wan Sulaiman, Ahmad Sukari Halim School of Medical Sciences, Universiti Sains Malaysia

Reconstruction after resection of soft tissue has advanced over the last 20 years. This advancement complements the surgical treatment which has been recommended as primary modality to achieve local control. The present primary treatment consists of wide or extended resection, adequate primary reconstruction with or without radiotherapy.

Local recurrence and disease-specific survival are closely related to tumour grade, size, depth, site and completeness of surgical resection margin. In achieving adequate clear resection margin, which is the main therapeutic goal for the treatment , closure often requires flap coverage. With the advent of reconstructive procedures, the concept of limb-sparing surgery has evolved and majority of patients undergo successful limb-sparing procedures. Flaps provide well-vascularized tissue to fill dead space, cover exposed vital structures and correct contour deformity. It also facilitates multimodality treatment as this reconstructed tissue can undergo early radiotherapy treatments. The reconstruction soft tissue defects can be combined using a composite tissue transfer providing structural support. The use of innervated myocutaneous flaps can address the functionality following resections of major muscle groups.

Beside tissue coverage, arterial and venous reconstructions using synthetic or autogenous vascular grafts of involved blood vessels can further facilitate wide en bloc resection and organ salvage.In cases where amputation is unavoidable , fillet flaps , a component of ‘spare parts’ concept has been used as pedicled or free flaps

Durable reconstruction and good function can now be routinely achieved with the multiple reconstructive techniques. Therefore plastic surgical reconstruction plays a key role within the multimodal concept of therapy. Modern reconstructive surgery, particularly free tissue transfer, has made more extensive and curative resections possible while providing cosmesis, beside good functional outcome and more importantly preserve quality of life.

SO07 Principles And Advances In Radiotherapy And Brachytherapy

Biswa Mohan Biswal Department of Radiotherapy & Oncology, KPJ Ipoh Specialist Hospital Ipoh, Perak, Malaysia

Radiotherapy continue to be a part and parcel of multidisciplinary management of musculoskeletal malignancies. The incorporation of radiation before, during and after curative surgery improve local control rate and ultimately long-term survival in high risk sarcomas. With the advancement in radiation technology it is possible to deliver precise dose of radiation to the affected bone and soft- tissue structures that suites to unique anatomy. Intensity modulated radiotherapy is one of the preferred technique to deliver therapeutic dose of radiation to intended target volume without affecting normal structures. This method is an invaluable tool for the treatment of paraspinal tumours.

Delivering radiation soon after surgical excision is the best way to control micrometastatic disease in the tumour bed. However in conventional radiotherapy technique, radiation is normally delivered 4-6 weeks after surgery and sometimes delayed beyond 8 weeks due to wound complications. Delaying initiation of radiotherapy could adversely affect outcome. Therefore single fraction radiation could be started very early to the target using intraoperative brachytherapy during surgery or in multiple sittings in perioperative brachytherapy. The most difficult area to deliver effective radiotherapy is in head and neck zone in paediatric rhabdomyosarcomas. Recently developed technique Ablative surgery MOuld brachytherapy and surgical REconstruction (AMORE) treatment is very popular in the management of childhood rhabdomyosarcoma in critical head and neck sites. The AMORE treatment reduce short-term and long-term radiation complications compared to standard radiotherapy techniques

Unsealed radionuclides like strontium-89, radium-223 etc could accumulate in the tumour site due to their unique metabolic properties and deliver very high dose radiation to the tumour bearing areas. Radium-223 (Alfaradin/Xofigo) radionuclide therapy find place in the long-term management of symptomatic bone metastases in castrate resistant prostate cancer. Whereas strontium-89 therapy is used in extensive bone metastases those cannot be covered by external beam radiotherapy. Therefore radiotherapy play a crucial role in the multidisciplinary management of bone and soft tissue malignancies. The choice of radiation technique depends on the site, size, biology and stage of neoplasm.

SO08 Chemotherapy And Targeted Therapy In Soft Tissue Sarcomas: Can We Improve Survival?

Marniza Saad Department of Clinical Oncology, University Malaya Medical Centre, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia

Most cases of advanced soft tissue sarcoma (STS) are incurable. The median survival after development of distant metastases is 11 to 15 months, and 20 to 25 percent of patients are still alive at two to three years. The mainstay treatment approach is systemic therapy. This is administered with palliative intent to decrease tumour bulk, reduce symptoms, improve quality of life and prolong survival. Judicious use of systemic therapy is critical in order to achieve the intended outcomes without significant compromise to the patients’ general health and quality of life. The selection of systemic therapy must be individualized and based upon several factors, including the aim of treatment, histology and biologic behaviour of the disease, as well as the health status and preferences of the patient. Chemotherapy has been the mainstay treatment. Single agent doxorubicin remains the standard of care for most subtypes. Combination regimen has failed to show survival benefit over single agent therapy. Several second line options are now available which include gemcitabine-docetaxel, trabectedin and eribulin. After the tremendous success of imatinib in gastrointestinal tumour (GIST), more targeted therapy drugs are being explored for use in STS. Pazopanib has been approved in the second line setting. Other tyrosine kinase inhibitors e.g. sunitinib has shown some activity in specific subtypes. Patients with oligometastatic disease may enter prolonged remission with the use of multimodality therapy which include systemic therapy, surgery, radiation therapy, whenever feasible.

SO09 Managing Fungating Wounds

Chye Ping Ching Department of Orthopaedic, Hospital Kuala Lumpur, Malaysia

Approximately 5-10% of patients with metastatic diseases will develop a fungating wound. The incidence will be much higher taking into considerations of primary cutaneous malignancies like squamous cell carcinoma, basal cell carcinoma, malignant melanoma and even cutaneous T cell lymphoma. It is often associated with distressing symptoms like pain, discomfort, foul smelling discharge and bleeding. Its management is both challenging and exhausting to both patients, their caretakers and the clinicians. Contrary to common beliefs that fungating wounds are encountered only towards the end of life, many especially those caused by primary tumours can actually be successfully treated surgically and cured. For the metastatic fungating wounds, it is important to tailor the management according to the needs of the individual patient, focusing on symptoms control and improvement of quality of life. SF01 Overuse Injuries Of The Foot

Mohd Asni bin Alias Hospital Raja Permaisuri Bainun, Ipoh, Malaysia

Overuse injuries, otherwise known as cumulative trauma disorders, are described as tissue damage that results from repetitive demand over the course of time. The term refers to a vast array of diagnoses, including occupational, recreational, and habitual activities.

Overuse injuries of the ankle and foot are common on the general and athletic populations. The wide spectrum of overuse injuries includes ligamentous injuries, soft tissue and osseous impingement, osteochondral lesions, tendon injuries, and stress fractures.

Some conditions such as impingement syndromes and stress fractures may be missed on initial physical examination, and patients with such injuries often present to a sports or orthopaedic clinic with persistent symptoms.

A good knowledge of the spectrum of overuse injuries is essential to ensure appropriate investigation and subsequent early treatment.

Most overuse injuries resolve after 3-6 months. However, unless the offending causes are addressed, recurrences are quite common. Patient motivation and commitment to prevention are key to rehabilitating these injuries.

SF02 Approach To Medial Foot Pain

Aminudin Che Ahmad Department of Orthopaedics, Traumatology & Rehabilitation, Kulliyyah of Medicine, International Islamic University Malaysia, Kuantan, Pahang, MALAYSIA

Midfoot pain is a common presentation in general practice. It is important, therefore, to have a scheme of assessment and awareness of possible causes. In particular, the red flags of navicular stress fracture and Lisfranc ligament disruption require careful consideration as delayed care can result in poor outcomes.

The differential diagnosis of medial foot pain is broad and͒can be overwhelming if a systematic approach is not used. Focused questions and physical examination can help identify medial foot pain as tarsal tunnel syndrome or plantar fasciitis, or as due to a common cause such as gouty arthritis or osteoarthritis.

The medial arch task of converting lower limb; vertically oriented stresses into propulsive horizontal motion. A complex interaction of bones, joints and connective tissues has been engineered to accommodate these demands. However, these entrusted tissues will encounter acute traumatic stresses or cumulative micro stresses, leading to structural and functional deficits.

Certain populations appear to be at increased risk of developing medial foot pain. These include: older adults, the obese, active adults who participate in sports that involve running and jumping, active military personnel, and those engaged in certain occupations.

It is important to have guidance in recognizing and managing the conditions affecting the medial foot region. Recent trends in imaging and medical management will also be outlined.

Keywords: medial foot region, foot pain, clinical approach

SF04 Management Of Toe Deformities

Tze-Choong Low Kuala Lumpur Sports Medicine Centre, Malaysia

Toe deformities can be categorised according to the affected digit. 1. Big toe 2. Lesser toes

These problems can affect the metatarsal-phalangeal joints or the inter-phalangeal joints. The most common aetiology of these deformities are degenerative but in addition, there are congenital, inflammatory and traumatic causes.

A good history, thorough physical examination and plain X-rays will suffice to diagnose these conditions although in limited situations an MRI or CT scan would be indicated,

Non-surgical treatment with orthotics, splints and taping are effective only for milder early deformities. The surgical techniques used for correcting these deformities range from using basic implants such as K-wires to carefully executed .

Among the newer concepts and understanding that have recently been publicised is that of subluxation of the MTP joint as a result of plantar plate injury. In response to this, a number of specialised instruments and implants have been developed to access and repair the injured plantar plate.

SF05 Neuropathic Foot Assessment

Edewet Daun Hospital Raja Permaisuri Bainun, Ipoh, Perak , Malaysia

Complications arises from neuropathic foot in patients with diabetes are common can be prevented with a proactive involvement of multidisciplinary approach. Early detection in clinical visit is mandatory as most of the patients seen are in the early stages of the disease process. Early assessment and detection of the loss of protective sensation and initiate a protocol to prevent ulceration will reduce the risk of limb threatening condition. In order to achieve this, clinicians should have a routine, comprehensive foot examination and risk assessment protocol to examine the feet of diabetic patients. Furthermore, education in foot care and proper footwear with regular follow-up are required in order to identify and prompt measures to be taken when neuropathic foot injury occurs.

SF06 Foot And Ankle Amputation Update

Mohammad Izani bin Ibrahim Foot and Ankle Unit, Orthopaedic Department, Hospital Raja Permaisuri Bainun, Ipoh, Malaysia.

Foot and ankle amputations (FAA) are more commonly performed compared to a transtibial and transfemoral amputation. Among them, the most common procedure performed are Ray and transmetatarsal amputation. The much less common ones are Chopart, Boyd, Pirogoff and Syme’s amputation. Even though FAA produces a longer stump requiring less energy used to walk, it usually end up needing a higher amputation or not suitable to be used with a prosthesis due deformities secondary to muscle imbalances and poor surgical techniques which may not be addressed well during the surgery . Therefore as an orthopaedic surgeon, we should be able to evaluate patients as a whole to identify good candidates for a FAA and able to perform the proper and up to date technique to reduce the possible complications which can arise from the procedure. I will try my best to highlight important points in FAA as well as sharing few new techniques in performing certain types of FAA which is described in recent literature.

SH01 Usage Of Adrenaline In Hand Surgery

Shalimar Abdullah Consultant Hand and Microsurgery, Department of Orthopaedics, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

Injection of adrenaline into the digits has always been a big taboo in the mistaken belief that it can cause ischaemia of the extremities. However this is a myth and there is enough evidence to disprove this.

In the early 1920s, procaine – a more primitive precursor of lignocaine was used for digital anaesthesia. Procaine (with or without adrenaline) resulted in numerous cases of finger necrosis. However adrenaline was blamed for this although procaine was the likely culprit.

Lignocaine came to be developed later and has had a very safe record. Similarly, lignocaine with the addition of adrenaline too has had an impeccable record. Accidental injections of high-dose adrenaline (eg Epi-pen injections) in patients with allergies has also not resulted in finger necrosis yet the dose of adrenaline is 100 times more potent than commercially available 1% lignocaine.

Utilising adrenaline in finger and hand surgery produces a bloodless field hence eliminating tourniquet use. This allows a longer duration of surgery. Patients are conscious and this is very useful in tendon repair surgery to observe possible tendon gapping or tendon transfer surgery to allow adequate tensioning of the transfer. More cases can be done in outpatient surgery allowing the surgeon more control of the operating list without dependence on anaesthetic services. Some cases with multiple medical problems can also be done safely. It is also more cost-efficient.

The speaker has had the privilege to learn this technique from Dr Donald Lalonde from Saint John, Canada who is a strong proponent. Since Nov 2015, all local daycare cases in the speaker’s institute (UKM Medical Center) utilizes this method with no complications seen.

SH02 A Common Sense Approach To Upper Limb Infection

Tunku Sara Ahmad National Orthopaedic Centre of excellence in Research and Learning (NOCERAL) Department of Orthopaedic Surgery, Faculty of Medicine University of Malaya

Upper limb infection can be trivial and easily treated with no complications or it can be devastating and very difficult to eradicate with major complications including loss of part of the limb.

A pragmatic approach using aids such as vacuum dressing and ultrasonic debridement, using useful dressing solutions and materials, and correct surgery which is carried out at the correct time would help to get the best outcome.

The patient’s wishes should be respected even if they do not coincide with the surgeons idea of what is possible.

SH03 Plaster Of Paris In Hand Practice

Manohar Arumugam Department of Orthopaedic Surgery, Faculty of Medicine & Health Science, University Putra Malaysia, Serdang, Selangor, Malaysia

Temporary immobilization prior to surgery or immobilization as a definitive treatment is a common practice. Plaster of Paris the most common material used for immobilisation of the injured hand. The bandage or slab form is still commonly used. It is cheap and can be applied with ease. They can be moulded to form a conforming and safe cast. There are many indications for use of Plaster of Paris in hand surgery. The immobilization should be done properly taking into consideration the functional anatomy. The injured hand should be immobilized. Improper immobilization can lead to stiffness of the finger joint. The correct position used to immobilise the injured hand is the intrinsic plus position. There are also many complications that can occur. One has to be aware of these complications when using Plaster of Paris cast.to immobilise the hand. Controversies with regards to method of immobilization for various hand condition will be discussed in this paper

SH04 Management Of Complex Regional Pain Syndrome Of The Upper Limb

Lai Hou Yee Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

Complex regional pain syndrome of the upper limb is a chronic pain condition that is characterized by allodynia, hyperalgesia, swelling as well as colour, temperature, perspiratory or trophic changes to the skin or nail. The condition is often, but not necessarily, preceded by trauma or neurological damage. Treatment can be difficult but should be initiated early. A multidisciplinary approach should be used with focus on medical treatment, interventional pain procedures, physiotherapy and rehabilitation as well as cognitive behavioral therapy.

Medications such as gabapentinoids may alleviate the neuropathic pain. Tricyclic antidepressants or selective noradrenaline reuptake inhibitors work as pain modulators. In refractory cases, opioids or even cannabinoids can be considered. Ketamine infusion performed with close monitoring over a few days has also shown to provide relief.

A series of local anaesthetic injection of the stellate ganglion under ultrasound guidance provide sympathetic blockade without affecting the motor function of the upper limb during which physiotherapy could be intensified. In selected cases, a trial of spinal cord stimulator in the cervical region could be performed before implantation of permanent leads and impulse generator.

These treatments should be done in conjunction with physiotherapy and rehabilitation to maintain range of movement as well as motor power of the hand. Mirror box therapy could also help “remap” and normalize the pain pathway.

Patients should also be enrolled in cognitive behavioral therapy and mindfulness programs to manage pain behavior. Concomitant depression and anxiety should be treated. Social stressors should also be identified and addressed.

FH02 Comparison Between Usage Of Sponge Foam And Orthoban As Undercast Padding In The Treatment Of Distal Radius Fracture With Plaster Of Paris

Ngim HLJ; TS Ahmad Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia.

INTRODUCTION: 2.65±1.72 mm, and 8.92±9.32 degrees Distal radius fracture can be satisfactory respectively for orthoban, and 4.78±3.62 treated conservatively using a cast. However, degrees, 2.44 ±1.80 mm, and 8.46±7.08 there is a possibility of displacement of the degrees respectively, for sponge foam group. fracture site that can occur while being All the differences of the analysis were not immobilized by the cast after satisfactory statistically significant. There were also no alignment is achieved via closed manual statistically significant difference in all reduction. Sponge foam used in lymphedema components of the patients satisfaction score compression bandage can be used as an between the two types of cast padding. alternative cast padding to in distal radius DISCUSSIONS: fracture among adult population. This study There are very limited studies done to investigates the effectiveness and patients’ compare different types of cast padding. The satisfaction of Rosidal sponge foam as cast question of whether the type of cast padding padding in maintaining the alignment of distal can be a significant independent predictor of radius fractures compared with traditional outcome has not been reported. From this cotton based orthoban. study, orthoban and sponge foam did not have METHODS: a statistically significant impact on the ability We screened all adult patients from September of the cast to maintain the alignment of the 2014 to March 2015 who presented to fracture. This is comparable to the result of University Malaya Medical Centre with distal Robert & Jiang (2011) and Rozansky (2010) radius fracture. Eligible patients fulfilling the who also found that there was no significant inclusion criteria were randomly assigned to difference in Gore-Tex waterproof cast-liner either the orthoban or sponge foam group. The and cotton cast-liner in maintaining the mean difference between initial post reduction of distal end fractures in paediatric reduction/casting radiographs and follow-up patients. radiographs were measured for radial CONCLUSION: inclination, radial height and volar tilt at two, Rosidal sponge foam and cotton based four and six weeks post trauma. The number orthoban were equally effective in their ability of cast change and patients’ satisfaction in five to maintain the alignment of distal radius components: comfort, itchiness, smell fracture in adult. Patients’ satisfaction were heat/sweatiness and overall satisfaction were also similar in both types of cast padding. also analyzed. Statistical analysis was done REFERENCES: using chi-squared, t-test and Mann-Whitney 1. Robert, C. E., Jiang, J. J., & Khoury, J. G. test with SPSS version 20. (2011). A prospective study on the RESULTS: effectiveness of cotton versus waterproof cast A total of 73 eligible patients with acceptable padding in maintaining the reduction of alignment of the distal radius were recruited pediatric distal forearm fractures. J Pediatr into the study. 51 patients completed the study Orthop, 31(2), 144-149. while the rest were lost to follow up. 25 2. Rozansky, A., Adamcyzk, M., Schrader, patients were treated with orthoban-lined cast, W., Riley, P., Weiner, D. S., Wasserman, H., while 26 patients had sponge foam as cast Jones, K. (2010). Gore-Tex vs. traditional cast padding. The mean difference for radial padding after closed reduction of displaced inclination, radial height and volar tilt of the distal radius fractures in children: A radius from the initial post reduction/casting to retrospective review. Journal of Bone & Joint 6th weeks post trauma was 4.57±4.03 degrees, Surgery, British Volume, 92-B(SUPP I), 10. FH03 Ophthalmic Scalpel The Sungai Buloh Sword For Percutaneous Release Of Trigger Finger

Nishand G; Samsher Singh; Azlan Sofian; Zamyn Zuki Department of Orthopaedic, Hospital Sungai Buloh, Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia.

INTRODUCTION: DISCUSSIONS: Trigger finger, also known as stenosing tenosynovitis, occurs when one of the tendons Percutaneous release for trigger finger was responsible for bending a finger or the thumb first performed in 1958. Several technique develops thickening and inflammation in the were used since then and almost all of them tendon sheath. The thickened tendon and produced good results with minimal failure inflamed sheath can prevent smooth gliding rate. The common used technique of during motion, resulting in a popping or percutanoues release were the needle catching sensation while attempting to extend technique but however produces higher failure the finger from the palm. rate due to inadequate release of the tendon Trigger finger is a common hand condition sheath. The scalpel used here is actually used among adults between 40 and 60 years of age for opthalmologic surgeries which is rhomboid and repetitive gripping and grasping is often edges and has 2 cutting sides. the underlying cause of the condition. Surgical method for trigger finger release that is usually CONCLUSION: practice is the open method where incision is made over the A1 pulley and the sheath is THE ophthalmic scalpel used here showed released with a blade. good results with more than 90% success rate with minimal complications. The operative METHODS: time is much lesser than the conventional open method. Percutanoeous release also gives good A total of 25 trigger fingers were treated with patients satisfaction as recovery is faster with using ophthalmic scalpels percutaneously. The minimal scars. outcome of the surgeries are studied. Immediate and late post operative outcome REFERENCES: such as post operative pain, bleeding, infection rates and rehabilitations for both the technique 1. Egyptian Orthopaedic Association, The are compared. percutaneous release of trigger finger , Mohsen M Elsayed RESULTS:

Of the 25 fingers treated, there was complete resolution of symptoms in 22 of them. 1 of the fingers had residual deformity in the second follow-up. We performed open release in that patients and verified that the release was incomplete. The open releases were successful in that case. Two patients with locked trigger thumb had persistent symptoms, in spite of the reduction of the trigger deformity. There were no other significant complications, such as injury to the digital nerve of the tendons, infection of the tendon sheath, or arching of the flexor tendons. SOS01 Bone Failure: Fragility Fractures & Its Implication For Subsequent Mortality

Chan Siew Pheng Department of Medicine, University of Malaya Medical Centre, KL, Malaysia

Osteoporosis is silent until a fragility fracture occurs, before patients realise that they have the disease. It can have devastating physical, psychosocial, and economic consequences. The age- standardised mortality risk is increased 2-3 fold after ANY fracture. However, hip fractures confers the worst outcomes, as it tends to occur in the elderly; and there is a high mortality that usually occur in the first 3–6 months after the event, of which 20–30 % are causally related to the fracture itself. Only one-third of hip-fracture patients regain their pre-fracture level of function, while one-third do not regain independence and require nursing care.

If treatment is begun when the bone disease is detected early, the outcome is improved, with reduction in risk of fracture. In addition, a recent meta-analysis found that with active osteoporosis therapies, mortality is significantly reduced (Bolland et al, JCEM 2010). Major advances have been made in therapies for osteoporosis; with potent anti-resorptive therapies eg bisphosphonates, denosumab, strontium ranelate and anabolic therapy eg parathyroid hormone. Large clinical trials have shown early and sustained fracture efficacy; within the 1st year of treatment and for up to 10 years. Unfortunately, reports of adverse events, such as osteonecrosis of the jaw and atypical femoral fractures (AFFs) have caused concern among Clinicians, especially Orthopaedic surgeons as well as the lay public, resulting in lower rates of treatment after fractures and lower adherence / compliance among patients. Algorithms for use of bisphosphonates beyond 3-5 years to address issues of benefits of fracture risk reduction against risk of AFF have been drawn up to assist in clinical decision making.

Secondary fracture prevention (after an initial fragility fracture) is Never too late – Capture the Fracture should be the mantra for all orthopaedic services! Working together with Medical colleagues, effective anti-osteoporosis therapies should be initiated and appropriate monitoring for efficacy and adherence to ensure best outcomes. For those without prior fractures, but considered at high fracture risk, treatment should also be started.

Effective therapies, when indicated, should not be withheld to improve the quality of life of our senior citizens!

SOS02 Osteoporosis Treatment: Does Benefit Outweigh The Risk?

Hew Fen Lee Consultant Endocrinologist, Subang Jaya Medical Centre, Selangor. Malaysia.

Osteoporosis leads to fractures and the common low trauma fracture sites are the wrists, the vertebrae and the hips. Osteoporotic fractures carries with it not only morbidities including pain, deformity and loss of function but also mortality with the highest mortality associated with hip fracture at more than 10%, a figure that rises further with age of the patients. Anti osteoporosis treatment pharmacologically has shown a reduction of fracture rate of 40-60% depending on the agents used. This is a substantial reduction of fracture especially in those with high risk of fracture defined as a 10 year major fracture risk at any of the 3 sites mentioned above of more than 20% or 10 year hip fracture risk of more than 3% as calculated by FRAX. All pharmacological agents have side effects and many of the side effects are reversible with the cessation of therapy eg allergic reactions, GI side effects with oral bisphosphonates. However there are certain individuals who have co morbidities for which certain drug are contraindicated eg cardiovascular disease for strontium, gastro-oesophageal reflux disease for bisphosphonate therapy. Thus these drugs should be avoided in these patients. There are concerns about the occurrence of atypical femoral fracture (AFF) and osteonecrosis of the jaw (ONJ) for those who are treated with bisphosphonate. The mechanisms for both AFF and ONJ are not well understood. The risk for AFF is less than 0.01% but this increases with the length of bisphosphonate exposure. Thus patients on bisphosphonate should be assess regularly and for those who have been treated for 5 years and with a marked improvement of fracture risk should be considered for a drug holiday. Stopping bisphosphonate reduces the risk of AFF immediately and quickly. ONJ is even more rare with an incidence of 0.01% and tends to occur in those who are on high dose bisphosphonate in oncology patients. Good oral and dental hygiene is important to prevent ONJ. All pharmacological agents have side effects. Our role is to maximise benefit with the minimise side effects of each of the agents we prescribe our treatment. Failing to treat leaves many high risk patients with high risk of fracture and the accompanying high morbidities and mortality. Selective and judicious use of drug would achieve the best balance in reducing future fracture and minimise side effects.

SOS03 What’s Next After A Fragility Fracture

Alexander Tan Tong Boon University of Malaya Medical Centre, Kuala Lumpur, Malaysia

Osteoporosis is systemic and not usually limited to a single bone. Following a fragility fracture, 3 things ought to occur:

1) The fracture is fixed.

2) A secondary cause for fragility fracture is excluded.

3) Steps are taken to prevent further fragility fractures.

Point number 1 does not require any further elucidation from an endocrinologist attending an orthopaedic conference. Most secondary causes for fragility fracture can be detected by clinical history, physical examination plus a panel of routine investigations. Steps to prevent further fractures include non-pharmacological measures (e.g. diet, fall avoidance) and pharmacological measures. The lecture will cover the recommendations for all of the above made by the Malaysian clinical practice guideline on the management of osteoporosis (2015).

SPA01 Universal Portable Traction Device (UPTD)

S Tejinderpal, S Andrew, M Sukri, W Alice, S Hikmah, J Anisah Novatech Inovision team, Orthopedic Department Queen ElizabethII Hospital Kota Kinabalu,

Nekad Ortopaedics Group has successfully brought the Universal Portable Traction Device (UPTD) to attention in 2014. The UPTD is the latest innovative product to address issues among patients that have sustained fractures and need traction support/treatment in Orthopaedics field. Before this advancement, previous traction devices lacked the effectiveness, which made patients feel uncomfortable when applied and being in constant pain due to the inefficiency of the traction angle and pulling force. Especially during transporting and transferring patients from stretcher to bed, operating room, X-Ray or ambulance vehicles. As a result, patients experienced additional pain, and even secondary complications, such as FES and neurovascular injury. Application of this traction device is not only confined to the limbs, but also to cervical and pelvic fractures that needs traction support, lumbar spine physiotherapy and aided traction support during surgery. Approval from the director allowed for research and development to be conducted with cost being relevant to the objectives. Research and a trial run was successfully conducted on patients with the permission from Hospital Director and Head of the Orthopaedic Department. Safety and sterile condition of the tools required were also taken into consideration before the project was carried out. This innovation project by the Group was carried out over a period from March 18th to August 2014 and has now passed the trial period. This system is now in place at the Orthopaedic Ward QEH II Kota Kinabalu,Sabah. Among the main advantages of undertaking this medical innovation is that it reduces patient complications, reduces the overall cost of traction usage especially for patients with long term infections that needs long term traction in ward, saves time during application, user friendly and reliable. The UPTD was created at the cost of RM 600 per set. In conclusion, the UPTD is truly an innovative device that is capable of performing as a reliable functional traction device and as an aided device in various fields. With a low cost in mind it has also opened up the potential ability for this device to be utilized throughout the hospitals in this country.

SPA02

Bone Banking – What It Is All About

Rajendran Krishnan Hospital Kuala Lumpur, Malaysia

As we know, Hospital Kuala Lumpur (HKL) has set up a Joint Replacement Unit in 1993 (officially launched by the Director General of Health). As a spin-off from this unit, a Bone Bank was set up in 1993 and the first bone graft (allograft) was harvested, processed and used in 1994. The rapid development of orthopaedic surgeries has lead to the urgent need for Bone Banking facilities and we foresee such need and have set in motion the initial steps in the processing and storage of deep frozen bone grafts.

Although bone allografts are being widely used in orthopaedic surgery, many of clinicians appear to be unfamiliar with their preparation and processing as well astheir use as safe and effective graft materials. The major concerns associated with these materials are antigenicity and risk of disease transmission from donor to recipient. To minimize this risk, the production of an allograft worthy of distribution and implantation requires strict attention to detail through a comprehensive process and there is a commensurate increase in patients' demands for assurance that bank bone will not be infected with pathogens.

Knowledge of human bone allograft procurement, processing, and tracking may allow surgeons to better educate patients and address concerns about this valuable treatment option. The purpose is to furnish and update the current knowledge on processing, safety, and efficacy of allograft materials. The goals of bone banking are to preserve the physical integrity of the graft and the inductive protein, to reduce its immunogenicity, and to ensure sterility.

Bone banking has greatly increased the options for the surgeons in the management of severe osseous defects. Bone graft procedures are no longer limited by available autogenous bone. The possibility of disease transfer with bone allografts is very unlikely if the material is procured and processed according to tissue-banking protocols.

SA18 Addressing Bone Loss: Diagnostic And Management

Karina E M Besinga Hip Knee Geriatric Trauma Center Siloam Hospital Kebon Jeruk, Jakarta, Indonesia

Bone loss is found in revision total knee arthroplasty (TKA) but sometimes in primary TKA. The management should be based on defect size, location, patient specific factors, physical examination, supportive examination, surgeon expertise, and availability of bone graft, or more complex option of TKA system at the surgeon’s hospital or institution.

Keywords: knee arthroplasty, bone loss, diagnostic, management

SA19 Instability After TKA

Nor Hamdan Mohamad Yahaya Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

Instability after total knee arthroplasty is still among the leading cause of failure of total knee arthroplasty. The most important role of orthopaedic surgeon is to prevent of its occurrence by doing proper mechanical axis alignment and flexion- extension gap balancing.

The diagnosis of suspected knee instability after TKA begins with accurate and complete history including the instability symptoms and related history during perioperative period. A detailed physical examination includes varus valgus laxity in 0, 30 and 90 degrees; also anterior-posterior laxity.

Detailed radiographic analyses include stress view and full-length weight-bearing radiographs needed to assess the knee.

Types of instability include extension (varus –valgus) instability either symmetric or asymmetric, flexion (anterior-posterior) instability or global instability.

Surgical options for for post TKA instability include polyethylene exchange, single component revision, full component revision or hinged knee arthroplasty

SA20 The Painful TKA

Lai Choon Hin AP Centre for Joint Reconstruction Mt Elizabeth Novena Hospital, Singapore

TKA is a universally successful operation with good result and function. In rare circumstances, It can present as a painful joint both soon after surgery to many years later.

Causes of the painful knee ae many. But the common ones are reflex sympathetic dystrophy and other neurogenic causes, infection, malalignment and component malpositions, loosening, polyethylene wear and periprosthetic fractures. These will be discussed with how to diagnose and manage them accordingly

SA21 Help, My Knee Is Infected!

Thanainit Chotanaphuti Orthopedic department, Phramongkutklao Medical college, Bangkok, Thailand.

Periprosthetic joint infection is a very unsatisfying outcome to patients and surgeons. But early diagnosis and proper management can solve this situation. The most difficult procedure comes from improper steps of treatment. Good preoperative and operative procedure is all-important. When the patients came back to see the surgeon with suspicion of unexplained pain, infection should be considered. The first step before you left the patients is knee joint aspiration. Knee joint aspiration can make diagnosis and critical time to identify organism. If organism cannot identify, the outcome will be lower than we can do it. Before you take culture, make sure that the patients have antibiotic free interval no less than 2 weeks. To retain the prosthesis there should not have any signs of chronic infection. The evident for higher good outcome are early symptoms, usually less than 4 weeks of pain. Adequate debridement is extensively debridement, all synovial tissue and previously inserted should be removed. Prolonged antibiotic is important due to biofilm property. If there are any signs of chronic infection, the surgeon should not hesitate to talk with patients to remove the prosthesis. Two stage of reimplantation is world wide accepted because of the better outcome. Choice of antibiotic is the critical key of success. Before reimplantation especially in culture negative patients antibiotic free interval should be between 4 – 6 weeks with good clinical symptom and low CPR. PJI has a chance to recur and long period of treatment is unsatisfying. Keep talking with your patients. Many time of reoperation will make relationship terrible.

SA23 Management Of Peri-Implant Fractures Around A TKR

Jamal Ashraf Department of Orthopedics, UM&TC, Lucknow, India

Introduction: Fractures around total knee implants pose unique fixation challenges to the treating reconstructive orthopaedic surgeon, especially since no clear cut guidelines are available for their management. With increase in the aging population, joint replacement and fracture fixation is now indicated more often. Consequently, peri-implants fractures are also increasing exponentially. This increase is attributed to the higher life expectancy, poorer bone quality, and higher fall risk. This is most common in the femur and to a lesser degree in the tibia.

Material & Methods: This review presents an overview of the current diagnostic and treatment approaches, with the goal of providing a template for optimal decision making when dealing with these complex injuries. Pre-operative planning includes taking a detailed history of previous surgery, and assessing the patient for any signs of septic loosening. Complete radiological assessment is required to ascertain the type of fracture and stability of the implant. Failure to identify an unstable implant is likely to lead to treatment failure if osteosynthesis rather than revision arthroplasty is performed. The main risk factor is osteolysis associated with implant loosening. Other pathologic process that weaken bones like osteoporosis, RA, Paget’s dis. etc may also contribute to the risk of a perimplant fracture. In our review, the most common mechanism for sustaining these fractures was a low energy fall from sitting or standing position. As with all fracture fixation surgeries, pre-operative planning is essential. Planning begins with accurate classification of the fracture pattern.

Results: Final outcome may differ depending on fracture location, bone condition, primary implant stability, patient characteristics and surgeon experience. It is imperative that adequate and sufficient mechanical fixation be achieved in the treatment of these fixations.

Conclusion: It is crucial that the treating orthopaedic surgeon has a clear and effective treatment plan to manage these complex cases. The patient’s final outcome is dependent on fracture union, implant stability, early functional recovery, and return to pre-injury independence. Poor cortical bone quality is a common finding among a majority of the patients. Thus it is important that adequate and sufficient mechanical fixation be achieved in the treatment. Routine radiological follow-up of high-risk patients may help to identify loose implants and enable early intervention prior to fracture occurrence. SA24 Biomechanics Of Hip Arthroplasty

Charlee Sumettavanich Lerdsin General Hospital, Silom, Bang Rak, Bangkok 10500, Thailand

One of the most important factors to determine the long-term survival rate of total hip arthroplasty is wear of bearing couple. To achieve the lowest wear rate, there are many factors including bearing couple, position of implant and the restoration of hip biomechanics. Since the reaction force on the bearing couple is determine by the force from body weight, muscle function across the hip. All the parameter in hip biomechanics such as the load distribution, center of rotation, the medial offset, the neck-shaft angle, femoral head size etc. should be best considered to produce minimum joint reaction force. And the normal biomechanics should be comparing to the prosthesis design to achieve the best result for total hip arthroplasty.

SA25 How Do I Decide On My THR Implants

Shaifuzain Ab-Rahman Department of Orthopedic & Traumatology, School of Medicine, Universiti Sains Malaysia, Kubang Kerian, Malaysia.

It has been more than 50 years since the first modern total hip replacement (THR) implant, the Charnley hip apparatus has been performed. Back then, there was very little consideration given to the type of hip replacement to be done, as there were only a few choices available. Today due to rapid progress of technology in THR, there are many decisions to be made for an ideal choice of THR implant.

There are many factors to be considered for ideal features of THR implant. Good implant survival and proven track record, bearing surface and mode of implantation are among the major issue to be considered for ideal THR implant choices.

The hard on hard bearing surface such as ceramic on ceramic is gaining popularity due to its long survival bearing. It also allows bigger head size to be used for added stability. The uncemented implant is gaining popularity due to faster fixation and good survival record. Obviously, a surgeon must understand properties, advantages or disadvantages of the implant of his choice before the implantation. The support for future revision is also needed to be taken into consideration.

Interestingly, in Malaysia & many other ASEAN countries, financial support is one of the major determinants to help decide on an implant. Thus the patient’s input should always be included in the decision for implant choice.

As a conclusion, choice for THR implant is multifactorial. It is also a personal preference which is acceptable, as long as one could justify the choice of that particular implant by balancing advantages over disadvantages.

SA26 Surgical Approaches To The Hip

Mohammad Zaim Chilmi School of Medicine Airlangga University, Indonesia Department of Orthopaedic & Traumatology, Dr Soetomo General Hospital, Surabaya, Indonesia

Sir John Charnley popularized primary total hip arthoplasty in the early 1960s, total hip requires complete visualization of the acetabulum and proximal femur, and recognition of the surrounding landmark is crucial for the correct orientation and implantation of prosthetic components. The ultimate goal is to achieve adequate surgical exposure while minimizing complication. Several approaches had been developed, and today the most commonly performed methods for total hip arthroplasty are the anterior (Smith-Petersen), anterolateral (Watson-Jones), lateral (Hardinge), transtrochanteric lateral (Charnley), and posterior approaches (Moore-Gibson), with constant improvement in procedure and instruments - mini incision has been developed

SA27 Pre-Operative Templating For Total Hip Arthroplasty

Marcelino T. Cadag Philippine Orthopedic Institute, Makati, Philippines Makati Medical Center, Makati City, Makati, Philippines

Total hip arthroplasty is one of the most successful procedures in orthopedic surgery. However, surgical complications such as, component malposition, limb length inequality, fixation failure, and mechanical failure, remain important concerns. Many of these factors are greatly influenced by the surgeon; thus, a thorough pre-operative planning and templating may decrease the likelihood of arthroplasty failure.

SA28 NOF Fractures: Hemiarthroplasty Or THA?

Mark Chong Division of Hip & Knee Surgery, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074.

Established treatment options for displaced neck of femur fracture (NOF) include internal fixation with cannulated or sliding hip screws, hemiarthroplasty, or total hip replacement. Well recognised goals of surgical treatment are immediate pain relief, rapid mobilization and ambulation, accelerated rehabilitation, and maintenance of independent living.

In addition to these prerequisites, the ideal implant must be associated with a low risk of surgical complications and subsequent revision. At best, patients should not be hampered by the treated hip during their remaining lifetime.

The optimal approach for the surgical management of displaced femoral neck fractures remains unknown.

In a limited group of femoral neck fracture patients who have concurrent ipsilateral degenerative or inflammatory arthritis, total hip arthroplasty has been the treatment of choice. The evidence of the use of THR in the ‘active’ and independent elderly population is less clear.

We will explore the indications, current evidence including joint registry data, tips and techniques to avoid pitfalls in THR in the treatment of NOFs in the elderly population.

SA30 Recurrent Hip Dislocation Post THA

Viroj Larbpaiboonpong Department of Orthopedic Surgery, Police General Hospital,492/1 Rama Rd.,Bangkok,Thailand,10300

Post operation hip dislocation is one of the most common complication in Total Hip Arthroplasty (THA). It is very important to understanding all mechanism of hip dislocation, surgical technique, implant selection and patient selection.

To provide stability of hip is primary depend on soft tissue tension, head size, impingement.

Soft tissue tension is directly related to surgical approach, quality of soft tissue (eg, primary vs revision, scar, previous hip disease) and final THA offset.

Posterior approach trend to has higher dislocation rate more than other approach. How ever in skillful hand surgeon and appropriate soft tissue repair incidence of hip dislocation is not different from other approach.

Vertical offset affect to both soft tissue tension and leg length while horizontal offset affect only soft tissue tension.

Although all THA need both proper soft tissue tension and leg length equity. Stability of hip by soft tissue tension is much important than leg length equity.

Bigger head is better hip stable but limited by durable of liner material and neck diameter. Too thin liner is risk to volumetric wear in polyethylene or fracture in case of ceramic liner. Too thick liner result in smaller head and higher hip dislocation rate.

Too high head/neck ratio (small neck) is risk to fracture neck metal. Too low head/neck ratio is risk to impingement and dislocation.

Post operation care and rehabilitation program is also important to reduce post operation hip dislocation

In conclusion, all dislocation risks can be prevented by appropriate patient selection, skillful surgical technique, implant selection and post operation care program.

SA31 THA For Dysplastic Hips: Management Of LLD

Lai Choon Hin AP Centre for Joint Reconstruction Mt Elizabeth Novena Hospital, Singapore

THA is a universally successful operation with good result and function. Leg length discrepancy is not often encountered in most circumstances. However in patients with the more severe grades of dysplastic hips, leg length discrepancy is a major concern in unilateral cases. These patients present a challenging and interesting situation for the surgeon especially for those who do less than 50 cases of hip replacement a year

The problems of reducing the hip to the original acetabular position from a high riding supracetabular position are many with the risks of injuring the neurovascular structures. The issue of leg length discrepancy need to be considered and managed carefully. These will be discussed in my presentation

SA32 THA For Dysplastic Hips: Determining Cup Position And Femoral Version

Azhar M Merican University of Malaya Medical Centre, Kuala Lumpur, Malaysia

Dysplasia presents as a spectrum. In its most severe form, congenital dislocation of the hip, the hip is dislocated and the acetabulum and head is rudimentary. The true acetabulum although undeveloped is the best location for the prosthetic cup. Small implants are essential, femoral shortening may be required and surgery is not easy. In moderately severe dysplasia, there is a psedoacetabulum and subluxation and in less severe dysplasia the acetabular cup is shallow and lengthened from superior to inferior. The surgical goals remain 1.Avoid infection and complications 2.Good fixation & orientation of implants 3. Achieve a stable hip 4.Restore or preserve bone stock and 5. Achieve good biomechanics with restoration of the hip centre. In achieving one goal, the other may be some what compromised. Depending on the individual patient, the individual goals have different priority. A younger patient would benefit from bringing the hip down to the true acetabulum, giving optimal biomechanics in terms of joint reaction forces that should translate to better wear and loosening rates. However, this would necessitate dealing with the resultant acetabular defect by autograft (particulate or bulk) or other options utilised in revision surgery, (large cups, impaction grafting or augments). The younger the patient the more desirable it is to restore defect with graft, ideally autograft. In the older patients augments can be used. Alternatively, the older patient may be better served with a high hip centre especially when the hip is stiff or when better host bone fixation can be achieved there with less complexity for defect reconstruction. Fixation at a slightly higher hip centre with medialising would not be too detrimental for biomechanics. Overreaming to a larger size to chase the posterior inferior dimension of the shallow elongated cup will damage the anterior and posterior walls which are important for implant stability.Native neck version may be excessive. This necessitates the use of a modular stem or a small cemented stem allowing the surgeon to dial the stem to 10 to 15 degrees relative to the tangent of tibia in the 90 degree flexed knee

SA33 Total Hip Arthroplasty Following Acetabular Fractures

Deejay Manuel Pacheco Veterans Memorial Medical Center, Quezon City, Metro Manila, Philippines University of Santo Tomas, Manila, Philippines

While open reduction and internal fixation has always been the preferred method of treatment for most displaced acetabular fractures, there have been increasing evidence that certain types have a poor outcome, notable in patients with osteopenic or osteoporotic bone. Total hip arthroplasty (THA) may serve as an excellent option in terms of functional outcome subsequently offering the patient a better quality of life. The speaker will be discussing when it would be favorable to do a THA following acetabular fractures (Acute THA vs. Delayed THA), review the current evidence, and give a few clinical pearls in his current practice.

SA34 Osteonecrosis Of The Femoral Head: How To Preserve The Head?

Taek Rim Yoon Chonnam National University Hospital, Gwangju, Korea

Osteonecrosis(Avascular Necrosis) of the femoral head is developed due to the interruption of the blood supply to the head, which leads to collapse and final destruction of the joint.

There has been a lot of debate on the successful treatment ranging from observation, nonsurgical treatment, head preserving surgery, and hip replacement surgery.

Early diagnosis and intervention is very important to a successful outcome. However, many patients find it in a quite later stage.

As the results of total hip arthroplasty has been better and better due to the improvement of the materials and design of the implants, the indication for joint-preserving surgery gradually decreased. However, there remains many young patients who still need joint preserving procedures.

The indication joint-preserving surgery in the treatment of this disease should be considered individually based on clinical and radiographic situation. Many surgeons agree that the results are better when the surgery is performed before collapse of the femoral head. Various types of head preserving surgeries has been performed: multiple drilling, core decompression with or without cell therapy, tantalum trabecular implantation, impaction bone graft, viable bone graft(vessel-pedicle bone graft, free vascularized fibular graft, muscle-pedicle bone graft), and various types of osteotomy. . In this presentation, I will discuss about my personal experiences on the femoral head preserving surgery focused on the rotational osteotomy and viable bone grafting.

I believe the head preserving surgery should be considered before THA in young patients. The result depends on patient selection, choice of surgical methods, and the surgeon’s skill.

SA36 Computer Assisted: Navigation & PSI In THA

Pornpavit Sriphirom Orthopedic Department, College of Medicine, Rangsit University, Bangkok, Thailand Orthopedic Department, Rajavithi Hospital, Bangkok, Thailand

Computer assisted surgery in Orthopedic surgery was began more than 20 years ago. The navigation system instrument and software have already been developed for this area. The navigation system is currently the most popular system in Europe and America. The navigation is used for surgery in hip/knee arthroplasty, spine, sport and traumatology. However, the computer navigation system has quickly developed in hip and knee arthroplasty. Many Orthopedics surgeons used navigation TKA more than THA as there are many results and publications in CAS TKA The highlight of this presentation is on computer navigation system for total hip arthroplasty. The objectives is to report the short-term and long-term results of CAS THA, to review the results of advantage and disadvantage of navigation THA, and to compare radiographic outcomes of conventional method THA to the CAS THA. Our review of the literature in meta-analysis of CAS THA shows improved accuracy in post-operative radiograph of acetabulum cup position especially inclination angle comparing to the conventional THA technique. The improvement is however less in ante-version angle. CAS THA has excellent control the limb length discrepancy. For clinical result, the CAS THA and the conventional THA technique has no significant differences result. Somes reported of pin tract infection. The new technique of acetabular cup position “Combined ante- version technique” by CAS THA. This theory be difference from Lewinnek et al, “safe zone“can improve in CAS THA. Other computer assisted THA is Patient Specific Surgery “PSI.” PSI THA is a new technique using radiographic (CT or MRI) to plan component size and position by designing the custom mold for acetabulum reaming and femoral neck cut. This presentation reviews design concept and result of PSI THA comparing to the conventional THA technique. FA01 Impact Factor In Tissue Tension Of Extension And Flexion Gap Balance In Computer Assisted Surgery Total Knee Replacement (CAS TKR)

Bernard Devadasan1, C.L Teng2 1Mawar Renal Medical Centre, Jalan Rasah, 70300 Seremban, , Malaysia 2International Medical University, Jalan Rasah, 70300 Seremban, Negeri Sembilan, Malaysia

INTRODUCTION: CONCLUSIONS: CAS TKR is aimed to improve accuracy in Change of tissue spreader tension in EG or FG realignment with balanced knee joint. The causes improper registration with mismatch in Aim: To measure gap balance to assess EG/FG/Bone cut. This study provides a effectiveness of CAS on ligament balance baseline to further assess and develop the using gap balancing approach with tibia 1st concept of optimal soft tissue balance as cut. ligaments function properly only with the desired isometry in gap balancing technique. METHODS: OrthoPilot system with 4.3 software and Statistical evaluation with Testimate Version 6.0, IDV Gaunting Germany with a two sided Wilcoxon-Pratt test ( P<0.05) used simulating errors in extension and flexion gap balance. P1, control with 16 datasets created and P2-P7 (96 case series) was propagated with ±3mm variants in extension and flexion gap both medial and lateral, only varying 1, keeping others constant. Controls fixed: distal transverse plane cut at 0° to femoral mechanical axis in frontal plane and 3°external rotation in sagittal plane. Tibia cut 90° to mechanical axis. Mechanical axis constant 0° and gap balance 0mm. Deviations in gap errors using trigonometrical calculations based on E-Motion femoral implant, size/thickness; 3/7mm and 4/8.5mm with variation of insert size 10/12mm equal to sum of gap and bone cut.

RESULTS: Over tensioning (OT) distal lateral extension gap (DLEG) causes tight distal medial extension gap (DMEG). Under tensioning (UT) DLEG causes loose posterior medial flexion gap (PMFG). UT DLEG causes tight DLEG. Impact factor >2mm increased PMFG with lateral lift off with only PMFG as variant. Increasing PMFG >2mm caused lax PMFG. UT even by 1mm PMFG causes error by notching and tight PMFG. A considerable number of errors observed in frontal plane of femur. Relationships between OT/UT analyzed by Spearman rank ratio p<0.001.

FA02 Permanent Mobile Cement Spacer In Octagenarians With Infected Total Knee Replacement-Innovative Technique

Bernard Devadasan Mawar Medical Centre, 71, Jalan Rasah, 70300 Seremban, Negeri Seremban, Malaysia.

INTRODUCTION: articulating spacer has greater volume for Antibiotic-loaded cement spacers allows antibiotic elution with a well contoured delivery of local antimicrobial agents and polished surface articulation. Cement maintenance of collateral ligament length in articulating spacers require precise mechanical infected knee replacement usually before a alignment and tissue tension. The bone loss second stage revision total knee surgery. In requires reconstruction with cement. The compromised or elderly patients, this cement correct size of the prosthesis needs to be spacer can act as a permanent spacer to allow replicated. The flexion and extension gaps full weight bearing. need to be balanced. The femoral implant is 1st implanted and then the tibial cement spacer METHODS: which is made as a unit with the tibial insert. 2 techniques are described. 1. Spacer made This allows proper tissue tension and from Dental Alginate preformed mould. This maintains length. Elution of antibiotic is an innovative technique with the alternative impregnated cement requires careful mixing of a post-cam posterior stabilized knee and sufficient time to prepare the mould. replicating the original component. Custom Extension stems using Steinmann pin with the mould made intra-operatively with Palacos mechanical axis of the stem extension in the antibiotic loaded cement decided on cultures femur and tibia must be aligned. prior to operation to protect the implants from bacterial colonization and sustained antibiotic CONCLUSION: elution levels for 4 to 6 weeks. Mobile cement articulating spacers provide a The extracted components after autoclaving salvage method from arthrodesis of the knee was inserted into impression mould and bone and as a permanent articulating spacer. cement filled in the mould in the late doughy Combined Palacos with vancomycin provide phase. The insert is incorporated with the an effective coverage as compared to tibial prosthesis to provide a single interphase intravenous antibiotics. Sterilized dentists’ between the femur and tibia. After the cement impression material of hydrophilic addition had set, the mould surrounding was removed silicone and polyether have similar distortion to have an identical silicone impression of effects for transfer procedures when using the implant prosthesis. 2. Implant Cast direct impression technique which is simple (Germany) preformed mold. and economic in elderly patients as a permanent spacer. RESULTS: Infection was eradicated with debridement and REFERENCES: removal of the infected prosthesis. Patients Hofmann, Aaron A MD; Goldberg, Tyler MD; allowed full weight bearing with an Tanner, Amie M BS; Kurtin, Stephen M MD. articulating cement spacer. The mechanical Clinical Orthopaedics & Related Research. axis was maintained with corrected knee 430:125-131, January 2005. alignment. The average American Knee Society Score was 63.2, and function score was 50.9. Mean maximum flexion was 90°.

DISCUSSIONS: The articulating spacer in situ can be a definitive treatment without revision TKA in elderly patients. An all-cement surface FA03 Fretting Corrosion At Modular Taper Junction: What About Ceramic Femoral Heads?

Zimmermann M; Pandorf T; Streicher RM CeramTec GmbH, CeramTec-Platz 1-9, 73207 Plochingen, Germany.

INTRODUCTION: metal ball heads showed signs of corrosion. The significance of fretting and corrosion in The taper angle difference (same modular hip endoprostheses has been more manufacturer) showed no significant influence and more discussed in the last years ([1], [2]). on the fretting-corrosion behavior, neither in The tissue reaction of the herewith released the cohort of ceramic nor in the cohort of metal ions and -particles may lead to revision metal ball heads. rates of 4-15%. Especially bearing couples B) No significant influence of the surface with large diameters may experience high structure of the stem taper on the fretting- frictional moments leading to increased micro corrosion values has been determined. It has to movements in the taper connections. Goal of be remarked that the fretting phenomena of the these investigations was to determine the CoCr ball head trunnions are 5 to 10 times influence of the ball head material, the taper higher compared to those on the stem taper. angle difference between ball head and stem, and the roughness of the stem taper on the DISCUSSION: fretting and corrosion behavior using The results of the fretting and corrosion retrievals. investigations using retrievals show a significant decrease of the corrosion hazard METHODS: when ceramic ball heads are used. This is A) To determine the influence of the ball head mainly due to the finding that most of the material and the taper angle difference on fretting phenomena are observed at the fretting and corrosion, matched cohorts of 50 trunnions of the CoCr ball heads whereas the ceramic and 50 CoCr head-stems retrievals of ceramic ball heads exhibit no material loss at the same manufacturer were measured to all. An influence of the taper angle difference exclude mix-and-match influences. The or the stem taper roughness could not be qualitative visual fretting-corrosion scores observed. were compared with the quantitative volumetric loss for correlations. REFERENCES : B) To determine the influence of the [1] Chana et al., JBJS(BR) 2012 roughness of the stem taper, 398 explanted [2] Gill et al., JBJS(BR) 2012 metal ball heads from CoCr/PE bearing [3] Higgs et al., JOA 2013 couples were examined. In 171 combinations, the stem material was Ti6AL4V, in 227 CoCr. Each 203 taper surfaces without (<4 microns average roughness) and 195 with micro structure were paired to minimize other influencing factors.

RESULTS: A) The taper surfaces were qualitatively evaluated using a modified Goldberg score [3] as well as quantitatively using a validated quantification method. It could be shown that the fretting and corrosion scores of stems with ceramic ball heads were significantly lower (p=0,03, Wilcoxon-Test) than with metal ball heads. Additionally, only the trunnions of the FA04 Periprosthetic Joint Infection in THA: Does the Bearing Surface Play a Role?

Zimmermann M; Streicher RM CeramTec GmbH, CeramTec-Platz 1-9, 73207 Plochingen, Germany.

INTRODUCTION: dislocation. Cox multivariate analysis revealed The significance of periprosthetic joint an independent, significant influence of the infection (PJI) in total hip arthroplasty (THA) bearing material for revision due to the and its devastating consequences has been diagnosis of PJI. The hazard ratio for MoM was realized more and more in the recent years [1]. 2.6 to 3.0 significantly increased compared to Apart from patient, hospital and surgical factors MoP, confirming the consensus that this material topography and chemical composition bearing combination has an increased risk of can influence bacterial colonization of PJI. On the contrary, the hazard ratio was orthopaedic implants. Other material reduced to 0.55-0.9 when ceramic components characteristics such as roughness, molecular were used compared to MoP, see Fig. 1: composition, pH and ionic content can also influence bacterial adhesion [2]. Recent studies related to the various causes of hip revisions indicate that actually a large part of the revision due to aseptic loosening were in fact due to PJI [3]. The goal of the paper is to analyse the potential effect of implant bearing materials on the incidence of reported revisions for PJI based on several national and regional registries.

METHODS:

Revision reasons of cementless primary THA DISCUSSION: procedures for PJI from nine joint replacement This study based on a huge patient collection registries with a total of 762’880 patients have from various registers demonstrates that the been analysed in detail by using statistical bearing material is an independent risk factor methods to determine if the bearing materials is for revisions due to PJI. MoM increases its an independent risk factor for PJI. Following incidence substantially, while the use of bearing couples have been analysed: ceramic- ceramic components (CoP, CoC) can mitigates on-ceramic (CoC), ceramic-on-polyethylene this risk by 10-45%. Substituting Co based (CoP), metal-on-polyethylene (MoP) and alloy bearing by a stable, non-ion releasing metal-on-metal (MoM). In general only ceramic component seems to reduce the risk of degenerative joint desease patients were this devastating complication with an included in the analysis to reduce the number advantage for CoC articulations. of potential confounders for PJI. Cox multivariate analysis of several common REFERENCES: confounding factors for PJI was applied. In [1] Parvizi et al., Bone and Joint Journal 2015 order to compare the results from the various [2] Rimondini et al., Journal of Applied registries, the revision rates obtained have been Biomaterials & Biomechanics 2005 normalized to MoP bearing being assigned 1 [3] Gundtoft et al., Acta Orthopaedica 2015 (100%).

RESULTS: The overall revision rate of primary THA due to PJI was 0.4 to 1.2%. PJI is the reason for 10- 16% of the revision burden, making it the number three reason after aseptic loosening and FA06 Femoral Neck Fractures: The Paradigm Shift Towards Total Hip Arthroplasty? A 5 Year Retrospective Review Of Local Surgical Trends And Outcomes In Two Tertiary Hospitals

1Rampal S; 2 Chopra S; 2Kassim AF; 2Chen BJ ; 2 Kishanraj K; 3 Pinzon AA; 4 Wong YJ; 4 Paul P 1 Department Orthopaedic,Faculty of Medicine,University Putra Malaysia, 43000 Serdang, Selangor, Malaysia 2Department Orthopaedic,Sultanah Bahiyah Hospital, Ministry of Health Malaysia, 05100 Alor Setar, , Malaysia 3Department of Orthopaedic, Javeriana University ,1100100 Bogota,Colombia 4Hospital Serdang,Ministry of Health Malaysia, Jalan Puchong, 43000 Serdang, Selangor, Malaysia.

INTRODUCTION: Displaced femoral neck fractures are common 9 with screw fixation total hip replacement 6 cause of poor morbidity and mortality. Serious surgery (42percent). health, social and cost issues need to DISCUSSION: addressed by evidence based medicine. The Our retrospective review showed that current aim of this study was to compare the current surgeon prefer to replace the head of femur in surgical trends, peri-operative morbidity and elderly with total hip replacement and fix it outcomes of different types of fixation. MATERIALS & METHODS: A total of 224 (median age 73 Years) subjects were treated at Hospital Serdang and Hospital Sultanah Bahiyah. Subjects consist of 83 male and 141 females. The subject were treated by multiple resident surgeons which had undertaken 51 internal fixation (32 screw fixation,13 Dynamic Hip Screw(DHS) and 6 cephalomedullary fixation) ,40 unipolar replacement , 54 hemiarthroplasty and 79 total hip replacement. Perioperative factors including operation time in minutes, pain analyzed with visual analogue score, infection rates, time to full ambulation in months, need for revision surgery and non union rates were assessed retrospectively. The statistical with extra medullary screw in younger age analyses were conducted using Statistical group. Our study also outlines the poorer Package of the Social Sciences (SPSS) version outcomes when dealing with younger age 22.0 for Windows (SPSS Inc, Chicago, IL). group. RESULTS: CONCLUSION: Current trend of treating elderly neck fracture Conventional trends of treating elderly with is by total hip replacement (THR) (Figure 1). internal fixation first is not recommended. Our Time to full ambulation was significantly study suggest THR as primary treatment for faster in the first 3 month with replacement the elderly. group especially THR (Figure2). Operating REFERENCES: time and post operative pain was comparable 1. Sendtner E; Renkawitz T;Kramny P Et Al : in all groups. Infection and non union rates Fractured Neck Of Femur –Internal Fixation were significantly higher in the internal Versus Arthroplasty. Dt Sch Arzebl Int fixation group especially with screw fixation. 2010;107(23):401- We report 19 revision surgeries which mainly 7;DOI:10.3238/Arztebl.2010.0401 FA07 Total Hip Replacement Acetabular Posterior Superior Screw : How Long Do U Need It? A 5 Year Retrospective Of How Long Posterior Superior Screw Used In Tertiary Hospital

1Rampal S; 2 Chopra S; 2Kassim AF; 2Chen BJ ;2 Teh HL ;3 Lingesh 1 Department Orthopaedic, Faculty of Medicine, University Putra Malaysia, Jalan UPM, 43000 Serdang, Selangor, Malaysia 2Department Orthopaedic,Sultanah Bahiyah Hospital, Ministry of Health Malaysia, 05100 Alor Setar, Kedah, Malaysia

INTRODUCTION: number of patients Safe zones of the acetabular is variable at times due to anatomical variants. Placing a too long screw at times can cause increased morbidity and mortality.Our aim in this fair retrospective review was to look at the average screw size used for posterior superior screw colomn in total hip replacement, its functional outcomes and perioperative results. BAR CHART SHOWS THE HARIS HIP SCORE AT 9 MONTHS. METHODS: All patients who underwent total hip DISCUSSIONS: replacement at Sultanah Bahiyah Hospital Our study outlines the the common acetabular Alor Setar was included into the study from defect is type 1. duration of 2010 to 2014. A total of 111 subjects were included in study with 87 female CONCLUSION: and 24 male. The subject age ranged from 49 Screw sizes hould be less than 40 mm to have years to 88 years old. Subjects were treated by minimal damage. 2 resident surgeons and had successfully conducted surgeries with 3 implant products ( REFERENCES: Zimmer, Stryker and Johnson and Johnson 1. Jui-Ting Hsu et al Effects US). Pre operative Acetabular Paporsky Grade of screw eccentricity on the initial stability of (radiographs) and functional outcomes using the acetabular cup. Int Orthop. 2007 Haris hip Score were assessed retrospectively. August; 31(4): 451–455

RESULTS: The most common grade of acetabular defect is type 1 with Stryker implant being commonly used(80percent Figure 1).Most patients experience significantly better results at 6 month and 9 months follow up on haris hip score.(figure 2).

Line chart 1 shows paporsky grading of acetabular defect

FA08 A Prospective Comparative Study Of Functional Outcome Of Total Knee Arthroplasty (TKA) For Primary Osteoarthritis In Patients Aged Less Than 60 Years.

Vijaya Kumar SL1; Ashutosh Rao2; Tan CS1; Chew YW1; Vijay Kumar1 1 Hospital Sultan Abdul Halim, Sungai Petani, Jalan Lencongan Timur, Bandar Amanjaya, 08000 Sungai Petani, Kedah, Malaysia 2Melaka Manipal Medical College, Jalan Padang Jambu, Bukit Baru, 75150 Melaka, Malaysia

INTRODUCTION: of patients. We also observed 2.7% (n=6) Arthritic disease in active, younger patients (< patients to have postoperative persistent knee 60 years) is not uncommon and its prevalence is pain. Our patients in the cohort had a mean expected to increase1. More recently, there has post-operative KSS score of 77.98 (± 10) and been a trend of offering knee arthroplasty as an WOMAC score of 93.28 (±7). option to provide pain relief and improve function in the active, younger patient with Table 1: Baseline Characteristic of Study knee osteoarthritis2,3. Subject

OBJECTIVE: Mean± SD Study on functional outcome in patients Age of TKA(years) 63.94 (±8) requiring TKA in the younger age group (<60 BMI (Kg/m2) 28.81 (±5) years) as measured by standard outcome scores Months of follow up 51.52 (± 25) when compared to those aged more than 60 post-operative KSS 77.98 (± 10) years. post-operative 93.28 (±7) WOMAC METHODS: Data of Hospital Arthroplasty Registry revealed Table2: Comparison of functional score in age that 384 patients had undergone primary TKA. groups less than 60 and above 60 years. However, only 224 cases had minimum 6 months post-operative review data. All 224 FACTORS MEAN ± SD p-value cases were evaluated clinically and KSS Score radiologically till the last follow up. Exclusion ≤60 years 38.66 (±20) 0.628 criteria were adhered to in patient selection. All >60 years 37.07 (±24) patients underwent standard primary TKA WOMAC Score using FDA approved implants. Pre and post- ≤60 years 40.52 (±15) 0.126 operative clinical evaluation was done using >60 years 37.08 (±16) Knee Society (KSS) and WOMAC scores to measure functional outcome. DISCUSSIONS / CONCLUSION: RESULTS: In the entire cohort of 224 cases, 87.5% (n=196) The mean follow up of all the 224 TKA cases had good to excellent post-operative KSS score was 51.52 months. 83.9% patients in the cohort (mean = 77.98±10), while only 4% (n=9) had (n=188) were female. 32.6% (n=73) were <60 poor post-operative KSS score. 68.5% (n=50) years old. The p-value for KSS and WOMAC cases belonged to <60 age group. The mean score in the two age groups showed no post-operative WOMAC score was 93.28 (±7) statistical significant difference (Table 2). Sub- in our TKA cohort of younger aged patients. analysis reveal similar clinical improvement In conclusion, our study of 224 primary TKR irrespective of patella resurfacing among both with minimum 51.52 months follow up had group (p >0.05) in our cohort, TKA revision 87.5% of patients with good to excellent rate was 1.33% (n=3), all revision were due to outcome in functional score among both sub groups, which is comparable with existent aseptic loosening of implant. Intra-operative 4 manipulation of knee was done to 1.33% (n=3) literature .

ABSTRACT TRUNCATED FA09 Reducing Blood Loss In Total Knee Replacement

1Tung Sing, Wong; 1Azlina Amir Abbas; 1Azhar Mahmood Merican ; 1Chan Chee Ken ; 2Fahrudin Che Hamzah; 2Siti Munira Binti Seri Masran 1Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia. 2Department of Orthopaedic Surgery, University Putra Malaysia (UPM) 43400 Serdang, Selangor, Malaysia

INTRODUCTION: allogenic transfusion rate. Obesity and Total knee replacement (TKR) surgery may be increase duration of surgery were identified as associated with substantial blood loss the risk factors for increased calculated total requiring transfusion which is associated with blood loss. No symptomatic deep vein transmission of infectious diseases, thrombosis or pulmonary embolism was found haemolysis, immune sensitization, transfusion in all patients. related acute lung injury and even death. (1) Tranexamic acid (TA) is an anti-fibrinolytic Figure 1: Total Blood Loss in Unilateral TKR drug that is commonly used to reduce bleeding during total knee replacement. (2) However, the efficacy and the ideal method of tranexamic acid administration still remain controversial. In this study, we will investigate the blood saving effect of tranexamic acid in patients undergoing unilateral and simultaneous bilateral total knee replacement. Figure 2: Total blood loss in Bilateral TKR

METHODS: This prospective randomised controlled study was conducted in two centres (University Malaya Medical Centre and Serdang Hospital). Patients undergoing unilateral or bilateral total knee replacement were included in the study. Patients were randomised to one of the four groups (Group 1 = Intravenous tranexamic acid; Group 2 = Topical Figure 3: Maximum Haemoglbin Decline in tranexamic acid; Group 3 = Combination of Unilateral TKR intravenous and topical tranexamic acid; Group 4 = Control group). Targeted sample sizes were 20 patients per group. Randomization was by means of sequentially numbered, opaque sealed envelopes (SNOSE).

RESULTS:

In unilateral TKR patients, tranexamic acid Figure 4: Maximum Haemoglobin decline in (TA) groups had significant less calculated Bilateral TKR total blood loss, haemoglobin decline and total drain volume than the control group. However, there was no difference in term of allogenic blood transfusion rate. In bilateral TKR patients, the TA groups showed no differences in the calculated total blood loss and haemoglobin decline but the combined group showed a significant reduction in the ABSTRACT TRUNCATED FA10 Measurement Of Femoral Anteversion And Its Relation To Lesser Trochanter And Linea Aspera; A 3D CT Study

Thjudeen, Z; Hashim, MS; Merican, AM Division of Joint Replacement, Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia.

INTRODUCTION: RESULTS: Total Hip Arthroplasty is a common Mean femoral anteversion was 11.84º ± orthopaedic procedure performed for various 10.06º. Mean linea aspera and lesser indications and has a high success rate. trochanter version was 7.27º ± 12.17º and Understanding the rotational morphology of 38.54º ± 7.86º respectively. There has been no the femur gives an understanding of final previous studies measuring linea aspera and component position and is important to lesser trochanter version, however femoral achieve optimal hip biomechanics in hip anteversion was similar to previous studies. arthroplasty. Radiological study of femoral This study found that there was a good inverse rotational profile has been done previously on correlation between femoral anteversion and plain radiograph, cadaver, CT scan and 3D- linea aspera version, and lesser trochanter CT. However plain radiographs has inherent version with r value of -0.85 and -0.72 errors in measurement due to positioning and respectively. magnification. Published studies involving 3D CT scan is still limited worldwide and focuses DISCUSSIONS: on Caucasians. The main objective of this In this study, a reliable method has been study was to [1] develop a reproducible and developed to measure femoral anteversion accurate measurement of femoral anteversion using 3D reconstruction of the femur from CT using a 3D femoral computer model scans. In addition, lesser trochanter version reconstructed from CT scans, [2] determine a can be used as a guide to estimate femoral relationship between lesser trochanter version anteversion during total hip arthroplasty. and femoral anteversion as an additional bony Finally, linea aspera version can also be used landmark to assist in implant positioning as an additional landmark to estimate femoral intraoperatively and [3] determine relationship anteversion, which is a useful parameter in between linea aspera version and femoral pre-operative planning. anteversion as an additional landmark to assist in pre-operative planning. CONCLUSION: The lesser trochanter and linea aspera are METHODS: important landmarks that can be used to CT scans of 100 patients, with equally determine final femoral component position to distributed number of males and females, in achieve optimal hip biomechanics in total hip raw format were converted into 3D using a athroplasty. commercially available software, Materialise Mimics (Belgium). A new method was developed to align the femur to its anatomical and neck axis to produce accurate and reliable measurement of femoral anteversion, which is used as a reference point to determine the rotational profile of the linea aspera and lesser trochanter. The rotational profile of the linea aspera and lesser trochanteris termed linea aspera and lesser trochanter version respectively. Interobserver and intraobserver reliability was > 0.95 for each parameters measured using Intraclass Correlation (ICC). SPL02 Prevention Of Perioperative Infection: Role Of Evidence-Based Practices To Improve Patient Outcomes In Total Joint Surgery

Charles E. Edmiston, Jr Medical College of Wisconsin, Milwaukee, WI 53226 USA

Infection is the most common indication for revision of TKA and the third most common indication in THA. S. aureus and coagulase negative staphylococci are the most common pathogens associated with orthopaedic SSI. The major of infections involve a microbial biofilm, recalcitrant to traditional antimicrobial therapy. The goal of reducing the risk of prosthetic joint infections involves embracing an evidence-based pathway. In 2016, the Center for Disease Control (CDC) released revised Guidelines for the Prevention of SSI that includes strategies for reducing the risk of orthopaedic-associated infections. The following evidence-based strategies warrant consideration: Antimicrobial Prophylaxis - Patients should be dosed 30 to 45 minutes prior to skin incision; dosing should be weight-based (3 grams if >120 kg); Preadmission Antiseptic Showering -To reduce the microbial burden on the skin, patients should take 2 standardized antiseptic showers, the agent of choice is chlorhexidine gluconate (CHG). Patients who cannot shower prior to surgery should have their skin cleansed using an antiseptic agent (CHG) at hospital admission; Preadmission Staphylococcal Surveillance - Because of the risk of staphylococcal total joint infection, patients should be screened for MRSA or MSSA skin colonization. Recovery of these organisms from a nasal swab is presumptive evidence of skin colonization in other remote locations on the body. Patients positive for MRSA or MSSA should undergo a decolonization regimen involving 5-7 days of mupirocin (BID) and two preadmission antiseptic (CHG) showers. Intraoperative antiseptic irrigation - Irrigation with dilute 0.35% povidone iodine or 0.05% CHG has been suggested to be an effect strategy for removing residual bacterial contamination prior to closure; Antimicrobial Sutures - Evidence-based meta-analysis and CDC recommendation suggests triclosan-coated sutures are effective for reducing the risk of superficial and deep incisional SSI. Furthermore, skin closure with clips is viewed by evidence-based metrics to be a risk factor for postoperative surgical site infections. Current demographic data suggests that future candidates for total joint procedures will present with multiple comorbid risk factors, requiring that surgical practitioners embrace evidence-based “bundled” practices that reduce risk, while improving patient outcomes.

SPL03 Biofilm And Implant Related Infection: How To Win The Battle

T Fintan Moriarty AO Research Institute Davos, Davos, Switzerland

The most significant virulence factors retained by the most successful pathogens causing implant related bone infection are biofilm formation, adhesion to host-tissue components and inactivation of host defense mechanisms. Many bacteria retain the ability to adhere and attach to the surface of implanted materials, and once adherent on the implanted device, many bacteria will rapidly form a complex biofilm and adapt their metabolism and gene expression profile accordingly. The ability of bacterial biofilms to resist antibiotic therapy is one of the key challenges in treating implant- associated infections. Bacterial biofilms have been described to resist antibiotic concentrations over 1,000 times higher than that described for non-biofilm-growing (so-called planktonic or free floating) bacteria. In brief, biofilm growth offers bacteria protection against antibiotics by features such as reduced metabolic activity within the biofilm, reduced penetration of antibiotics due to the extracellular polymeric substances that surround the bacterial cell, and the generation of phenotypically distinct populations with distinct metabolic activity with the biofilm. It should be noted that there are some antibiotics with activity against biofilm, i.e., rifampin against Gram- positive biofilms, and quinolones against Gram-negative biofilms. As such, these antibiotics are crucial in the treatment of established infection. The limitations of current treatment regimens, as well as performance targets for next generation interventional strategies targeting the biofilm will be discussed in this presentation.

SHU01 Volunteering: How To Help Responsibly

Shalimar Abdullah Mercy Malaysia Medical Relief Society Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

Many of us with good intentions embark on volunteerism as a way to help relief the burden of others. However many times this noble intentions can result in a hindrance to those we are helping and prevent real assistance from arriving to beneficiaries. (Note: Victims are referred to as beneficiaries)

Issues which will be discussed include unnecessary donation of goods eg clothes, shoes, food, toys and mixed items. The best item to donate would be monetary donation and reasons to support this.

Our attitude too can psychologically affect others with unrealistic promises. Attitudes not to share with beneficiaries include statements telling them we know how exactly they feel as we do not, giving false hopes and taking undignified photos of suffering beneficiaries and splashing them all over social media.

Preparation and training of volunteers are vital. “Volun-tourists” are to be avoided at all costs. The media as a powerful influencing factor should not be forgotten.

It is easier for most of us to join an institution or NGO or society as a means to assist. However ensure your institution / NGO / society is accountable. The needs assessment is the first vital step to ensure the appropriate help is rendered rather than wishful assumptions of what we think beneficiaries require.

We ourselves are accountable for our actions to ensure we help responsibly.

SHU02 Humanitarian: Kelantan Floods 2014

Nor Faissal Yasin Department Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

Floods are an annual occurrence of varying severities in Kelantan state on the east coast of . They also affect its neighbouring states, especially and Pahang. Previous floods, including those of 1927 and 1967, were considered significant in Kelantan’s history. The 1967 flood had a major impact on the Kelantan population; but the 2014 flood was the most significant and largest recorded flood in the history of Kelantan. It was considered to be a “tsunami-like disaster” in which 202,000 victims were displaced. This flood was called ‘Bah Kuning’ (yellow-coloured flood) because of its high mud content.

The flood has caused a major national disaster and volunteers began to arrive in Kelantan on the 28th of December 2014. Most of the volunteers were healthcare providers from universities and the Ministry of Health. A total of 261 volunteers registered with the Volunteer Operations Office (Bilik Gerakan Banjir Sukarelawan HUSM) to assist with the administration of healthcare services. Coordination between the volunteers with all of the departments in HUSM and JKN Kelantan was also a challenge during the disaster.

Volunteerism is important during a national disaster and all of us should be part of a humanitarian effort regardless of our medical field.

SHU04 The Nepal Earthquake 2015, MERCY Malaysia’s Emergency Response

Mohamed Ashraff Bin Mohd Ariff Mercy Malaysia, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia

Mercy Malaysia (MM) is an international NGO based in Kuala Lumpur. It is a Volunteer Relief Organization that provides medical and humanitarian services both locally and abroad. MM implements its programmes based on the Total Disaster Risk Management framework which was adopted by the UN in 2005. Part of the framework is emergency medical response to disasters.

On the 25th April 2015 a magnitude 7.8 earthquake struck the northwest of Kathmandu, Nepal. MM through the coordination of UNOCHA (United Nations Office for the Coordination of Humanitarian Affairs) deployed a specialist medical team and field hospital (FMT Type 2) to Sankhu, an ancient Newar town 17km on the outskirts of Kathmandu. Large parts of Sankhu were reduced to rubble. Fortunately there weren't that many serious casualties.

We ended our field hospital operations on 30th May 2015. By the time we wrapped up we had treated a total of 786 patients.

SPH01 Physiotherapy Management Of Orthopaedic Conditions

Nur Hidayah Ong Abdullah Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia.

World Confederation of Physical Therapy, 1999 defined physiotherapy as a healthcare profession which provides services to people and population, to develop, maintain and restore maximum movement and functional ability throughout the life span. Physiotherapy is concerned with identifying and maximizing movement potential within the spheres of promotion, prevention, treatment and rehabilitation. Physiotherapy uses a variety of techniques to help your muscles and joints work to improving, maintaining or restoring physical strength, cognition and mobility with maximized results. And also helps people gain greater independence after illness, injury or surgery. Physiotherapy works in the areas of healing, repair and recovery in a wide range of injuries, illnesses and conditions and treating the basic disease and preventing complication.

The principles of physiotherapy in treating musculo-skeletal cases are to maintain the normal movement and function of the uninjured structures and to restore the normal movement and function of the injured area as soon as condition allowed.

The roles of physiotherapy are to control pain and inflammation, then promote and progress healing. In order to gain safe return to function, physiotherapist has to analyze and integrate the entire kinetic chain incorporate with neuromuscular re-education. Prescribing effective exercise to strengthen and increase flexibility, meanwhile correct posture and movement impairment syndromes. The main objectives are to improve functional outcome and maintain or improve overall fitness. Therefore, efficient and effective patient education is needed to gain patient compliance and enable to empower self-management.

The intervention varies to condition. The common managements are Therapeutic Exercise Therapy, Proprioceptive Neuromuscular Facilitation, Task Orientated Therapy and Pain management. The therapeutic modalities used are electrotherapy (Faradic current/ IDC/TENS/Biofeedback/IFC/FES/EMS); Thermal Modalities (SWD/IRR/Hydrocollator Pack/Wax Therapy/US/ Cryotherapy); Laser Therapy; Mechanical Modalities (Traction/isokinetic/ Suspension therapy/Pulley System and exercise gadgets) and Manual Modalities (STM/Joint Mobilization/PNF/MLD/ Manipulation /Myofascia Release/Active & passive movement/Trigger Point Therapy)

Current approaches consist of Dry needling, kinesio taping, manual therapy, high intensity laser, combination of SWT and cryotherapy by air. All approaches are highly evidence-based.

SPH02 The Basic Principles Of Manipulative & Joint Mobilization Therapy

Thomas Ng Chao Feng Physiotherapy Unit, Department of Rehabilitation Medicine, Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia Faculty of Traditional Chinese Medicine, Southern University College, Skudai, Johor, Malaysia

Manipulative and joint mobilization (MJM) therapy, comprising a continuum of skilled passive movements to the joints and/or related soft tissues that are applied at varying speeds and amplitudes, including a small-amplitude or high-velocity therapeutic movement. It is a highly specialized skill, effective and non-invasive therapy. It is widely being used by Physiotherapist, Osteopath and Chiropractor. In olden days, MJM had exist in various traditional medical practice including traditional Malay bone settler, traditional Chinese medicine practice (tuina᧘᤯, zhenggu↓僘). The modern MJM therapy is moving into evidence-based medical practice, equipped with understanding of joint mechanism, biomechanics, osteokinemetics and others related science. The exploration of MJM therapy thru its history and evolution, basic principles, joint plays, physiological, and latest evidence-based findings and reports will be discussed in this presentation.

SA37 Bone Loss In Revision Total Hip Arthroplasty

Jonathan Flordelis Cebu Orthopaedic Institute, Cebu City, Philippines University of Cebu Medical Center, Cebu City, Philippines Cebu Doctors University Hospital, Cebu City, Philippines

A case of septic loosening of acetabular component will be presented. This case will show mostly Acetabular bone loss as the main problem of the patient.

The importance of radiographic analysis using the Paprosky Classification for acetabular defects will be highlighted with emphasis to the parameters seen on AP Pelvis radiograph such as Hip Center of Rotation, Teardrop Destruction, Ischial Osteolysis and the Kohler Line. Other radiographic views such as Judet Views may also help. CT scan & MRI are not routine but useful in certain cases as well.

The management for acetabular bone loss should always be tailor made to the needs of a patient. The Paprosky Classification serves as a guide for treatment options. Althought there are many options available, there should always be a balance between mechanical and biologic fixation.

And surgeons should be able to understand the interplay between bone, biomaterials and biomechanics because the patient’s recovery will depend on achieving early function, osteo- integration and bone remodeling. A patient should have good primary stability immediately post- operatively meaning the cup is steadily anchored to bone and secondary stability is when bone remodeling and osteo-intergration of graft has been achieved.

The use of the Bursch-Schneider acetabular cage has been shown to have good results in Paprosky III defects, when combined with impacted bone grafting. A mesh may be used to serve as a scaffold and can help in the containement of large defects in the medial wall.

Our index patient’s hip was exposed using a modified-Hardinge Approach and a mesh was first applied followed by bone graft, and Bursch-Schneider cage. After which a cemented acetabular cup was applied and long cementless, revision stem was applied.

At 3 month’s post-operatively patient was able to ambulate with one crutch full weight bearing. At 6 months post-operatively the patient was walking without any assistance.

In conclusion the management of acetabular defects more often then not need bone graft. Smaller defects may be treated with graft and standard implants, while larger defects need graft with special reconstruction cages.

SA38 Management Of Periprosthetic Fracture After Total Hip Arthoplasty

Mohammad Zaim Chilmi School of Medicine Airlangga University, Indonesia Department of Orthopaedic & Traumatology, Dr Soetomo General Hospital, Surabaya, Indonesia

Periprosthetic fracture of the femur in association with total hip arthroplasty are increasingly cause of THA procedure has broadened and life expectancy of population has increased. To determine individual treatment plan will consider several factor, including fracture type and location of the fracture (classification), the quality of remaining bone, whether the implant in the femur is loose. The Vancouver classification facilitates treatment decision. In the presence of a stable prosthesis (type- B1 and C) recommended surgical stabilization of the fracture with plate & screw/cable wire, strut graft, or a combination thereof, if prosthesis unstable or loose revision using an long stem, with or without additional fracture fixation. Treatment may differ depending on fracture location, bone condition, implant stability, patient characteristics, and surgeon experience. It is imperative that adequate and sufficient mechanical fixation be achieved in the treatment. SA40 How To Avoid Limb Length Discrepancy After THA

Ahmad Hisham Abd Rashid Sunway Medical Centre

Limb length discrepancy following THA can pose a substantial problem to the surgeon and also the patient. It can leads to back pain, abnormal gait, patient dissatisfaction and even nerve palsy. Careful pre-operative planning and assessment with meticulous intra-operative measurement can minimize the risk.

SA41

Infection After THA

Cokorda Gde Oka Dharmayuda Sanglah General Hospital, Bali Indonesia

Periprosthetic infection post a THA occurs at a rate of approximately 0,5% to 1%. The prevalence will be increase substantially as the volume for this procedure grows to meet the projected demand. Prevention relies on optimizing patient selection and other host factor, improving the surgical suite envirovment and administrating antibiotic prophylactic. The most common infecting organism are gram positive cocci ( Staphylococcus sp) but some infections may be polymicrobal

The Diagnosis is made by a high level of suspicion, a thorough history and physical examination, screeening ( ESR, C Reactive protein) , selected use hip joint aspiration and culture.

Successful treatment is predicated upon the duration of the infection: it is reasonable to attempt debridement and component retention in a acute post operative and resection arthroplasty and delayed recontruction ( two stages ) for chronic infection. SA42 Osseointegration In Uncemented Total Hip Arthroplasty A 5 Years Followup

Amjad Hossain Bangladesh Orthopaedic Society, Dhaka, Bangladesh.

Background: Aseptic loosening of cemented hip prostheses is recognized as a long-term problem. Much energy has been focused on developing new prostheses that are designed for cementless fixation. We evaluated the performance and periprosthetic bone response to tapered, hydroxyapatite (HA)-coated femoral hip prosthesis at a minimum of 5 years follow-up after treatment with primary total hip arthroplasty.Methods: 38 patients and 47 hips were included in the study. There were 20 men and 15 women; the mean age was 38 years (range, 19 to 71 years). We used a tapered, HA-coated femoral implant. We evaluated the patients at a minimum of 5 years. Clinical evaluation was performed using the scoring system and the hip scores were assigned according to the level of pain, the functional status and the range of motion. Radiographic follow- up was performed at six weeks, at three, six and twelve months and yearly thereafter. All the available radiographs were collected and assessed for implant stability, subsidence, osseointegration, osteolysis, stress shielding and evidence of periprosthetic lucency. Results: 47 hips (38 patients) were available for review at follow-up of greater than 5 years. The radiographs were obtained at 5-year follow-up for all hips, but all the patients would not come in for the 5-year clinical evaluation. Therefore, a phone interview was conducted to assess any change in the functional. Conclusions: The mechanical fixation of a tapered, HA-coated femoral implant was excellent in this study. This femoral design provided reliable osseointegration that was durable at a mean of 5 years follow-up.

SA43 Biomechanics Of Total Knee Replacement

Mohd Fairuz Suhaimi Department of Orthopadic and Trauma Surgery, Hospital Selayang, Selangor, Malaysia

Total knee replacement (TKR) has been known to produce excellent results in treating knee osteoarthritis. The primary aim of the surgery is restore alignment as well as reproduce normal knee kinematics. From its early inception, the design of TKRs has changed and transformed to suit this intention.

Understanding the biomechanics of the native knee is vital to help replicate it on the TKR designs. This comprise of the movements occurring at the tibiofemoral and the patellofemoral components, its alignment, stability and the forces acting around the knee on its movement.

TKR knee design has changed to replicate the normal knee as much as possible. The design has evolved around all components of the prosthesis. This include changes to the geometry of the femoral component, ligament retaining or substituting designs, bearings of the TKR and the role of computer navigation. All designs take into account the kinematics as well as the stress to the implants to provide longevity.

In summary, there are still a lot more clinical data needed as well as more research and development that needs to go into designs of these prosthesis. Selection of design should always into factor the patient’s need and should be based on proven clinical outcome.

SA44 Bearing Materials Used In TKA

Zulkifly, Ahmad Hafiz International Islamic University Malaysia, Kuantan Campus, Malaysia

New Material The success of a biomaterial or an implant is highly dependent on three major factors: the properties and biocompatibility of the implant, the health condition of the recipient, and the competency of the surgeon who implants and monitors its progress. Component interactions included: Corrosion Degradation Protein Deposition Encapsulation Thrombus formation Calcification Toxic Leaching Embrittlement Cell Lysis Systemic reaction

It is easy to understand the requirements for an implant by examining the characteristics.

These are: Acceptance of the plate to the tissue surface, i.e., biocompatibility Pharmacological acceptability (nontoxic, nonallergenic, nonimmunogenic, noncarcinogenic, etc.) Chemically inert and stable (no time-dependent degradation) Adequate mechanical strength Adequate fatigue life Sound engineering design Proper weight and density Relatively inexpensive, reproducible, and easy to fabricate and process for large-scale production

The two main reasons for a TKR to fail: (1) wear of the polyethylene insert resulting from articulation with the CoCr femoral component in combination with abrasive bone and metal wear particles, oxidation from gamma ray sterilization, and subsurface fatigue induced by high contact stresses, create biologically active wear debris. (2) Adverse biological reaction to indigestible microscopic wear debris leads to osteolysis, which undermines the implant and causes loosening and instability.

SA45 Bearing Material Used In Total Hip Arthroplasty

Ariyanto Bawono Hip & Knee Section, Ywrsis Hospital Surakarta, Indonesia

The goals of Total Hip Arthroplasty (THA) are reducing hip pain, improve hip motion and stable hip in a long duration. Option in bearing material THA are based on durability, level of performance, wear resistance, and personal needs (age, gender, weight, lifestyle) Choices of bearing material are metal on polyethylene, metal on metal, ceramic on polyethylene and ceramic on ceramic. Extensive research on bearing material is performed to seek an ideal bearing surface on THA Many studies try to search where is more resistant to wear, reduced osteolysis, longevity better, cost effective and easy to implant. These done by modification of bearing surface, improvement and reinforcing in polyethylene and ceramic material. As expected, all bearing surface combination have advantages and disadvantages. Long term studies still need to conform the efficacy of the bearing surfaces THA

SA46 Stable Fixation In THA

Christopher S. Mow Department of Orthopaedic Surgery, Stanford University Medical Center, 300 Pasteur Dr, Stanford, CA 94305, United States

Achieving stable fixation of both femoral and acetabular components in THA remain challenging despite major advances in technique, implant geometry, and surface preparations. The basic principles of both cemented and noncemented femoral and acetabular fixation have remained essentially unchanged for 2 decades. Fortunately, early loosening is no longer a frequently encountered postoperative complication. Continued refinements in implant surface preparation and surgical technique have improved the reliability of obtaining secure and long lasting fixation intraoperatively. On the acetabular side, a commonly accepted practice is underreaming by 1-2mm to achieve good press fit fixation. The routine use of adjunctive screw fixation, and how many to use, remains somewhat controversial, as is the use of solid shells, although concerns about debris migration in the effective joint space have been largely alleviated by the advent of highly crosslinked polyethylene. Highly porous metal implants are now readily available and further enhance initial fixation and reliability of bony ingrowth for long term fixation. On the femoral side, both fully coated and proximal taper type stems have outstanding long term track records, and are both well established as reliable options in obtaining secure fixation. Both are somewhat technique dependent and have advantages and disadvantages, with the taper type stem being currently more popular. All of the major manufacturers offer some version of a proximally coated taper stem, either medial laterally (ML) or dual taper design. ML taper designs are usually broach only, with dual tapers requiring some reaming for endosteal preparation. Proponents of the dual taper type design maintain that a better, more anatomic fit and fill is achieved than with the ML type designs, which results in more reliable fixation and more secure sealing of the canal to prevent ingress of polyethylene debris. Proponents of the ML taper type designs point out that it may be difficult to obtain secure initial fixation in Dorr B and C femurs, especially in the elderly osteoporotic female. When performed properly, both achieve excellent initial and long term results. The arthroplasty surgeon should be familiar with both types and use what is technically most familiar and reliable for them.

      (Click Here...)  Combined Meeting of the 46th Malaysian Orthopaedic Association Annual General Meeting / Annual Scientific Meeting & 10th ASEAN Arthroplasty Association Meeting 2016

 Location: Outside Foyer Of Lecture Hall MOA 1, Level 3

Basic Science Poster Award Finalists

Poster ID Poster Cooling Material Composite For Cost-Effective Transportation Of Bone Allografts BBS01 Saravana R; Nurhafizatul Nadia H; Sharifah Mazni S; Suhaili M; Norimah Y; Azura M Accuracy Of Ottawa Ankle Rule For Diagnosis Of Ankle Fractures In Acute Ankle Injuries BBS02 Syed J; Jamaluddin S; Zamri AR; Ruben J; Zaharul A; Abdus S; Baskar P; Ahmad H Caffeic Acid Phenethyl Ester Significantly Inhibits Bone Resorption In A Murine Calvarial Model Of Polyethylene Particle- BBS03 Induced Peri-Prosthetic Osteolysis Zawawi MSF; Perilli E; Marino V; Cantley MD; Xu J; Dharmapatni AASSK; Haynes DR; Crotti TN The Role Of Stretch-Activated Calcium Channel On The Tenogenic Differentiation Of Human Mesenchymal Stromal Cells In BBS04 Vitro Nam HY; Balaji Raghavendran HR; Pingguan-Murphy B; Abbas AA; Merican AM; Kamarul T Incorporation Of PDGF-BB in 3D Coragraft For Differentiation Of Mesenchymal Stromal Cells In Vitro BBS05 Mohan S; Karunanithi P; Raghavendran HRB; Malliga Raman M; Kamarul T

Given Due Consideration For Basic Science Poster Award

Poster ID Poster Bacteriological Study Of Diabetic Foot Infections In Hospital Kajang, Selangor PB01A Ong CS; Ruzaimi MY Outcomes Of Lateral External Fixation And Kirschner Wiring Of Humeral Supracondylar Fractures In Children PB01B Kow RY; Zamri AR; Ruben JK; Jamaluddin S; Mohd Nazir MT; Gopindran M Prospective Study Of Factors Influencing The Outcome Of Intra-Articular Knee Viscosupplementation In Osteoarthritis PB01C Vijaya Kumar SL; Ashutosh R; Chew YW; Tan CS; Vijay Kumar NK; Tew MM Influence Of Bone Types On Lyophilization Process PB01D Ainnur Farhana A; Chan HH; Norimah Y; Suhaili M; Saravana R; Azura M; Ng WM Nitidine Chloride Modulates ITAM Signalling During Late Stage Osteoclast Differentiation PB02A Zawawi MSF; Dharmapatni AASSK; Haynes DR; Xu J; Crotti TN Diabetic Foot Infections: Are We Getting It Right? A 5 Year Retrospective Review Of Causative Organism And Emprical PB02B Antibiotics At Two Tertiary Hospitals In Klang Valley Rampal S; Kumar V; Yoganathan P; Ibrahim MI Comparison Of Biocompatibility And Biodegradability Of Poly-Lactic-Co-Glycolic Acid (PLGA) Combined With Fibrin Versus PB02C PLGA For Intra-Articular Screw Fixation; An In-Vivo Study With New Zealand White Rabbit Theenesh B; Ahmad Hafiz Z; Munirah S; Nurul Hafiza MJ; Mohd Zulfadzli I; Noorhidayah MN Polycaprolactone Triol-Citrate Scaffolds Enriched With Human Platelet Releasates Promote Chondrogenic Phenotype And PB02D Cartilage Extracellular Matrix Formation Suhaeb AM; Ammar YA; Hussin AR; Simmrat S Comparison Of Efficacy Of Post Operative Analgesic Regimes For Post Operative Pain Control In Adults With Long Bone PB03A Fractures – A Cross-Sectional Study In Hospital Tengku Ampuan Afzan Kuantan Abd Razak MAR; Awang MS; Mohamed AH; Abdul Razak AH Effect Of Adiponectin As A Growth Factor For Osteogenic Differentiation Of Mesenchymal Stromal Cells In Electron Spun PB03B PLLA Based Scaffolds Keerthana R; Murali MR; Balaji Raghavendran HR; Mukheem A; Kamarul T Fundamentals In Orthopaedics – Back To Basics

( Location: Outside Foyer Of Lecture Hall MOA 1, Level 3

Arthroplasty

Poster ID Poster Total Hip Arthroplasty In Neglected Development Dysplasia Of Hip With 7cm Limb Shortening PA01A Selvanathan N; Sharveen G; Suresh C A Case Report Of Early Outcome In Reverse Total Shoulder Arthroplasty PA01B Zulkifli KI; Thangaraju S; Hussin AR; Rajagopal S; Tahir SH Periprosthetic Fracture In Cemented Thompson Hemiarthroplasty: A Case Report PA01C Yeow AYS; Low CA Rotating Hinged Total Knee Arthroplasty In Patient With Global Instability Knee: A Case Report PA01D Tan HP; Ngiam CJ; Lau LQ; Avthar S; Kamil K Factors Predicting Post Operative Blood Loss In Total Knee Arthroplasty PA02A Mohd Ashraff MA; Loh KM; Othman NLF; Po JN; Shanmugam B; Haridass P; Mohd Sidek MKA; Sa’ari NA A Rare Case Of Ochronotic Arthropathy PA02B Wong TS; Abbas AA; Merican AM; Chan CK; Simret S BMI Changes After Total Knee Arthroplasty: A Comparison With Patients Treated Conservatively PA02C Low CA; Fazlin MEO; Wong MA Total Hip Replacement As Treatment Of Choice For Neck Of Femur Fracture In Chronic Renal Disease Patients PA02D Kong YM; Raj J; Kunalan K Case Report: A Rare Case Of Femoral Artery Thrombosis Following Total Hip Replacement PA03A Paul S; Gurjit S; Zamyn Z Outcome Of Nexgen Fixed Bearing And Posterior Stabilising Total Knee Replacement PA03B Mohammed Harris A; Ahmad Hafiz Z; Mohd Shahidan NR Case Report: Bilateral Total Knee Replacement In Severe Knee Osteroarthritis PA03C Mohammed Harris A; Ahmad Hafiz Z; Mohd Shahidan NR Primary Total Hip Arthroplasty With Restoration Gap II Cage Post Fracture Dislocation Of Femoral Neck With Acetabulum PA03D Fracture Ong LH; Ahmad Tarmuzi N; Arsad SR; Rutel A; Kamaruddin F A Case Report On Late Presentation Of Discoid Meniscus Masquerading As Chronic Iliotibial Band Syndrome Post Total Hip PA04A Arthroplasty Chang CW; Chan CK; Teo SH; Mohamed Ali MR; Abbas AA; Merican AM Variability In Magnification Of Pelvic Radiographs In Hip Hemiarthroplasty PA04B Chee WH; Low CA; Wong MA Tuberculous Knee Joint - Case Report PA04C Goonasegaran AR; Ong LH Primary Bipolar Hemiarthroplasty For Displaced Neck Of Femur Fracture In Young Patient: A Case Report PA04D Firdaus Z; Ramesh N; Arauf A Bilateral Hip Osteoarthritis With Systemic Sclerosis: A Case Report PA05A Anuar S; Farid FF; Shahrul H Total Knee Replacement In Hemophiliac Knee Arthropathy - A HKL Joint Replacement Unit Experience PA05B Bernard Cheu TL; Su EP Dislocated Polished Femoral Stems In A Cemented THR: 2 Case Reports PA05C Charl Satpal; Sulaiman SH; Sofian AA Study On Prevalence Of Patella Baja In Knee Osteoarthritis Patients And Its Association With Patellofemoral Osteoarthritis PA05D Ong TJ; Chan WH; Lee KH; Zulkiflee O Intracapsular Analgesic Cocktail Injections In Total Knee Arthroplasty (TKA) PA06A Lam AWC; Ng MG; Tan HP; A Singh Adolescent Primary Generalised Osteoarthritis A Case Report PA06B Liew STW; Chua WS; Kunalan G ! Combined Meeting of the 46th Malaysian Orthopaedic Association Annual General Meeting / Annual Scientific Meeting & 10th ASEAN Arthroplasty Association Meeting 2016

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Arthroplasty

Poster ID Poster Ceramic Femoral Head Fracture With Metallosis And Severe Wear: A Case Report PA06C Devarani P; Ooi CL; Lim MY; Zulkiflee O Minimally Invasive Lateral Approach In Total Hip Replacement PA06D Devadasan B

Foot & Ankle

Poster ID Poster A 2 Year Follow Up Of Functional Outcomes Following Endoscopic Gastrocnemius Recession PF01A Lai S; Tang C; Lee BH; Thevendran G Return To Work And Sport After Arthroscopic Debridement Surgery For Anterior Ankle Soft Tissue Impingement Syndrome PF01B Tang C; Lai S; Ng JW; Thevendran G A Rare Midfoot Injury Pattern: Open Navicular-Cuneiform And Calcaneal-Cuboid Dislocation PF01C Lingeshwaran RA; Leow VC; Abdul Aziz Knowledge Assessment Of Medical Officers On Ankle Impingement Syndrome. A Cross-Sectional Study PF01D Thinesh VS; Kularaj S; Michael DB; Mathavan G; Rauf A Outcome Of Endoscopic Calcaneoplasty In Retrocalcaneal Bursitis. A New Prospective Study PF02A Thinesh VS; Kularaj S; Mathavan G; Michael DB; Ramesh N; Rauf A Doctor… I Cannot Wear Shoes PF02B M Ashri MA; Samuel J; Han CS; Aziz MY Juvenile Tillaux Fracture: A Case Report PF02C Faisal Amir SM; Normawathy AO A Rare Case Of Septic Arthritis Of Talonavicular Joint: A Case Report PF02D Shyful S; Azhar M; Mohan R; Jasvindar S Meliodosis And Tuberculosis Co-Infection In A Health Care Worker In Pahang, Malaysia PF03A Rao M; Rahimawati N; Yusoff M Case Report Of A Rare Heel Swelling: Calcaneal Osteosarcoma PF03B Cheong KH; Gurmeet S; Azuhairy A; Zulkiflee O Dysplasia Epiphysealis Hemimelica (Trevor’s Disease) Of Medial Cuneiform And Right Foot: A Case Report PF03C Low WK; Chua YP Plantar Plate Rupture Of Second Metatarsophalangeal Joint: Repair Or Let It Be? PF03D Daun E; Bajuri MY; Shukur MH An Isolated Case Of Ankle Tuberculosis: Diagnosis & Treatment PF04A Kamarul A; Nurhanani AB; Bajuri MY Non-Traumatic Foot Pain And Deformity In Elderly Within Klang Valley PF04B Chan HZ; Chua YP; Rukumanikanthan S Modified Bridle Procedure With Achilles Tendon Lengthening For Acquired Spastic Equinovarus PF04C Azamuddin A; Izani IM; Melvin D; Asni A Early Functional Outcome Of Tibiotalocalcaneal Fusion With Intramedullary Nail: HRPB Foot And Ankle Unit Experience PF04D Azammuddin A; Yap KS; Tan YJ; Asni A; Izani M; Leow VC; Manoharan K Case Report On A 9cm Defect Chronic Achilles Tendon Rupture: An Alternative Repair Technique PF05A Yap KS; Azammuddin A; Izani M; Asni M; Leow VC; Manoharan K Case Series In 3 Different Method Treating Chronic Ankle Syndesmosis Injury PF05B Asni M; Azammuddin A; Yap KS The Challenge In Management Of Plantar Foot Ulcer: Early Intervention Of Advance Dressing With Modified Off-Loading To PF05C Reduce Healing Time Maizatul MK; Syahrizal AR; Zubair AA; Omar F; Fareez W; Amiruddin AR; Andrew MSK; Kew KH Fundamentals In Orthopaedics – Back To Basics "

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Foot & Ankle

Poster ID Poster A Rare Presentation Of A Growing Calcaneum Osteochondroma In Adult: A Case Report PF05D Izani IM; Bilal B; Azamuddin A; Nahulan T; Asni M An Underlying Soft Tissue Infection In A Bilateral Closed Calcaneal Fracture PF06A Danappal S; Vincent J; Nadia MK; Kadir KMS Effects Of Hyperbaric Oxygen Therapy In Chronic Diabetic Foot Ulcer PF06B Nurhanani AB; Bajuri MY; Shukor MH A Missing Navicular PF06C Shankari S; Ariffin MA; Naveen VS; Afifi M; Sajali H

Hand

Poster ID Poster Radiographic, Functional And Patient-Rated Outcome Of AO Type-C Fracture Of Distal Radius Treated Primarily With Volar PH01A Locking Plate In A District Hospital - A Case Series Liew HC; Siek IM; Sem SH; Mohd Sallehuddin H; Kamarulzaman MA Dupuytren Disease Was Diagnosed As Multiple Ganglions PH01B Chooi YJ; Manohar A Flexor Tendon Injuries: Delayed Single Stage Reconstruction PH01C Ezainy MA; Teo PC; Sa’adon I Feasibility Of Full Length Phrenic Nerve Transfer Via Video Assisted Thoracoscopic Surgery (VATS) To Restore Elbow Flexion PH01D In Post Traumatic Brachial Plexus Injury Embun D; Ahmad TS A Rare Case Of Pigmented Vilonodular Synovitis Of The Elbow PH02A Ramalingam K; Sivanoli R; Farid M; Kamil MK; Jamari S Giant Cell Tumor Of The Bone Of The Hand In Children PH02B Idris R; Ruban S; Tiew; Sam Use Of Bone Graft Substitutes In Hand Surgery – A Singapore Experience PH02C Rex Premchand AX; De Cruz J; Rajaratnam V Rupture Of The Flexor Tendons Of The Index Finger After Distal Radius Fracture PH02D Chung WH; Randhawa SS; Norsaidatul AS; Suhaeb AM; Jayaletchumi G; Ahmad TS Transligamentous Variant Of The Recurrent Motor Branch Of The Median Nerve PH03A Toyat SS; Chuah CK; Rashdeen F A Black Finger Does Not Mean A Dead Finger PH03B Hau W; Belani LK; Selvanathan N; Abdullah S Unusual Locked Trigger Finger Due To Tophaceous Infiltration Of Wrist Flexor Tendon PH03C Hau W; Abdullah S; Sapuan J Carpal Tunnel Syndrome With Abnormal Lumbrical Muscles PH03D Ewe B; Abdullah S; Sapuan J Multiple Carpometacarpal Joint Fracture Dislocation PH04A Mohd Faizal N; Lingeshwaran RA; Wong KA; Narinder SG; Aziz A Case Report: Bilateral Radial Head Replacement - A Deed Or Sin?? PH04B Paul S; Gurjit S; Zamyn Z Whitmore’s Disease Manifestation As Septicaemic Melioidosis, Septic Arthritis Right Elbow And Osteomyelitis Right PH04C Humerus: A Case Report Muhammad Firdaus; Abdul Muttalib AW; Suhana SB; Richford J Excision Of 4th Metacarpal Bone Giant Cell Tumour With Fibula Strut Graft Reconstruction And Metacarpophalangeal Joint PH04D Soft Tissue Arthroplasty Lau LQ; Raghavan S; Sivanoli R # Combined Meeting of the 46th Malaysian Orthopaedic Association Annual General Meeting / Annual Scientific Meeting & 10th ASEAN Arthroplasty Association Meeting 2016

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Hand

Poster ID Poster Salvaging The Mangled Hand: When Little Means A Lot PH05A Rampal R; Ahmad TS The Effects Of Hypnoanaesthesia On Carpal Tunnel Release Procedure PH05B Choong CL; Soh AH; Tay T; Ahmad TS Rice-Body Formation And Tenosynovitis Of The Wrist: A Case Report PH05C Loi KW; Ahmad TS A Case Of Madura’s Hand. Devastating Mycetoma Infection PH05D Harkeerat S; Ariffin MA; Hariharan K; Naveen VS Bilateral Hypoplastic Flexor Pollicis Longus Diagnosed As Congenital Locked Trigger Thumb PH06A Allaudeen MA; Sapuan J; Abdullah S Non-Specific Rice Body Formation In Tenosynovitis Of The Hand – A Mystery PH06B Ithnain A; Abdullah S; Sapuan J Painful ‘Ingrown Nail’ That Is Not Responding To Treatment PH06C TMFairuz TI; Azfan CY; Kamil MK; Suzanah K

LLRS

Poster ID Poster A Multicentre Study: The Outcome Of Femoral Reconstruction Using Ilizarof External Fixator PL01A Mustapa N; Ganaisan P; Manickam T; Towil MB; Vincent J; Danappal S Integra Bilayer Matrix Wound Dressing Closure Of Large Crushed Injury Wound Of Tibia PL01B Izham K; Lau HY; Thirumal M Pseudoaneursym: The Hidden Danger!!!! PL01C Karthigesu M; Mahendran S; Manoharan K Activity Of Daily Living For Patients With Lower Limb Reconstruction Using External Fixator PL01D Shazwani Z; Malik A; Suhaili M; Saw A Quality Of Life Assessment Following Limb Deformity Correction Surgery PL02A Shazwani Z; Suhaili M; Malik A; Saw A

Oncology

Poster ID Poster A Rare Case Of Primary Synovial Osteochondromatosis Of The Elbow: A Case Report PO01A Loh LL; Wong KA Marjolin’s Ulcer: A Case Report And Literature Review PO01B Kow RY; Jamaluddin S; Dhiauddin Hai I; Nor Hafliza MS A Rare Occurrence Of Cholesterol Granuloma Over Humerus Mimicking Malignant Bone Tumor PO01C Chan HZ; Salim A; Azura M; Vivek AS Two Scapular Tumor Cases Managed With Scapulectomy And Humeral Suspension Reconstruction PO01D Lee WK, Salim A, Azura M, Vivek AS Pathological Fracture Of Proximal Femur In Peadiatric Age Group, A Variant Presentation Of Bone Cyst PO02A Ganapathy S; Nanchappan S; Haryati MY Brown Tumour Mimicking Giant Cell Tumour: Problem Of Diagnosis And Management PO02B Tan TS; Yasin NF; Azura M; Vivek AS Chondroblastoma: Mimicking Malignant Bone Tumour PO02C Sia Ung; Yasin NF; Looi LM; Azura M; Vivek AS Fundamentals In Orthopaedics – Back To Basics $

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Oncology

Poster ID Poster Hand Acrometastasis: A Rare Presentation Of Lung Cancer PO02D Kumar RJ; Yasin NF; Azura M; Vivek AS How Unlucky Can You Be? A Case Report: Spinal Metastases To The Posterior Element Of Vertebra In Double Malignancies PO03A Zakhiri MR; Dzulkarnain A; Manmohan S; Goh JH; Norazlin ZA; Fazir M Radiofrequency Ablation: A Safe, Effective And Minimally Invasive Method For The Treatment Of Osteoid Osteomas In PO03B Children - A Case Report And Review Of The Literature Randhawa SS; Azura M; Vivek AS An Unusual Cause Of A Soft Tissue Tumour. Churg-Strauss Syndrome Revisited PO03C Lim CY; Narhari P; Duski S; Jamny Mahmood M; Mohd Dusa N; Chye PC Brown Versus White. Tales Of Two Fatty Tumours PO03D Lim CY; Narhari P; Duski S; Jamny Mahmood M; Mohd Dusa N; Chye PC An Uncommon Presentation Of A Common Tumour: A Rare Case Report PO04A Tan YJ; Yap KS; Vicknesh A; Manoharan K Haematoma Formation Within Pre-Existing Haemangioma Following Dengue Fever: A Case Report And Review Of 6-Year PO04B Data From University Malaya Medical Centre Khoo SS; Salim A; Yasin NF; Azura M; Vivek AS Tale Of A Late Presentation Of Malignant Peripheral Nerve Sheath Tumour: A Case Report PO04C Lee KW; Yasser AK; N Shakirah AH Management Of Seroma Using Stoma Bag PO04D Ngim HLJ; Vivek AS Recurrent Desmoid Fibromatosis Of The Neck PO05A Selvanathan N; Yazid K; Nor Hazla MH A Rare Case Of Giant Cell Tumour Involving The Medial Condyle Of Distal Humerus PO05B Shashank R; Izani M The Lymphoma Which Mimics Bone Tumour / Infection - Primary Bone Lymphoma: A Case Report PO05C Tan KT; Vivek AS; Azura M An Uncommon Presentation Of Giant Cell Tumour Of Bones: Aggressiveness In Immature Skeleton With Pulmonary PO05D Metastasis Lim MY; Yee TS; Chan WH; Azuhairy A; Zulkiflee O A Rare Case Young Gentleman With Bilateral Neck Of Femur Fibrous Dysplasia With Right Neck Of Femur Fracture, A Case PO06A Report Manas A; Elaine SZF; Abdul Wahid AM; Samsul BS; Richford J Steatosis Of Soleus And Gastrocnemius, A Case Report PO06B Choo QQ; Tan ST; Vivek AS A Case Of Pleomorphic Rhabdomyosarcoma In Pregnancy PO06C Ooi BH; Vivek AS Survival Rate For Osteosarcoma Paediatric Patients PO06D Ibrahim N; Babar B; Paul A Epidemiological Spectrum Of Bone Tumors Presented To Tertiary Care Oncology Hospital, Malaysia PO07A Saadon I; Bhardwaj A; Zolqarnain A; Firdaus Z; Swe KMM Epidemiological Spectrum Of Soft Tissue Tumors Presented To Tertiary Care Oncology Hospital, Malaysia PO07B Saadon I; Bhardwaj A; Zolqarnain A; Swe KMM; Firdaus Z A Handful Of Basal Cell Carcinoma PO07C Mohamed Mishwaar A; Nor Hazla MH; Farrah Hani I; Yazid K A Case Of Radiotherapy Induced Osteonecrosis Of The Femur Mimicking Local Recurrence Of Leiyomyosarcoma PO07D Harkeerat S; Babar B; Asrul YHN; Ibrahim N; Siti Zulaifah CS; Chan SK; Paul AG Floppy Lateral Position For Type II Internal Hemipelvectomy PO08A Ibrahim N; Babar B; Paul A % Combined Meeting of the 46th Malaysian Orthopaedic Association Annual General Meeting / Annual Scientific Meeting & 10th ASEAN Arthroplasty Association Meeting 2016

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Oncology

Poster ID Poster Rare Presentation Of Pseudogout Mimicking Malignant Tumuor PO08B Shanjay; Azammuddin A; Manoharan K Congenital Pseudarthrosis Of Tibia: Histopathology Revisited PO08C Teoh TJ; Noraini MD; Chye PC Large Distal Tibia Osteochondroma With Deformed Fibula: Excision And Anatomical Reconstruction Of Ankle Syndesmosis PO08D Goh KL; Mohamed Azril MA; Mohd Ariff S; Mohammed Harris AK Functional Outcome Following Excision Of Giant Cell Tumour Of The Distal Radius And Reconstruction By Autologous Non- PO09A Vascularized Osteoarticular Fibula Graft Koh TW; Vivek AS Metachronous Osteosarcoma In A 10 Year-Old Boy – A Case Report PO09B Hassan R; Hanif N; Azuhairy A; Zulkiflee O

Orthopaedic Research

Poster ID Poster Case Report Of Charcot Neuropathy-Rare Manifestation Of Syphilis PR01A Karthik TR; Hudzairy A; Tan BS Are The Microorganisms Isolated From Diabetic Foot Ulcer Sensitive To Our Empirical Antibiotics? PR01B Hartharanjeet SP; Prashant N; Sharil AR Effect Of Prolotherapy (Dextrose 10%) To Treat Articular Cartilage Injury And Speed Up Recovery In Rabbit Model PR01C Embun D; Razif A A Rare Case Of Septic Arthritis Masking Leptospirosis PR01D Ramalingam K; Ganaisan P; Nicholas WE Predictors Of Amputation In Necrotizing Fasciitis Of The Lower Limbs PR02A Low CA; Tam KH; Wong MA A Case Report; In Utero Femur Fracture Atypical Presentation In Day 2 Of Life Baby PR02B Saperi Z; Luqman A; Ruzaimi MY Tuberculosis Of The Knee, A Case Report PR02C Premdas V; Firdaus A; Ruzaimi MY Cardiac Complication Post Prosthetic Limb In Transfemoral Amputee, A Case Report PR02D Nurhanani MN; W Nursakinah WM; Aina ZB; Hairenazli A; Anuar A; Ruzaimi MY Acute Haematogenous Osteomyelitis In Paediatrics Following Upper Respiratory Tract Infection And Immunocompromised PR03A Patient; A Case Report Sallehudin A; Hairenazli A; Syarul AS; Kahir M; Anuar A; Ruzaimi MY Effects Of Bone Marrow Enhancement On The Integration Of Gamma Irradiated Allograft - A Preliminary Study PR03B Thong FY; Azura M; Norimah MY; Faizatul Izza R; Farhana F Effects Of Different Intensity Treadmill Training On Bone Mineral Density In Young And Old Rats PR03C Randhawa SS; Chong PP; Balaji H; Kamarul T Prevalence Of Neuropathic Pain Post Lower Limb Amputation In Hospital Selayang PR03D Abdullah N; Zakaria AF Similar Annexin-8 Expression Of Active Osteoclasts Found In Osteoblasts And Osteocytes In Vitro PR04A Zawawi MSF; Dharmapatni AASSK; Cantley MD; McHugh KP; Atkins GJ; Haynes DR; Pavlos N; Crotti TN Incidence Of Hospital Acquired Pressure Ulcers In Patients With Lower Limb Long Bone And Pelvic Fractures In A District PR04B Hospital Helmi MMR; Shariff MMS; Azura L Orthopaedic Surgery Schedule Online System (OSSOS) Improves Surgery Schedule Management In The Department Of PR04C Ortopaedics, Hospital Universiti Sains Malaysia Mohamed Faudzly AR; Zawawi MSF; Yusof MI; Nik Ismail NI Fundamentals In Orthopaedics – Back To Basics &

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Orthopaedic Research

Poster ID Poster Necrotising Fasciitis: A 3-Year Retrospective Study Of Cases At Hospital Duchess Of Kent, Sabah PR04D Lee KW; Yasser AK; N Shakirah AH; Loo WH Efficacy Evaluation Of HydrocynTM Aqua In Comparison To Commercially Available Super Oxidized Solution In Diabetic Foot PR05A Ulcers Abdul Aziz MS; Amran AS Atypical Femur Fracture With Use Of Bisphosphonates PR05B Avthar S; Ang C Role Of Baking Soda In Gouty Tophi Wound PR05C Wong KA; Sia Ung; Noreen FMN; Azira Y; Faris K The Effect Of Age And Exercise On Tendon Characteristics – An Animal Study PR05D Kasim NS; Kamarul T Study Of Post-Operative Fever In Patients Undergoing Orthopedic Surgeries PR06A Rao M; Chung SH; Yusoff M Instructional Videos In Orthopaedic Surgery: Determining The Effectiveness Of Instructional Teaching Videos On Learning PR06B Outcome And Learner Satisfaction In Application Of Above Elbow Plaster Of Paris Aridz MR; Abbas AA; Chan CK; Suhaeb AM An Experience In Human Donor Bone Harvest PR06C Ramalingam S; Sudhagar K; Sanjeevan R; Denesh M; Sharveen G Core Decompression With Reverse Bone Graft Technique And Hydroxyapatite Granules In Avascular Necrosis Of The PR06D Femoral Head Devadasan B; Hafiz A

Paediatric

Poster ID Poster Infantile Cortical Hyperostosis Secondary To Prostaglandin Therapy: Case Report PP01A Kishan R; Wong; Ashwini S; Chuah SK Locked Knee In Child: A Rare Presentation Of Trevor’s Disease PP01B Hanif K; Kartik TR; Hudzairy A; Tan BS Traumatic Lisfranc Variant Injury Complicated With Brachymetatarsia In A Toddler PP01C Agung ND; Lim MJJ; Sharizan MY; Kamalruzaman MA A Rare Bilateral Post-Axial (Wide Metatarsal Head) Polydactyly Of Great Toe: A Case Report PP01D Muhammad Faiz K; Kamil MK An Early Experience Of Treating Paediatric Neck Of Femur Fracture PP02A Kesavan R; Hafiz D; Norzatulsyima N; Isymth AR Outcome Of Surgically Treated Subtrochanteric Femur Fractures In The Adolescent Age Group PP02B Ki RL; Ferdhany ME; Choo TY; Norhaslinda B; Zamyn Z Corrective Osteotomy Of ‘V-Shape’ Malunion Of Right Radius With ‘Double Dislocation’ Of Radio-Ulnar Joint: A Case PP02C Report Norzakiah AMM; Anuar RIM; Ashikin NJ; Azli AHM Neglected Hilton’s Law Causing Missed Diagnosis Of Slipped Upper Femoral Epiphysis: A Case Report PP02D Ramesh M; Surekha K; Suresh A; Suriya K; Shoba A; Asliza Y; Asyraf W Transphyseal Separation Of Distal Humerus: A Rare Injury In Young Children PP03A Md Yusoff Z; Abdul Rahim NR; Loong FYS Neglected Traumatic Hip Dislocation With Femoral Neck Nonunion In An Adolescent With Unexpected Long Term Outcome PP03B Choo W ' Combined Meeting of the 46th Malaysian Orthopaedic Association Annual General Meeting / Annual Scientific Meeting & 10th ASEAN Arthroplasty Association Meeting 2016

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Paediatric

Poster ID Poster Painful Pseudoparalysis Of The Upper Limb In An Infant: Pulled Elbow PP03C Nur Ayuni KA; Mohd Fairuz S Case Report: Atraumatic Bilateral Knee Dislocation In Newborn PP03D Azwan A; Phang ZH; Kamarul A; Riaz F; Razip S; Mujait K Case Series: Slipped Capital Femoral Epiphysis – A Commonly Missed Diagnosis In Adolescent With Knee Pain PP04A Gooi SG; Cheong KH; Ong TJ; Zulkiflee O A Successful Reconstructive Case Of Tibia Hemimelia In Syndromic Child: Experience In National Tertiary Centre PP04B Norzakiah AMM; Anuar RIM; Ashikin NJ; Azli AHM Indoctrinating An Application Of Artificial Neural Network In Envisaging Pediatric Fracture Healing Time Of The Lower Limb PP04C Sorayya M; Gunalan R; Kedijya SY; Lau CF; Mogeeb MM; Amber H; Saw A Is It Just Neuropraxia? A Report On A Neglected Supracondylar Fracture Of The Humerus With Wrist Drop PP04D Rizal Z; Ardilla Hanim AR; Shukrimi A 2-Pin Unilateral Gradual Distraction With Ulna Osteotomy For Treatment Of Chronic Monteggia PP05A Gooi SG; Wang CS; Zulkiflee O Subacute Osteomyelitis Of The Ulna: A Case Report PP05B Manharpreet SS; George E; Achdiat MF Developmental Dysplastic Hip With Ligamentous Laxity: A Case Report PP05C Devarani P; Gooi SG; Zulkiflee O

Spine

Poster ID Poster Normal Plain Radiograph In A Case Of Tuberculosis Spondylodiscitis Presenting With Cauda Equina Syndrome: A Case PS01A Report Tan HP; Faris; Ng MG; Avthar S; Kamil K Stepped In The Neck During A Brawl In Prison: A Rare Cause Of C3/C4 Bifacaetal Dislocation PS01B Lim SW; Sharon TXF; Thurai Kumar K A Rare Case Of Traumatic L1-L2 Spondyloptosis PS01C Amir FZ; Loke YH; Dzulkarnain A; Farid FF; Satpal SC Hodgkin’s Lymphoma Mimicking Spinal Tuberculosis PS01D Teo YM; Abdul Rauf KZ; Norlizam M; M Fauzlie Y Pott’s Disease In A 3 Years Old Toddler PS02A Fairuz K; Khadijah N; Sharizan MY; Kamalruzaman MA Radiographic Outcomes Versus Patient Reported Quality Of Life Following Surgical Treatment Of Adolescent Idiopathic PS02B Scoliosis (AIS) Ali Noor I; Hisam MA; Shaharuddin AR; Azmi B Deep Surgical Site MRSA Infection Post Minimally Invasive Percutaneous Posterior Spinal Instrumentation For T12 Burst PS02C Fracture: A Case Report Tan YY; Lim SW; Zamyn Z Spontaneous Drainage Of Purulent Material From Pyogenic T8/T9 Spondylodiscitis Into Pleural Space: A Case Report PS02D Lim SW; Tan YY; Thurai K; Zamyn Z Posterior Decompression And For Cervical Spondylotic Myelopathy: A Case Report PS03A Tan HP; Shafiq W; Andrew L; Avthar S; Kamil K Surgical Site Infection (SSI) In Transforamina Lumbar Interbody Fusion (TLIF) Surgery In HUKM From 2011-2013 PS03B Choong CYL; Rhani SA; Ariffin MH; Baharudin A Cervical Chordoma: A Case Report PS03C Zakhiri MR; Dzulkarnain A; Manmohan S; Goh JH; Norazlin ZA; Fazir M Fundamentals In Orthopaedics – Back To Basics

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Spine

Poster ID Poster Morquio Syndrome: To Intervene Or Not? PS03D Zakhiri MR; Dzulkarnain A; Manmohan S; Goh JH; ZA Norazlin; Fazir M How Common Is Epidural Haematoma Causing Neurological Deficit Post Epidural Pain Management In Children? What Is PS04A The Treatment Option? Zakhiri MR; Dzulkarnain A; Manmohan S; Goh JH; Nor Azlin ZA; Fazir M Surgical Reduction Of High Grade Adult Degenerative Spondylolisthesis PS04B Ayob KA; Chiu CK; Chan CYW; Kwan MK Acute Peripheral Arterial Insufficiency Presenting As Cauda Equina Syndrome: A Case Report PS04C Loh KW; Daud H; Abdul Rahman I; Nasirudin N Rare Presentation Of Non-Hodgkin Lymphoma With Paraplegia PS04D Chiew EL; Shamsul SA; Hishamuddin S Rugby Sport Injury Resulting In Traumatic Herniated Nucleus Pulposis L2/L3 With Progressive Neurological Deficit In A 15 PS05A Year Old: A Case Report Hashim MH; Lim SW; Chong KL; Kanniah T; Zamyn Z Incidental Dural Tear With CSF Leakage Post Lumbar Decompressive Surgery: A Case Report PS05B Chua CG; Lim SM; Asrul F; N Zarini Y; Yazid MD Comparisons Of Quality Of Life Of Adolescents With Idiopathic Scoliosis (AIS) Undergoing Anterior Spinal Fusion With Extra PS05C Pleural And Transpleural Treatments Using Online SRS-22 Questionnaire Ng BKW; Chau WW; Hui ACN; Wong CY; Shit FKY; Zhu Feng Double Noncontiguous Spinal Fracture Dislocation Of Cervical And Lumbar Vertebra: A Case Report PS05D Foo KT; Foo CF; Jaafar MSA Atlantoaxial Rotary Subluxation In A Child After General Anaesthesia. A Case Report PS06A Roslan AF; Foo CH; Jaffar MSA Nurses’ Experience In Caring For Patients With Traumatic Spinal Cord Injuries PS06B Shareena Bibi MA; Rasmussen P; McLiesh P TB Spine: Do We Need Biopsies? - A Case Report PS06C Gan YH; Muhammad A; Jaswindar S Leap Of Faith - Cliff Diving: An Avertable Cause Of Spinal Injuries PS06D De Silva S; Ooi GK; Ling JL; Alan MS; Zamyn Z Case Series Of 2-3 Level Thoracic Vertebrectomy And Expandable Cage Insertion Via Posterior Only Approach; The Sungai PS07A Buloh Experience Lim SW; Murali Govindasamy MG; Zamyn Z Isolated Streptococcus Bovis T12 Spondylodiscitis: A Rare Case Report PS07B Murali Govindasamy MG; Lim SW; Zamyn Z Grisel’s Syndrome Is Associated With C1C2 Severe Rotatary Subluxation. An Experience In Managing Severe Deformity In PS07C Hospital Kuala Lumpur Zakhiri MR; Dzulkarnain A; Manmohan S; Goh JH; Nor Azlin ZA; Fazir M Case Series Of Tuberculous Spondylodisciitis With Asia A PS07D Zakhiri MR; EP S; TL T; Dzulkarnain A; Manmohan S; Goh JH; Norazlin ZA; Fazir M An Unusual ‘Triple Crush. A Case Report PS08A Othman MS; Ramlee FA; Ibrahim KN; Ariffin MH; Rhani SA; Sapuan J; Baharudin A Motorcyclist Vs Blocking Bar Accident Resulting In Cervical Bifacetal Dislocation: A Rare Case Report PS08B Loh KW; Lim SW; Shahadeevan Y; Zamyn Z High Single Dose Of Tranexamic Acid Effectively Reduces Perioperative Blood Loss In Scoliosis Surgery Without PS08C Compromising Patient Safety Ibrahim K; Freddy A; Ariffin MH; Rhani SA; Baharudin A Dysphagia Secondary To Anterior Cervical Osteophytes: A Review Of Three Cases From A Single Institution PS08D Mulok HJ; Sia Ung; Azmi A; Faruk NA; Tan BB; Teo YY; Wong CC; Kamaruddin F Rare Three-Level Percutaneous Vertebroplasty: A Case Report PS09A Loi KW  Combined Meeting of the 46th Malaysian Orthopaedic Association Annual General Meeting / Annual Scientific Meeting & 10th ASEAN Arthroplasty Association Meeting 2016

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Sport

Poster ID Poster Acromioclavicular Joint Ganglion: A Rare Presentation Of Chronic Rotator Cuff Tear PX01A Gan JT; Tan TS Painful Snapping Hip In Adolescent: Case Report PX01B Liong MF; Ezrat BS; Loong FYS Management Of Multiple Ligament Injuries Of The Knee PX01C Ayob K; Teo SH; Alfaiadh Z; Ali R; Ng WM Non-Traumatic Anterior Cruciate Ligament Rupture Due To Anterior Intermeniscal Ligament In A Patient With Generalised PX01D Joint Laxity: A Case Report Khoo SS; Teo SH; Zubair M; Razif A; Ng WM Unusual Traumatic Locked Young Knee – Our First Experience In UiTM PX02A Miswan MFM; Alsagoff A; Ibrahim MI; Effendi FM; Rozali KN A Case Report: Traumatic Multidirectional Shoulder Instability PX02B Khor JK; Dzuraimy; Siva T; Siti HT Unusual Cause Of Acute Locked Knee In A 39 Years Old Volleyball Player PX02C Sazali S; Abdullah AR; Siva L; Siva T; Azrin SH; Moganandas M; Siti HT Medial Patellofemoral Ligament Reconstruction In Medial Patellofemoral Ligament Avulsion Fracture Over Patella With PX02D Patella Chondral Injury For A Patient With Recurrent Patella Dislocation Yeoh KH; Teo SH; Alfaiadh Z; Ali R; Ng WM Symptomatic Ring-Shaped Lateral Meniscus: A Case Report PX03A Alsagoff A; Ibrahim MI; Miswan MFM; Effendi FM; Rozali KN Arthroscopic Debridement For Elbow Osteoarthritis; The Hospital Serdang Experience PX03B Arifaizad A; Johan AK; Syahril Izwan A Case Report: Bilateral Knee Mucoid Anterior Cruciate Ligament PX03C Aridz MR; Teo SH; Al-Fayyadh Z; Ali R; Ng WM The Outcome Of Medial Patellofemoral Ligament Reconstruction: The Hospital Serdang Experience PX03D Yeak RDK; Paisal H; Zaidi M; Nizlan NM Arthroscopic Release Of Elbow Arthrofibrosis; The Hospital Serdang Experience PX04A Johan AK; Arifaizad A; Tan JA Repair Of Contracted Degenerative Achilles Tendon Avulsion Rupture With Augmentation Using Plantaris Tendon And V-Y PX04B Lengthening: Surgical Technique Yusof MR; Teo SH; Zubair; Ali R; Ng WM

Trauma

Poster ID Poster Strontium Ranelate Reduces Duration Of Consolidation Phase In Bone Transport: Case Report PT01A Kishan R; Ashwini S; Chuah SK Pulmonary Embolism: Fat, Thrombus, Or Both? PT01B Cheng T; Azura M; Wengvei CTK Malunited Neglected Tibia Shaft Fracture Treated With Osteotomy And Reamed Intramedullary Nail: A Case Report PT01C Foo YH; Chong TS; Qureshi AS; Wong YD Comminuted Periprosthetic Total Knee Arthroplasty Fracture Of Proximal Tibia, Fixed With Single Proximal Tibial Medial PT01D Locking Plate. A Case Report Ng WL; Mahendran S; Manoharan K Conservative Treatment Of Traumatic Hip Dislocation With Acetabular Both Column Fractures: A Case Report PT02A Ong CS; Ruzaimi MY; Mashayati M; Anuar A Heterotopic Ossification Of The Hip: A Case Report And Literature Review PT02B Kow RY; Low CL; Jaya Raj J; Jacob Abraham VA Fundamentals In Orthopaedics – Back To Basics

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Trauma

Poster ID Poster Bone Lengthening With Monorail External Fixator System In Chronic Osteomyelitis Of Tibia PT02C Elaine SZF; Manas; Ammar; Suhana SB; Richford J; Muttalib A Open Reduction And Internal Fixation Of Post Trauma 2 Month Acetabulum Fracture: A Case Report PT02D Firdaus Z; Ramesh N; Gerry M; Arauf A Fat Embolism In Post Operative Case Of Tibial Fracture PT03A Chelsia EG; Lingeswaran; Normawaty; Abdul Aziz Y Proximal Humeral Locking Plate – An Alternative To Proximal Femur Locking Plate For Subtrochanteric Femur Fracture In PT03B An Adolescent Boy Lau FHY; Tan HP; Kamarulzaman SK; Singh A Removal Technique For A 45 Degrees Bent Intramedullary Femoral Nail: A Case Report PT03C How HM; Abdul Hamid MY; Sharizan MY; Kamalruzaman MA Damage Control Orthopaedics In A Complex Pelvic Ring Fracture With Obturator Artery Laceration PT03D Mahendran S; Abilash K; Manoharan K Medial Condylar Hoffa Fracture With Posterior Cruciate Ligament Avulsion Fracture In Right Knee Joint PT04A Lingeshwaran RA; Chelsia EA; Leow VC; Abdul Aziz Bilateral Proximal Femur Fracture In A Patient With Renal Tubular Acidosis: A Case Report PT04B Charl Satpal; Farid FF; Rusdi A; Shahrul H Salvaging Tibial Interlocking Nail Cut Out With In-Situ Plating: A Case Report PT04C Sankar P; Muhamnad A; Jaswindar S; Prashant N; Manoharan K Concomitant Ipsilateral Fractures Of Proximal And Distal Ends Of The Radius: A Rare Injury PT04D Chung WH; Randhawa SS; Sim SE; Adnan YK; Sankara Kumar C Outcome Following Surgical Fixation Of Patella Fractures PT05A Rex Premchand AX; Raghunathan R; Seah VWT Management Of Traumatic Tibial Bone Loss By Acute Shortening A Case Series PT05B Rex Premchand AX; Khan SA Contralateral Footdrop Post Intermedullary Nailing Of Femur: A Case Report PT05C Nasruddin AR; Nur Rahimah AR; Loong FYS Bicondylar Hoffa Fracture - A Rarely Occurring And Commonly Missed Injury PT05D Randhawa SS; Chung WH; Wong TS; Bong CP; Ling XW; Sankara Kumar C A Rare Case Of Floating Elbow Injury In Adolescent PT06A Raghavan S; Kamarulzaman MSK Bywaters’ Syndrome Exacerbated By Alcohol Intoxication: A Case Report PT06B Ramesh M; Surekha K; Suresh A; Anna R; Nisha T; Firatul A; Asyraf W Case Study: Modified Dimon - Hughston Osteotomy With Proximal Femoral Locking Plate For Unstable Intertrochanteric PT06C Femur Fracture Khaw YC; Or SY; Ong TK; A Aziz Y A Rare Case Of Spontaneous Bilateral Quadriceps Tendon Rupture; A Case Report PT06D Sabbir Husain A; Ahmad MH; Ahmad MFH Retrograde Femoral Nailing In Femoral Segmental Fracture Involving Subtrochanteric And Supracondylar Regions: A Case PT07A Report Chuah SK; Jesslyn L; Mikhail R; Kishan R; Ashwini S A Rare Scapula Fracture Associated With Acromion Fracture: A Case Report PT07B Azahari IM; Ahmad Tajudin A Lengthening Of Ulna By Ilizarov Technique In Hereditary Multiple Exostosis PT07C Thinesh VS; Kularaj S; Ramesh NA; Abdul Rauf HA Case Study: A Rare Case Of Traumatic Lateral Dislocation Of The Elbow PT07D Mustapa N; Rifa AS; Vincent J; Danappal S; Karrupiah V Long Segment Bone Loss! – Teluk Intan Experiences PT08A Thanesh A; Shukur A; Sharifudin S ! Combined Meeting of the 46th Malaysian Orthopaedic Association Annual General Meeting / Annual Scientific Meeting & 10th ASEAN Arthroplasty Association Meeting 2016

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Trauma

Poster ID Poster Percutaneous Bone Marrow Grafting For Large Bony Defect. A Case Report PT08B Lee YK; Ab Razak MR; Ab Zawawi Z; Shafei S Percutaneous Bone Marrow Aspiration And Grafting For Delayed And Non Union Long Bone Fracture – A Case Series PT08C Lee YK; Ab Razak MR; Ab Zawawi Z; Shafei S A Rare Case Of Traumatic Floating Clavicle PT08D Lee HS; Vicknesh A Luxatio Erecta: Understanding Its Unique Features, Mechanisms And Two-Step Reduction Maneuver PT09A Faisal Amir SM; Kartinawati M Case Series: A Modified Judet Approach To The Scapula In Floating Shoulder PT09B Ho SC; Ooi CL; Ong KS; Zulkiflee O Kickstand Modification External Fixation For Impending Open Distal Tibia Spiral Fracture PT09C Ling LT; Tan TS; Wong YD; Foo YH As Rare As Hen’s Teeth; Atypical Trans-Scaphoid Perilunate Fracture Dislocation Presentation PT09D Ling JL; De Silva S; Azlan MS; Zamyn Z Ossification Of Coracoclavicular Ligament Post Acromioclavicular Disruption: A Case Report PT10A M Husyaini H; A Mahyuddin M; M Yusof A Development Of Management Algorithm On Scapulothoracic Dissociation PT10B Vernon T; Yeo SY; Sia Ung; Nazari AT; Kamaruddin F Case Report: A Lucky Man With Foreign Body Transversing The Spinal Canal PT10C Lee KW; Yasser AK A Rare Case Of Floating Arm Injury In An Adult PT10D Ramalingam K; Kamarulzaman MSK Bedside Continuous Irrigation And Drainage: A Treatment For Septic Arthritis Of The Knee In Patients “Unfit For Surgery PT11A And Anaesthesia” Ngim HLJ; Khoo SS; Suhaeb AR; Simmrat S Biplane Double-Supported Screw Fixation For Neck Of Femur Fracture PT11B Abdul Rashid ML; Ho JPY; Suhaeb AM; Simmrat S “I Survived A Parasailing Fall” PT11C Faruk NA; M Firdaus A; Khoo EH Minimizing A Major Problem: A Humongous Infected Morel-Lavallee’ Lesion Of The Thigh PT11D Shamsher S; Achannan R; Azlan MS; Syed Azmi AS; Zamyn Z Outcome Of Tibial Plateau Fractures Treated With Ilizarov Fixator PT12A Paul S; Gurjit S; Zamyn Z Case Series Of Distal Humerus Fracture With Chevron Osteotomy Technique: Experience In Tertiary Hospital In East Coast PT12B Hazizul HH; Zaraihah MR; Anuar Ramdhan IM Exceedingly Rare Procedure: Post Traumatic Hemipelvectomy PT12C Hazizul HH; Zaraihah MR; Ruh Akmal AR; Isnoni I; Suzanah K Intramedullary Kirschner Wires For Clavicle Fracture: Case Report PT12D Zaraihah MR; Hazizul HH; Azahari IM; Tajuddin AA Excellent Temporary Short Term Outcome With Masquelet Technique In Long Bone Defect Following An Open Fracture PT13A Grade IIIA: Case Report Zaraihah MR; Hazizul HH; Suzanah K; Kartinawati M Management Of An Unstable Hip In A Psychiatric Patient PT13B Vincent J; Singh A; Mustapa N; Danapal S Chronic Morel-Lavallée Mimicking A Soft Tissue Tumour – A Case Report PT13C Rabin V; Ngiam A; Ganaisan P Experience With MINAR In Treatment Of Distal Clavicle Fracture: A Case Series Of 3 Young Patients PT13D Lim MY; Ooi CL; Devarani P; Zulkiflee O Fundamentals In Orthopaedics – Back To Basics "

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Trauma

Poster ID Poster Our Experience On Fibular Grafting For Large Gap Non Union Of Tibia Fracutre PT14A Firdaus MA; Ooi GK; Chua HS; Zulkiflee O Ipsilateral Femoral Head And Neck Fracture-Dislocation And Concomitant Shaft Fracture: A Rare Encounter PT14B Eo CK; Lim HC; Sharveen G; Haryati MY; Suresh C A Case Of Community Acquired MRSA Necrotizing Fasciitis Following Traditional Treatment With Acupuncture PT14C Paul K; Sia Ung; Leong WH; Faris K Open Comminuted Extrarticular Distal Femur Fracture: A Cost Effective Method Of Treatment PT14D Md Yusoff Z; M Shariff MS; Loong FYS Fat Embolism Syndrome In A Unicortical Fracture Of The Tibia – A Case Report PT15A Eva MZ; Tan HP; Mohd Ghazali AG; Tiew SK Treatment Of Osteoporotic Lateral Hoffa Fracture With Variable-Angle Condylar Locking Plate Through Minimally Invasive PT15B Lateral Approach – A Case Report Bong CP; Randhawa SS; Sankara KC; Adnan YK Bilateral Humerus Fracture: A Case Report PT15C Suresh A; Adnesh K; Ramesh M; Suriya K; Noramirah D; Lidiana A; Asyraf W A Traumatic Inferior Hip Dislocation PT15D Lau CL; Tan HL; Shukri Y An Alternative Fixation Method For Tibia Plateau With Tibia Shaft Fractures PT16A Shamsul SA; Thevarajan K; Hafifi M Inferior Pole Patella Fracture: Simple And Easy Approach PT16B Muhamad Taufik ML; Farid F; Loke YH; Yusof Y Save The Leg With Honey, A Case Report. PT16C Choo QQ; Adnan YK; Kumar CS Domestic Animal Bite Injury – A Retrospective Review And Case Series PT16D Balakrishnan SD; Hussin P Irreducible Traumatic Acute Anterior Dislocation Of The Shoudler: Candida Arthritis PT17A William CCH; Suhaeb AM; Simmrat S Case Report Of A Traumatic Forequarter Amputation - Extreme Case Of Avulsion Injury PT17B Hwang PX; Or SY; Wong KA; Aziz A Chronic Osteomyelitis Of Ulnar With Bone Loss Treated With Autologous Tricortical Iliac Bone Grafting And Titanium PT17C Locking Plate Fadzli M; Abd Muttalib AW; Suhana SB; Richford J Chronic Osteomyelitis Of The Femur: Concepts Approach PT17D Kamarul A; Bajuri MY; Daun E; Hilmi N; Naim N; Yuen JC; Ali Noor I; Shukur MH Tibia Fractures: A Singaporean Perspective PT18A Decruz J; Rex Premchand AX; Khan SA A Review On Lower Limb Necrotizing Fasciitis Mortality In Hospital Segamat PT18B Elaine SZF; Cheong KW; Richford J; Suhana SB; Muttalib A Limb Salvage In Necrotizing Fascitis: A Case Report PT18C Elaine SZF; Richford J; Suhana SB; Muttalib A Open Reduction And Internal Fixation (ORIF) Of Clavicle Fracture: 3 Years Serdang Hospital Experience PT18D Wong YJ; Hussin P Soft Tissue Cysticercosis Of The Left Leg PT19A Low WK; Suhaeb AR; Simmrat S Orthopaedic Related Trauma In Industrial Injury: A Serdang Experience PT19B Wong YJ; Liew SK; Yeak RDK Luxatio Erecta: Report On 4 Cases PT19C Wong YJ; Faris IP; Hussin P # Combined Meeting of the 46th Malaysian Orthopaedic Association Annual General Meeting / Annual Scientific Meeting & 10th ASEAN Arthroplasty Association Meeting 2016

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Trauma

Poster ID Poster Recontruction Of Coronoid Process Using Autologous Tricortical Iliac Bone Graft After Persistant Traumatic Elbow PT19D Dislocation - Case Report Khairul NS; Ardilla AR; Shukrimi A; Amin CA Pattern Of Emergency Orthopedic Cases Delayed During Long Weekends In Hospital Temerloh PT20A Hasni MH; Khairunjauhari NM; Han CS; Aziz MY Meliodotic Osteomyelitis Of Right Femur – A Case Report PT20B Ram KR; Foo CH; Jaffar MSA; Maris SW Common Microorganisms In Diabetic Patients In Kota Kinabalu. A Tertiary Hospital Experience PT20C Harkeerat S; Babar B; Asrul YHN; Ibrahim N; Siti Zulaifah CS; Chan SK; Paul AG Nonunion Fractures: Does Strontium Ranelate Offer Any Benefit? PT20D Ramlan MKR; Bajuri MY; Daun E; Shukur MH; Suraya A Floating Shoulder: Ipsilateral Clavicle, Scapular Body, Glenoid Fracture And Superior Shoulder Suspensory Complex PT21A Disruption Mithun V; Thinesh VS; Ramesh NA; Rauf A Case Report - Luxatio Erecta: A Rare Shoulder Dislocation Within 10 Days Opening Of A New Hospital! PT21B M Afiq MA; A Zubair AA; M Afiq MF Cost Assessment Of Dynamic Hip Screw (DHS) Versus Proximal Femoral Nail (PFN) In Treating Intertrocheneric Fractures PT21C Azwan ZB; A Wafiy MP; M Faiz HK; Shafiq M Open Subtalar Dislocation With Infection 6 Months Clinical Outcome PT21D Sim SE; Randhawa SS; Adnan YK; Sankara Kumar C Antibiotic Impregnated Cement Spacer As Definitive Treatment For Shoulder With Infected Implant: A Case Report PT22A Ng MG; Lam AWC; Dian DL; Ang HL Review Of Autogenous Morcelized Fibula Bone Graft In Illizarof External Fixator Patients With Delayed & Non-Union Tibia PT22B Choong JN; Ganaisan P; Rabin V; Manickam T; Vincent J; Selvan D Coronal Shear Fracture Of Distal End Of Humerus Treated With Headless Screw Fixation Via Antero-Lateral Approach – A PT22C Case Report Ram KR; Maria SW; Foo CH; Jaffar MSA Open Reduction And Internal Fixation Mason Type lV Radial Head Fracture: Case Report PT22D Mohd FR; Amir FZ Establishing Standard Operating Procedure For Femoral Head Procurement And Preparation As Allograft PT23A Eva MZ; Abdul Wafiy MP; Lim HK; Ristiman I; Tiew SK; Rifa AS Primary Soft Tissue Reconstruction Versus Delayed Soft Tissue Reconstruction In Grade IIIB Open Tibia Fractures. A District PT23B Hospital Experience Harkeerat S; Ariffin MA; Hariharan K; Fauzlie Y; Naveen VS Ipsilateral Traumatic Fracture Proximal And Distal Humerus (Floating Arm): A Case Report PT23C Lloyd S An Alternative In Managing Open Grade IIIB Tibia Fracture. Is 8 Months Enough? PT23D Teoh TJ; Thirumurugan K; Prashant N (    )*  BBS01 Cooling Material Composite For Cost-Effective Transportation Of Bone Allografts

Saravana Ramalingam; Nurhafizatul Nadia Hanafi; Sharifah Mazni Samsuddin; Suhaili Mohd; Norimah Yusof; Azura Mansor UMMC Bone Bank, NOCERAL, Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia

Introduction Discussion UMMC Bone Bank supplies sterile frozen All DI & GI composites recorded minimum bone allografts for orthopaedic surgeries. The temperature below -40oC as AATB bone allografts must be maintained frozen recommendation and maintained from 76.4h below -40oC as recommended by AATB (DI alone) to 6.3h (GI alone). Time taken to Standards to retain highest level of safety and despatch bones from Bone Bank to in-house quality.1, Dry ice (DI) slab is deemed to be a OT is usually 30 min and up to 5 h before the reliable cooling material2,3 but it is expensive bone is transplanted therefore all GI can be and some banks have used gel ice (GI) instead. used as cooling material. The process for Thus the study was conducted to identify a radiation sterilization takes normally 2 days cheaper cooling material by using composite of including transportation therefore composite of dry ice (DI) and gel ice (GI) and validated the 15kg DI:9 packs GI is suitable. GI alone can be frozen state in-situ for use of our bank. used to transport procured bones below -20oC if the trip less than 12h. The cost of 20kg DI at Materials & Methods RM 6.15 per kg (slab) can be reduced from Five composites of DI & GI as cooling RM123.00 to only RM 30.00 when only GI materials were used: 20kg (DI alone ), 15kg DI (RM 1.00 including freezing >48h) is used. + GI, 10kg DI + GI, 5 kg DI + GI and 0kg DI (GI alone). Five frozen and dummy bones Conclusion individually packed in triple plastic bags were Different DI & GI composites can be used to put in the middle of a polystyrene box (49.5cm maintain the frozen bones below -40oC for x 36.5cm x 33.5cm). Bones were surrounded despatch and sterilization process, and below - by the cooling materials and insulated by 20oC for transporting procured bones. This bubble wraps covering the internal walls. approach can reduce the amount of DI used Probe of calibrated thermocouple thermometer hence cost saving especially when the price was placed in between the bones and the box keeps escalating. was sealed with masking tape. The boxes were placed in non air-conditioner storeroom. The References boxes were weighed before and after the [1] AATB (2008) Standards for Tissue experiment for density calculation. Data were Banking, American Association of Tissue retrieved from the logger of thermocouple Banks, Maryland. thermometer for analysis. [2] Rooney P, Eagle MJ & Kearney JN (2015) Validation of cold chain shipping environment Results for transport of allografts as part of a human DI: GI Min Temp -40oC -20oC 0oC tissue bank returns policy. Cell Tissue Bank, (kg: pack) ±SD (oC) (h) (h) (h) 16:553-558. 20 :0 -73.9±2.55 76.4 94.1 119.6 [3] Bryce S, Taylor F & Shaw W (2010) 15 : 9 -69.7±2.57 61.0 95.6 124.9 Packin’ Ya Eskies!. Cell Tissue Bank, 11(3): 10 : 17 -59.1±6.73 35.5 57.8 78.3 291-294. 5 : 15 -63.3 7.5 25.2 64.5 0 : 28 -68.0± 4.91 6.3 11.8 91.2

Temperature in the storeroom was 26.0-28.0oC

BBS02 Accuracy Of Ottawa Ankle Rule For Diagnosis Of Ankle Fractures In Acute Ankle Injuries

1Syed Jeffrey; 1Jamaluddin Shafie; 1Zamri Abdul Rahman; 1Ruben Jayakumar; 1Zaharul Azri; 2Abdus Syakur; 2Baskar Panirsheellam; 2Ahmad Hazani 1Department of Orthopaedic and Traumatology, Hospital Kuala Lipis, Kuala Lipis, Pahang, 27200, Malaysia 2Emergency Department, Hospital Kuala Lipis, Kuala Lipis, Pahang, 27200, Malaysia

INTRODUCTION: The Ottawa ankle rules (OAR) are a set of were male and 7 were female. The average clinical guidelines used to identify whether group age is 29 years. In our study 7 patients patients with ankle injuries need radiography were OAR positive and 16 patients were OAR to rule out ankle fracture, thus reducing negative. 4 patients from the OAR positive unnecessary radiography. This study was group had ankle fractures whilst all patients in conducted to assess the applicability of the the OAR negative group did not have any OAR in our setting and to examine its fractures. Furthermore, in our study the OAR accuracy for the diagnosis of fractures in acute has a sensitivity of 100%, specificity of ankle injuries. 84.2%, positive predictive value of 57.1% and MATERIALS & METHODS: negative predictive value of 100% for All patients with acute ankle injuries who met detection of ankle fractures. Based on the our study criteria and presented to our hospital OAR, 16 (69.5%) ankle x-rays in this study within 72 hours of injury from 1st to 31st would be unnecessary radiography. Overall in December 2015 were selected for this 1-month our study the OAR is 86.9% accurate at prospective study. Our inclusion criteria diagnosing ankle fractures in acute ankle included patients more than 8 years of age and injuries. close injury. Polytraumatic, unconscious or patients with open wounds were excluded from this study. The ankle area was defined as the entire malleolar area and distal 6 cm of the tibia and fibula. Eligible patients were examined by emergency and orthopedic medical officers using the OAR, and then underwent standard anteroposterior and lateral ankle x-ray. According to the OAR, ankle x- ray is required if there is pain in the malleolar zone and any one of the following: bone tenderness at tip of medial mallelolus or along the distal 6 cm posterior tibia or; tip of the lateral malleolus or along distal 6 cm posterior fibula or; inability to weight bear Figure 1: Summary of the results immediately and four steps in the emergency department. The results of examination using Type of fracture Total the OAR were compared with the radiographic Lateral malleolus 2 results Avulsion fracture tip 1 RESULTS: of lateral malleolus 28 patients were initially enrolled. However, Medial malleolus 1 only 23 patients fulfilled our study criteria. 5 Figure 2: Type of ankle fracture patients were excluded; 1 had open wound, 1 had polytrauma and 3 patients’ forms were not completed. Out of the 23 selected patients 16 ABSTRACT TRUNCATED BBS05

Incorporation Of PDGF-BB In 3D Coragraft For Differentiation Of Mesenchymal Stromal Cells In Vitro

Mohan, S; Karunanithi, P; Raghavendran, HRB; Malliga Raman Murali, Kamarul, T Tissue Engineering Group, NOCERAL, Department Of Orthopaedic Surgery, Faculty of Medicine, University Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

INTRODUCTION: Figure 1. Scanning electron microscopy & Combination of scaffold, growth factor and Confocal of cell on coragraft loaded PDGF-BB stem cells gaining more attention in tissue engineering. Growth factors such as PDGF- BB is a potent mitogen and chemotactic factors for cells of mesenchymal origin, including periodontal ligament cells and osteoblast (Lynch et al.1991) but due to short half-life which is below 4 hours in vivo resulting to encapsulation in nanoparticles such as microspheres to protect from Confocal is done to confirm the cell attachment exponential decay. This study investigated the on the coragraft embedded with microsphere The effects of sustained release of Platelet derived cell proliferation is studied through the increase growth factor (PDGF-BB) encapsulated in in reduction rate of Alamar blue and the cell mircosphere embedded on 3D coragraft on the differentiation was examined through osteocalcin proliferation and differentiation of and ALP which showed positive result compared mesenchymal stromal bone marrow cells in to coragraft with unloaded PDGF microspheres. vitro. Gene expression showed up-regulation of genes compared with control. MATERIALS & METHODS: Microspheres are fabricated through the DISCUSSIONS: double emulsion method. Characterization of Initial result shows a burst release due to the the scaffold was confirmed using SEM, AFM, protein which is present on the surface during Confocal microscopy, FTIR, Staining fabrication. The 2nd and 3rd week protein is methods, Marker assay and gene expression. released through diffusion method. Higher release was found on 4th week due to the RESULTS: degradation of microspheres. PDGF increase the Microspheres fabricated through double expression of ALP and osteocalcin. emulsion method have a mean size of 400uM. FTIR examines the functional groups present CONCLUSION: in coragraft loaded and unloaded with The sustain release of PDGF from PLGA microspheres. AFM shows the 3d positioning microspheres has showed a better proliferation of microspheres within the coragraft. BET and differentiation of MSC on coragraft calculates the pore size as unloaded coragraft embedded with PDGF loaded microspheres. has more pore size compared to loaded coragraft. SEM done on coragraft embedded REFERENCES: with microspheres confirms the cell Lynch et al. Effects of the platelet-derived attachment on the coragraft and microspheres growth factor/insulin-like growth factor-I which shows no toxicity and gene expression combination on bone regeneration around showed up-regulation of genes related to titanium dental implants. Results of a pilot study osteogenic lineage . in beagle dogs. Journal of Periodontology. 1991:62:710-716

 + , *   (    )* PB01A Bacteriological Study Of Diabetic Foot Infections In Hospital Kajang, Selangor

Ong CS; Ruzaimi MY Department of Orthopaedics, , Jalan Semenyih, Bandar Kajang, 43000 Kajang, Selangor, Malaysia

Introduction: essential to select antibiotics that are more Diabetic foot infections are one of the major effective against Gram-negative bacteria based complications of diabetes mellitus associated on severity and depth tissue infection or with non-traumatic lower extremity infected gangrene. A relatively low in amputations. polymicrobial infection rate (27.8%) might be due to clinically mild and superficial Methods: subcutaneous infection as well as low A retrospective study was conducted and virulence of isolated organisms in this study. patients with diabetic foot infections admitted The management of DFIs usually requires to Kajang Hospital over a 12-month period combination of antibiotics therapy with from March 1, 2014 to February 28, 2015 adequate surgical debridement to eliminate included in the study. Specimens taken from source of infections. The choice of antibiotic the wound were sent to the clinical laboratory therapy is depends on the sensitivity of the for culture and sensitivity testing. pathogen isolated. However, there was no single antimicrobial agent can cover all of the Results: possible organisms isolated from the DFIs. A total of 97 pathogens were isolated from 151 patients. 61.6% had single organism Conclusion: infections. 27.8% of patients had There is an increased incidence of Gram- polymicrobial infection and 10.6% cultures negative organisms in bacterial agents isolated had no growth. The most common pathogens from DFIs. Stap. aureus and Proteus spp. were isolated were Gram-negative (66.0%) the most common Gram-positive and Gram- including Proteus spp. (20.6%), Pseudomonas negative organisms respectively. Cefotaxime aeruginosa (14.4%), Escherichia coli (11.3%) was a good alternative against Gram-positive and Klebsiella spp. (5.2%), as compared to organisms. Gram-positive organisms (34.0%). The most frequently found Gram-positive organisms References: were Stap. aureus (17.5%), followed by Strep. 1. Abd Al-Hamead Hefni, Al-Metwally R. agalatiae (6.2%). Antimicrobial susceptibility Ibrahim, Khaled M. Attia, Mahmoud M. results showed that meropenam were most Moawad, et al. Bacteriological study of effective against Gram-negative organisms diabetic foot infection in Egypt. J Arab Soc whereas cefotaxime showed good activity Med Res 2013; 8: 26-32. against Gram-positive bacteria, although 2. Raja NS. Microbiology of diabetic foot vancomycin remain the most effective against infections in a teaching hospital in Malaysia: a Gram-positive pathogens. retrospective study of 194 cases. J Microbiol Immunol Infect 2007; 40: 39-44. Discussion: Several studies from the recent literature have reported an increase in the prevalence of aerobic Gram-negative bacteria isolated from DFIs.1,2 Gram-negative organisms comprised almost twice the rate in patients with diabetic foot osteomyelitis from superficial wound cultures indicated that the more chronic or complicated DFIs are, the more Gram- negative agents will predominate. It is PB01B Outcomes Of Lateral External Fixation And Kirschner Wiring Of Humeral Supracondylar Fractures In Children

Kow RY; Zamri AR; Ruben JK; Jamaluddin S; Mohd Nazir MT; Gopindran M Department of Orthopaedic Surgery, Hospital Kuala Lipis, Kuala Lipis 27200, Malaysia.

INTRODUCTION: Result Cosmetic factor: Functional Displaced supracondylar fractures of the Loss of carrying Factor: Loss of humerus are the commonest fractures at the angle (degree) motion (degree) elbows in children.1 Treatment for Gartland III Excelle 0-5 (4 patients) 0-5 (5 patients) supracondylar fractures can be challenging nt and options include percutaneous Kirschner Good 6-10 (2 patients) 6-10 (2 patients) wiring and open reduction with Kirchner Fair 11-15 (1 patient) 11-15 (0 patient) wiring. Here, we explore the treatment Poor >15 (0 patient) >15 (0 patient) outcomes of lateral external fixation and Table 1: Outcome of lateral external Kirschner wiring of humeral supracondylar fixation and Kirchner wiring of humeral fractures in children at Hospital Kuala Lipis, supracondylar fractures in children based Pahang. on Flynn’s criteria.

MATERIALS & METHODS: DISCUSSIONS: This is a retrospective study involving In displaced humeral supracondylar fractures children treated for humeral supracondylar Gartland III, it is generally acceptable to fractures Gartland III at a single institution perform an open reduction and Kirschner st th from 1 October 2013 to 30 September 2015. wiring due to difficulty in manipulation. A A total of 7 children with irreducible Gartland lateral external fixator can act as a joystick for Type III humeral supracondylar fractures were a surgeon to manipulate both the proximal and treated with closed reduction, lateral external distal fracture fragments to achieve a good fixation and lateral Kirschner wiring. Patients reduction. Besides that, lateral external were subsequently followed up for a duration fixation and Kirschner wiring also minimizes of 6 months and final outcomes were assessed the risk of ulnar nerve injury as compared to using the Flynn’s criteria. the medial approach.1 Proximal Shanz pin should be inserted under direct vision to RESULTS: prevent iatrogenic radial nerve injury.1 The All 7 patients achieved fracture unions. advantages of this method as compared to Majority of the patients had excellent or good open reduction include easier wound care, cosmetic and functional status. One patient reduced pain and scar formation and it allows (14%) had pin site infection Checketts- earlier mobilization. Otterburn grade 2. None of the patients underwent a revision surgery. There was no CONCLUSION: neurological injury reported. All parents were Treatment of displaced humeral supracondylar satisfied with the treatment outcomes. fracture with lateral external fixation and Kirschner wiring offer good cosmetic and functional outcomes.

REFERENCES: 1.Theddy S, Timo S, Kaye W et al. Lateral External Fixation – A New Surgical Figure 1: serial radiographs of a left Technique for Displaced Unreducible humeral supracondylar fracture Gartland Supracondylar Humeral Fractures in Children. III which was successfully treated with JBJS 2008;90:1690-7. lateral external fixation and Kirschner wiring. PB01C Prospective Study Of Factors Influencing The Outcome Of Intra-Articular Knee Viscosupplementation In Osteoarthritis.

1Vijaya Kumar SL; 2Ashutosh Rao; 1Chew YW; 1Tan CS; 1Vijay Kumar NK; 1Tew MM 1Hospital Sultan Abdul Halim, Jalan Lencongan Timur, Bandar Amanjaya, 08000 Sungai Petani, Kedah, Malaysia 2Melaka-Manipal Medical College, Jalan Padang Jambu, Bukit Baru, 75150 Melaka, Malaysia

INTRODUCTION evaluated, were not statistically significant Osteoarthritis (OA) is a common degenerative predictors. joint disease, characterised by focal and Table 1: Descriptive Statistics progressive loss of hyaline cartilage of joints. Variables Mean (SD) There is a decrease in concentration of average Age 59.6 (7.56) molecular weight native Hyaluronic Acid Body Mass Index 28.1 (4.95) (HA), an essential component of synovial fluid Duration of knee pain 3 (3.0)a Note: a Presented as median (interquartile) synthesized and secreted by fibroblast-like synovial lining cells. Management of chondral Table 2: Repeated Measure Multi-factorial disease is challenging because of its inherent ANCOVA a low healing potential1.Since 1997, after FDA Variables Pre-Inj Post-Inj F Stat. p-value WOMAC WOMAC (df) approved the use of intra-articular hyaluronic Mean (SE) Mean (SE) acid products in treating pain of osteoarthritis Overall 64.3 (8.25) 81.0 (6.46) 5.34 (1) 0.023 knee recalcitrant to conservative therapy, there Note: a: Repeated measure multi-factorial ANCOVA, has been a rapid rise in knee intra-articular HA adjusted by age, BMI and duration of knee pain, usage. However, there is a paucity of consistent SE:Standard Error, F Stat. (df):F statistics (degree of freedom). data on the factors influencing outcome of these injections.

METHODS This study included patients more than 45 years of age with Kellgren-Lawrance (K-G) osteoarthritis graded between 1 and 3. These patients were also evaluated clinically, with predictors including age, gender, body mass index (BMI), unilateral or bilateral knee injection, duration of knee pain and underlying comorbidity. Pre-injection WOMAC score was Figure 1: Pre- and Post-injection WOMAC Mean Score charted before injecting the viscosupplementation into the knee with strict DISCUSSION aseptic precautions and using 4 to 5mls of local It is traditionally believed that older age group anaesthetic (lignocaine) injected at the patients and those with higher BMI will have predetermined site. Patients were then followed poorer outcome post intra-articular knee HA up at 3 months and post-injection WOMAC injection.SH Han et al showed that age was not was evaluated to analyze the predictive factors a significant predictor2. Another study from and knee viscosupplement outcome. Egypt found significant correlation between

BMI and disease duration in visual analogue RESULTS 2 There were total of 125 patients (33 male, 92 score . Meta-analysis revealed that patients female) satisfying the inclusion criteria older than 65 years and those with advance knee OA were unlikely to benefit from HA included in the study. Significant improvement 3 noted in the post-injection WOMAC score with injections . In contrast to other studies, we the p-value of 0.023. The study indicated that found that there was significant and equal all indicators (clinical and radiological) improvement in majority of patients receiving ABSTRACT TRUNCATED PB01D Influence Of Bone Types On Lyophilization Process

Ainnur Farhana Ariffin; Chan Hong Hau; Norimah Yusof; Suhaili Mohd; Saravana Ramalingam; Azura Mansor; Ng Wuey Min UMMC Bone Bank, Department of Orthopaedic Surgery, NOCERAL, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia.

INTRODUCTION further reduce the water content to 2.9% while Lyophilization (freeze-drying) is a preservation cancellous bones needed only 6h to reach process to reduce water content of bones to 6- 2.26%. To reduce the water content to the 8% according to AATB Standards. The AATB recommended level of 6-8%, the lyophilized bone can be stored and dispatched cortical bone required longer lyophilization at room temperature while the low water level time of 6-8h compared to only 1.75-1.97h for can minimize indirect effects of radiation cancellous bone. Duration for oven-drying at during sterilization. The process is influenced 100oC for water content analysis was 5 hours by the size, amount and structure of the bone for both types of bone. samples. Cortical bone with porosity 5-10%1 is denser than cancellous bone (porosity 50- DISCUSSIONS 90%2). Human bones contain approx. 10-20% Water content in the cancellous bone was 8 water, comprising of water of inorganic times higher than the cortical bone due to its crystallization, collagen bound water and free highly porous structure hence hold more water. water3. The present study determined the However, the compact cortical bone required 4 influence of bone type, cortical and cancellous, times lyophilization time. Surface area of the on lyophilization process. cancellous bone which is approx. double the cortical bone4 may contribute to the shorter MATERIALS & METHODS drying time. Ethic approval was obtained prior to commencing the study. Donors (femoral head CONCLUSION from living donor and tibia from cadaveric Lyophilization time to reduce the water content donor) were screened according to UMMC to 6-8% was 1.86h and 7h for the cancellous Bone Bank selection criteria. Total of 15 and the cortical bone, respectively. Bone cortical cubes from tibia (av. wt. 0.1-0.2g) and structure in term of porosity influences the 21 cancellous cubes from femoral head (av. wt. lyophilization process. 0.02-0.2g) were prepared. During processing, bones were treated with 70% ethanol and 0.5% REFERENCES sodium hypochlorite for HIV inactivation. 1. Cowin SC (1990) Properties of cortical bone Bones were kept in -80°C prior to and theory of bone remodelling. In: VC Mow, lyophilization (-50oC, 0.042 mm Hg, A Ratcliff & SL Woo, Biomechanics of LABCONCO). Water content was measured at Diarthrodial Joints, Springer, N York, 119- time intervals by gravimetric method (oven- 153. dried at 100oC, MEMMET) until the bone 2. Goldstein SA, Hollister SJ, Kuhn JL & weight was constant. Kikuchi N (1990) The mechanical and remodelling properties of trabecular bone. In: RESULTS VC Mow, A Ratcliff & SL Woo, Biomechanics Initial water content of cancellous to cortical of Diarthrodial Joints, Springer, N York, 61- bone at the ratio of 8:1 was reduced with 81. increasing time of lyophilization process. 3. Smith JW (1964) Observations on the water Comparatively, water content of the cortical content of bone. The Journal of Bone and bone was slightly reduced from 10.93% to Joint Surgery, 46B:553-562. 9.3% but greatly reduced from 78.95% to 4. Retrieved from 2.29% in the cancellous bone after 4h http://www.umich.edu/~bme332/ch9bone/bme332bone.ht lyophilization. The cortical bone needed 28h to ml PB02A Nitidine Chloride Modulates ITAM Signalling During Late Stage Osteoclast Differentiation

1,2,3Zawawi MSF; 3Dharmapatni AASSK; 3Haynes DR; 4Xu J; 3Crotti TN 1Department of Orthopaedics, School of Medical Sciences, Universiti Sains Malaysia (USM), Kelantan, Malaysia. 2Department of Pathology, School of Medical Sciences, Universiti Sains Malaysia (USM), Kelantan, Malaysia. 3School of Medicine, The University of Adelaide, SA, Australia. 4School of Pathology and Laboratory Medicine, The University of Western Australia, WA, Australia.

INTRODUCTION: Induction of the transcription factor, nuclear factor of activated T-cells, cytoplasmic, calcineurin-dependent 1 (NFATc1) and nuclear factor-κB (NF-κB) has been identified as a potential target to inhibit osteoclast development and activity (1). In the osteoclast, the immunoreceptor tyrosine-based activation motif (ITAM) signalling involves Fc receptor common gamma chain (FcRγ) pairing with osteoclast-associated receptor (OSCAR) and DNAX-activating protein 12kDa (DAP12) Figure 2: NFATc1, OSCAR, FcRγ, TREM2 pairing with triggering receptor expressed in and DAP12 gene expression was myeloid cells (TREM2) have recently been significantly reduced at Day 10, the shown to activate calcineurin-NFATc1 terminal stage of osteoclast formation. pathway and blocking their activity has been shown to inhibit osteoclast formation (2). We aimed to investigate the effect of benzophenanthridine alkaloid, Nitidine Chloride (NC) on ITAM molecules at different stages of osteoclast differentiation.

MATERIALS & METHODS: Peripheral blood mononuclear cells (PBMCs) were differentiated by addition of receptor activator of NF-κβ ligand (RANKL) and macrophage-colony stimulating factor (M- CSF), and treated with/out 1.0 μM NC over a DISCUSSIONS: 10-day time course. Gene expression was Consistently NC reduced osteoclast formation assessed at days 3, 7 and 10 by quantitative and activity. real-time polymerase chain reaction (Q RT PCR). CONCLUSION: NC suppresses key mediators of ITAM signalling RESULTS: to inhibit the mature osteoclast development.

Figure 1: Osteoclast formation, as assessed REFERENCES: by tartrate-resistant acid phosphatase 1. Xu et al., Cytokine & Growth Factor (TRAP) expression was significantly Reviews (2009). reduced. Osteoclast activity was reduced as 2. Zawawi et al., Biochem Biophys Res assessed by dentine pit resorption. Comm 2012. PB02B Diabetic Foot Infections: Are We Getting It Right? A 5 Year Retrospective Review Of Causative Organism And Emprical Antibiotics at Two Tertiary Hospitals In Klang Valley

1Rampal S; 1Kumar V; 1Yoganathan P; 2Ibrahim MI 1Department Orthopaedic,Faculty of Medicine,University Putra Malaysia, Serdang 43400 Selangor 2University Teknology Mara, Sungai Buloh 4700 Selangor

INTRODUCTION: Figure 1: Distribution of Causative Prevalence of diabetes mellitus is increasing at Organism according to Hospital an alarming rate. Diabetic foot infection (DFI) Gram Number Percentage associated with morbidity and mortality rate stain of (%) owing to its risk of amputation. Causative isolates microorganism and empirical antibiotics (n) should combated with local evidence based Hospital Positive 211 30.62 medicine. The main aim of our study is to Serdang determine the distribution, prevalence of Negative 478 69.38 causative microorganism and empirical antibiotics used in clinical practice locally. Hospital Positive 122 25.96 MATERIALS & METHODS: Ampang This was a cross sectional study using Negative 348 74.04 retrospective data from January 2010 to December 2014 of all patients diagnosed and Overall Positive 333 28.73 treated for DFI in Hospital Serdang and Negative 826 71.27 Hospital Ampang. A total of 885 patients (157 DISCUSSIONS: Male and 117Female) with total of 1356 The prevalence of gram negative bacteria in pathogens were isolated with a rate of 1.53 DFI is higher than gram positive bacteria. The isolates per culture (IPC). The type of most common gram negative bacteria is organism and empirical antibiotics were Pseudomonas Aeroginosa followed by Proteus analysed. The statistical analyses were Mirabilis and Klebsiella spp whereas the most conducted using Statistical Package of the common gram positive bacteria is Social Sciences (SPSS) version 22.0 for Staphylococcus aureus Windows (SPSS Inc, Chicago, IL). CONCLUSION: RESULTS: Although Ampicillin/sulbactam is the most The prevalence of gram negative bacteria is commonly prescribed antibiotic to patient with predominant in DFI accounting for 71.27% DFI, the most common organism is whereas gram positive is only 28.73%. Among Pseudomonas Aeroginosa. However data the gram negative isolates the most common suggest that the equal prevalence of pathogen were Pseudomonas Aeroginosa polymicrobial and monoclonal organism. accounting for 24.49% followed by Proteus REFERENCES: Mirabilis (14.34%) and Klebsiella spp History of Foot Ulcer Increases Mortality (11.12%) Gram positive isolates consists of Among Individuals With Diabetes: Ten-year Staphylococcus Aureus with a percentage of follow-up of the Nord-Trøndelag Health 66.77% Streptococcus spp 33.23%. The Study, Norway Iversen, Marjolein M; Tell, Methicillin Resistant Staphylococcus Aureus Grethe SView Profile; Riise, TrondView (MRSA) accounts for 26.24% of the isolates. Profile; Hanestad, Berit RView Profile; There were more monomicobial cultures than Østbye, TrulsView Profile; et al. Diabetes polymicrobial culture (465 vs. 420). The most Care32.12 (Dec 2009): 2193-9 common antibiotic prescribed is ampicillin/sulbactam (55.57%) followed by cloxacilin (13.29%) and penicillin (10.77%). PB02C Comparison Of Biocompatibility And Biodegradability Of Poly-Lactic-Co- Glycolic Acid (PLGA) Combined With Fibrin Versus PLGA For Intra-Articular Screw Fixation; An In-Vivo Study With New Zealand White Rabbit

1 Theenesh B; 1 Ahmad Hafiz Z; 2 Munirah S; 1 Nurul Hafiza MJ; 1 Mohd Zulfadzli I; 2 Noorhidayah MN 1Department of Orthopaedics, Kulliyyah of Medicine, International Islamic University Malaysia, Bandar Indera Mahkota Campus, Jalan Sultan Ahmad Shah, 25200 Kuantan, Pahang Darul Makmur, Malaysia 2Department of Biomedical Science, Kulliyyah of Allied Health Sciences, International Islamic University Malaysia, Bandar Indera Mahkota Campus, Jalan Sultan Ahmad Shah, 25200 Kuantan, Pahang Darul Makmur, Malaysia

INTRODUCTION: 3 different time intervals, namely 6,12, and 24 Intra-articular fixation remains a challenging weeks aspect of orthopaedic surgery with regards to RESULTS: the long term functional outcome. A variety of Expected outcome indications among others include intra- The combination of PLGA and fibrin results in articular fracture, osteotomy, ligament faster biodegradation, less foreign body reconstruction, meniscal and cartilage repair. reaction and more biocompatibility. Whilst anatomical reduction of fractures, DISCUSSIONS: strength of reconstruction and early mobility The first generation biodegradable orthopaedic are among the common concerns addressed, devices, made of PGA(polyglycolic acid) the need for implant removal, revision surgery which has degradation time of less than 6 and biocompatibility are rather often neglected months, were found to have high incidence of upon using metallic implants. inflammatory foreign body reactions. Implant Biodegradable implants offer sufficient made of PLLA( poly-laevo-lactic acid) found rigidity for healing, maintain mechanical to have a longer degradation time and less strength for certain period of time while foreign body reaction, however degradation allowing degradation and replacement by host rate of PLLA can be very low, reported to be tissue. Other advantages include 2-5.6 years for total resorption in vivo. Fibrin biocompatibility, no need for implant removal, has been studied as an ideal biological scaffold easier revision surgery, no distortion of in various tissue engineering applications due radiological imaging and earlier transfer of to its many inherent properties. Thus, we functional load to healing tissue propose the usage of combination of polymers MATERIALS & METHODS: (PLGA), with and without fibrin Objectives : To compare biocompatibility and CONCLUSION: biodegradability of polymer (PLGA+fibrin) Biodegradabe polymer PLGA with with PLGA alone for intra-articular screw incorporation of fibrin results in superior fixation, specifically to study outcome compared to usage of other current histomorphological features , evaluate biodegradable polymers. radiological changes, assess macroscopic REFERENCES: appearance and observe for local reaction 1.Kulkarni RK, Pani KC, Neuman C, Leonard Methods: F. Polylactic acid for surgical implants. Arch In this pilot study, we use fabricated PLGA Surg 1966;93:839-43 scaffolds in combination with autologous 2.Kulkarni RK, Moore EG, Hegyeli AF, fibrin for an in-vivo prospective study. The Leonard F. Biodegrad-able poly(lactic acid) New Zealand White rabbit will be operated on polymers. J Biomed Mater Res1971;5:169-81 and the scaffolds will be placed at both medial 3.L.S. Nair, C.T. Laurencin / Prog. Polym. and lateral femoral condyles of bilateral knees. Sci. 32 (2007) 762–798 Post implantation, evaluation(gross, histology, 4.Williams DF. The Williams dictionary of radiological and local reaction) will be done at biomaterials.Liverpool: Liverpool University Press; 19995. Lloyd AW.  - . / PA01A Total Hip Arthroplasty In Neglected Development Dysplasia Of Hip With 7cm Limb Shortening

Selvanathan Nanchappan; Sharveen G; Suresh C Department of Orthopaedic and Traumatology, Hospital Sultanah Bahiyah, Alor Setar, KM 6, Jln Langgar, 05460 Alor Setar, Kedah Darul Aman

Introduction Discussion Neglected DDH in early adulthood can pose as In Crowe Type 4, possible alternative to restore major degenerative hip arthritis. THR in this acetabulum to anatomical center on the patient has been successful and the major goal dislocated femur is by subtrochanteric of treatment is rebuilding new stable artificial shortening and derotation, combined with an joint with painless range of motion. Traction of distally fixed cementless stem.This technique neurovascular structures during surgery pose avoids the chances of traction injury towards high risk of being injured. sciatic nerve1. Localising a normal hip is often difficult during surgery, hence to overcome Case report this problem a method of acetabuloplasty was 27 years old lady diagnosed to have right sided described 2 They termed this technique as DDH at 2 years of age. Patient presented to us, cotyloplasty. Uncemented acetabular complaining of right hip and lower back pain. components with augmentation have revision There was no numbness or any neurological rates of 0-5% compared to cemented deficit .On examinations, Patient had short components have revision rates of 10%-35% at limb gait. No foot drop was noted. She was long term follow-up3. There is strong support planned for right sided THR and cable in the literature for uncemented acetabular plate.Harris hip score 64.89 (graded as poor) fixation, even when acetabular augmentation is preoperative to 89 post-operatively (graded as required. good). Ideal position for femoral head center, is to be less than 35 mm vertically from the interteardrop line and 25 mm laterally from the teardrop 4.

Conclusion Total hip arthroplasty in neglected DDH is a complex surgery, which requires meticulous planning in order to ensure good functional Figure 1: X-ray AP pelvis- Right sided high hip outcome for patients. dislocation, Crowe Type IV. References:- 1.Cabanela M.E. Total hip arthroplasty for developmental dysplasia of the hip. Orthopedics. (2001) ;24, No.9. 2.Hartofilakidis G, Stamos K, Karachalios. Congenital hip disease in adults. J Bone Joint Figure 2: Post op Right sided THR with cable plate. Surg Am 1996; 3.Scott Yang, Quanjun Cui, Total hip arthroplasty in developmental dysplasia of the hip: Review of anatomy, techniques and outcomes. World J Orthop 2012 4.Hirakawa K., Mitsugi N., Koshino T. Effect of acetabular cup position and orientation in Figure 3:Restored equal limb length. cemented total hip arthroplasty. Clin Orthop

Related. 2001.

ABSTRACT TRUNCATED PA01B

A Case Report Of Early Outcome In Reverse Total Shoulder Arthroplasty

Zulkifli KI; Thangaraju S; Hussin AR; Rajagopal S; Tahir SH Department of Orthopaedic, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia

Introduction: Figure 1: Post-operative radiograph of right Reverse total shoulder arthroplasty (RTSA) is shoulder a highly-technical surgery in which the prosthesis reverses the orientation of the shoulder joint by replacing the glenoid fossa with a glenoid base plate and glenosphere and the humeral head with a shaft and concave cup.

Case report: 63 years old, right hand dominant Indian gentleman presented to orthopaedic clinic of Hospital Kuala Lumpur (HKL) with right shoulder pain of 1 year duration. This pain was associated with reduced active range of motion (AROM). He previously sustained closed dislocation of right shoulder with avulsion Discussion: fracture of greater tuberosity of right humerus Clinically, rotator cuff arthropathy is after involved in a motor-vehicle accident on characterized by pain, poor active motion, 15th November 2013. In former hospital, near-normal passive motion, crepitus, primary closed manipulative reduction and weakness and occasionally significant fluid fracture stabilization of right shoulder was build-up under the deltoid. Radiographic done. In view of persistent shoulder pain on changes include elevation of the humeral head, active motion following 2 weeks of surgery, formation of acromiohumeral magnetic resonance imaging (MRI) of right pseudoarticulation and loss of joint space at the shoulder was done, showing massive rotator glenohumeral joint. cuff arthropathy. He then underwent arthroscopic right rotator cuff repair. After a The primary indication for RTSA is a non- year of surgery, patient showed no functional rotator cuff. This encompasses a improvement of symptoms, with AROM of number of disease processes, including cuff forward flexion was 0-40°, abduction was 0- tear arthropathy, pseudo-paralysis due to 30°, internal rotation was 0-40° and external massive rotator cuff tear without arthritis, rotation was 0-10°. He therefore came to HKL multiple failed rotator cuff repairs and failed to seek for expert opinion and further shoulder hemiarthroplasty. intervention from orthopaedic team. In HKL, he underwent RTSA surgery. Ideally, the best surgical option for this patient is latissimus dorsi tendon transfer surgery. But, Post-operative outcome: unfortunately he is not the right candidate for Post-operatively, physiotherapy regime was that procedure as he lost the greater tuberosity commenced, where patient was on arm sling foot print and severely deformed humeral head. for 4 weeks, and then followed with passive range of motion. After 4 months of the surgery, Reference: AROM of right shoulder improved markedly. 1. Reverse Total Shoulder Arthroplasty Forward flexion is 0-90°, abduction is 0-70°, Protocol 2011. The Brigham and Women's internal rotation is 0-80° and external rotation Hospital, Inc. is 0-20°. Department of Rehabilitation Services

ABSTRACT TRUNCATED PA01C Periprosthetic Fracture In Cemented Thompson Hemiarthroplasty: A Case Report

Yeow AYS; Low CA Department of Orthopaedic Surgery, Hospital Tuanku Ampuan Najihah, 72000 Kuala Pilah, Negeri Sembilan, Malaysia

INTRODUCTION Intraoperative periprosthetic fracture (IPPF) in hip arthroplasty has reported incidence ranging from 0.1% to 14%. The revision treatment of IPPF can be technically demanding and is affiliated with higher frequency of complications. We report a case of IPPF which Figure 2: Plain X-ray of left hip (oblique) and pelvis was diagnosed by postoperative radiological (AP) showing post-operation of removal of the evidence and revision surgery was performed. prosthesis, allograft, and Versys cemented revision calcar femoral stem and bipolar cup insertion. CASE PRESENTATION This case report involves a 76 year old Malay woman who presented to our institution with DISCUSSION Neck of femur fracture is associated with pain over the left hip after sustaining a fall in (1) the washroom. Plain radiographs revealed a considerable morbidity and mortality and Garden IV neck of left femur fracture. Severe occurs in an elderly and infirm group of osteoporotic bone was noted introperatively and patients. Thompson hemiarthroplasty is commonly used in elderly patients with femoral Thompson hemiarthroplasty of the left hip was (2) performed. Postoperative radiograph showed neck fracture due to its cost effectiveness and periprosthetic fracture with the stem of most use it cemented to increase its stability. Thompson implant protruding from the Peri-prosthetic fracture is not an uncommon complication in Thompson hemiarthroplasty, posterior aspect of left femur approximately (3) 2cm below the lesser trochanter. Acute revision especially in severe osteoporotic patients . operation with removal of the prosthesis, Some studies showed that total hip replacement allograft, and Versys cemented revision calcar (THR) is used in revision of hip femoral stem and bipolar cup was performed. hemiarthroplasty as it provides better function Postoperative radiographs showed good and wider range of motion. However, in this positioning and geometry of implant. Patient case, we utilized Versys cemented revision achieved satisfactory range of motion of the left calcar (CRC) femoral stem with bipolar cup as hip and ambulates with walking frame revision arthroplasty with a longer stem implant postoperatively. is the recommended treatment for periprosthethic fracture associated with loose or failed prostheses (4,5) and there was no arthritic changes in the acetabulum. Cemented long-stem femoral components decrease the extent and progression of femoral lucencies (4,5), thereby lowering the incidence of mechanical failures and improving long-term functional result. THR

was not used as metal-on-metal resurfacing isn’t Figure 1: Plain X-ray of left hip (oblique) and pelvis suitable for people with low bone density or (AP) showing periprosthetic fracture with the stem of severe osteoporosis. Thompson implant protruding from the posterior

aspect of left femur approximately 2cm below the CONCLUSION lesser trochanter. Intraoperative periprosthetic fractures are an increasingly common condition. Treatment

ABSTRACT TRUNCATED PA01D Rotating Hinged Total Knee Arthroplasty In Patient With Global Instability Knee: A Case Report

Tan HP; Ngiam CJ; Lau LQ; Avthar S; Kamil K Department of Orthopaedics, Hospital Tengku Ampuan Rahimah, Taman Chi Lung, Jalan Langat, 41200 Klang, Selangor, Malaysia.

INTRODUCTION more on the medial compartment with bone Rotating-hinged knee implants are highly loss, multiple osteophytes formation and severe constrained devices able to provide the stability subchondral sclerosis. Total knee replacement needed for arthroplasty in case of severe bone in this patient group can be complicated by loss and complex instability. Notable doubts significant articular and metaphyseal angular still exist in using rotating-hinged devices, deformity, soft tissue contracture, muscle tone mainly due to risk of mechanical failure and abnormality and global ligament deficiency. risk of infection. CONCLUSION In severely affected knee with serious bony and Hinged total knee arthroplasty is a very useful ligamentous defects, a high constrained total solution in cases of severe bone loss, revision knee device represents a treatment option able surgery and, of course, ligamentous laxity to restore and maintain the correct anatomical where these conditions are usually present. By axis as well as to confer the joint stability, mean of the rotational degree of freedom and where it is impossible to obtain with lower design features, these implant provide high constraint implants. Rotating-hinged designs constraint and great inherent stability while are described to deal with such instances of avoiding patello-femoral instability and severe loss of bone stock, gross ligamentous torsional stresses to load at the prosthesis instability, combined deformities, oncologic interface. This finally leads to longer survival surgery and salvage situations both primary and and better clinical outcomes. revision surgery.

CASE PRESENTATION Here, we would like to share our experience of this 68-year-old lady presented with a painful and global instability of her right knee. Historically, she denied any previous trauma such as sport injury or motor vehicle accident. Initial symptom was only distant claudication where it is associated with limited range of movement. Clinical examination showed significant multi-directional laxity over her right knee which causes instant pain upon ambulation and stiffness as well. Quadriceps and calf muscles wasting are noted and it might be one of the factor contributing to poor post- operative outcomes.

Besides painful knee, she also complained of gradual angular deformity and diffused swelling of her right knee. Various type of analgesia does not provide her a comfort day rather than giving side effect like epigastric pain and nausea. A plain radiograph demonstrated obvious joint space narrowing PA02B A Rare Case Of Ochronotic Arthropathy

Tung Sing, Wong; Azlina Amir Abbas; Azhar Mahmood Merican; Chan Chee Ken; Simret Singh Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

ABSTRACT INTRODUCTION: Introduction: Ochronotic arthropathy is a rare Alkaptonuria is a rare autosomal recessive condition found in patients with alkaptonuria. metabolic disease. It is characterized by Alkaptonuria is an autosomal recessive homogentisic acid (HGA) deposition in all disorder of metabolism. The pathogenesis connective tissue especially articular cartilage involved chronic inflammation, degeneration, as a result of a deficiency in homogentisic and eventually osteoarthritis. acidoxidase. (1) The incidence of alkaptonuria Case Report: A 65-year-old gentleman is one in 250,000 - 1 million people. The presented after a 5 year history of worsening typical triads of the disease are characterized bilateral hips pain. He had a background by dark urine (called alkaptonuria), connective history of chronic low back pain associated tissue pigmentation (ochronosis) and with right radicular pain and bilateral knees degenerative arthritis of the weight-bearing pain since he was 40 years which were treated joints (ochronotic arthropathy). (2) The with and bilateral total knee pathogenesis of ochronotic arthropathy replacements. Diagnosis of alkaptonuria had includes chronic inflammation, degeneration, been made via urine analysis which and eventually osteoarthritis. The knee joint is demonstrated a high level of homogentisic the joint that is most commonly followed by acid. Bilateral total hip replacements were the hip joint. Other sites of involvement are performed in separated surgical occasions to shoulders, sacroiliac joints and lumbar relieve his bilateral hip pain. Intra-operatively, intervertebral discs. (1) the joint surfaces, neighbouring soft tissue and joint capsule were blackish in colour. CASE REPORT: Discussion: Alkaptonuria was first described A 65 years old gentleman presented with in 1584, in children with dark urine. Typically worsening of the bilateral hip pain for the past patients begin to develop symptoms in the late 5 years. He had a background history of 30s with low back pain and stiffness. chronic low back pain associated with right Involvement of the large peripheral joints radicular pain and bilateral knees pain since he usually occurs several years after spinal was 40 years old which were treated with changes. The knees are most frequently discectomy and bilateral total knee involved, followed by the hips. There is no replacements surgery. He was also specific medical treatment for alkaptonuria. complaining of dark coloured urine since The early management of ochronotic childhood (Figure B). Diagnosis of arthropathy patients is usually conservative alkaptonuria had been made via urine analysis and symptomatic treatment. In cases of which demonstrated a high level of advanced ochronotic arthropathy, total homogentisic acid. He had no family history arthroplasty is the preferred treatment. of metabolic abnormalities. The spine Conclusion: Ochronotic arthropathy is a rare radiograph demonstrated widespread metabolic disorder that can be underdiagnosed calcification of the (Figure many a times. Early management of C). For the past five years, he started to ochronotic arthropathy is mainly symptomatic. developed new onset of bilateral hip pain with In advance ochronotic arthropathy, limited range of motion. Radiographic arthroplasty is the preferred and effective evaluation of the bilateral hip showed treatment. advanced bilateral hip degenerative arthritis Key words: Ochronotic Arthropathy. with significant loss of joint space. Bilateral Alkaptonuria, Autosomal Recessive total hip replacements were performed in separated surgical occasions to relieve his symptoms. Intra-operatively, the joint

ABSTRACT TRUNCATED PA02C BMI Changes After Total Knee Arthroplasty: A Comparison With Patients Treated Conservatively

Low CA; Fazlin MEO; Wong MA Department of Orthopaedic Surgery, Hospital Tuanku Ampuan Najihah, Km 3 Jalan Melang, 72000 Kuala Pilah, Malaysia.

INTRODUCTION: Male 61.9 66.7 Osteoarthritis can be a debilitating condition Female leading to reduced mobility and subsequently Race 0.5 increase in weight. Surgical interventions such Malay 10(55.6) 7(38.9) as total knee replacement have been proposed Chinese 4(22.2) 7(38.9) to reduce the symptomatic barriers and indian 4(22.2) 4(22.2) facilitate weight loss. The objective of this Initial BMI 27.5 25.2 0.12 study was to determine if a reduction in body (kgm-2) (17.6-33.8) (23.9- mass index (BMI) was present following 38.6) unilateral total knee replacement (TKR) Final BMI 28.7 24.9 0.007 compared to patients with OA who were (kgm-2) (18.5-34.9) (21.1- treated conservatively. 26.6) BMI +1.72 -0.32 0.005 METHODS: change Eighteen adults with end-stage knee OA who underwent primary unilateral TKR and DISCUSSIONS: twenty-one persons who were treated This study has shown that a majority of conservatively participated in this study. patients lose weight following TKR, which is Height and weight were measured at baseline similar to a study conducted by Teichtahl.1 and at a 1-year follow-up. Study revealed that even as little as 1% loss of weight results in a reduction in the rate of RESULTS: cartilage volume loss and an improvement in The mean age of the patients in the TKR knee pain, stiffness and overall function.2 On group was 63.2 years whereas control group at the contrary, there are literatures which 59.4years. The average initial BMI of the TKR reported weight gain in majority of TKR group was 25.2 which was not significantly patients. A higher BMI postoperatively has different from the control group at 27.5 been proposed to increase the knee joint (p=0.12). The average final BMI was compressive forces up to 212N with each step significantly different in the control group taken, which may jeopardize the contralateral compared with the TKR group (24.9vs 31.8; non-operated knee.3 p=0.007). In the conservative group of patients, there was a mean increase in BMI of CONCLUSION: 1.72 compared to the post-TKR group which -2 Structured weight loss interventional programs achieved a mean loss of 0.32 kgm . may be beneficial for patients undergoing arthroplasty to improve physical abilities and Table 1 showing subject characteristics and functional outcomes. Postoperative change in BMI in conservative vs post-TKR multidisciplinary approach involving patients nutritionist and weight management Characteris Conservati Post- p- professionals may increase the magnitude of tic ve TKR value postoperative weight loss. (n=21) (n=18) Mean age 59.4 63.2 0.095 REFERENCES: (48-82) (52-70) 1. Teichtahl AJ, Quirk E, Harding P, et al. Gender 0.096 Weight change following knee and hip joint (%) 38.1 33.3 arthroplasty-a six-month prospective study of

ABSTRACT TRUNCATED PA02D Total Hip Replacement As Treatment Of Choice For Neck Of Femur Fracture In Chronic Renal Disease Patients

Kong, YM; Raj, J; K, Kunalan Department of Orthopedic, Hospital Queen Elizabeth, 88400 Kota Kinabalu, Sabah, Malaysia

INTRODUCTION: DISCUSSIONS: Patients with chronic renal disease are known Generally, mode of treatment is decided based to suffer from metabolic bone disease, which on pattern of fracture, age of patient, and in turn increases the incidence of hip fractures. patient co-morbid, where undisplaced fractures Besides that, they have higher rates of can be treated conservatively or with internal complications like non-union and avascular fixation, while displaced ones are treated with necrosis (AVN). In view of this, many argue prosthetic replacement. However, Schaab PC the choice of management for these et al mentioned that operative treatments are intracapsular fractures. Here, we report 3 cases more superior that conservative, to avoid of neck of femur (NOF) fractures on regular complications³. Because of poor bone quality, dialysis. chronic renal disease patients are poor candidates for internal fixation¹. Studies show CASE REPORT 1 a mean of 83.3% chance in conversion of 56 years old gentleman, sustained right NOF internal fixation to total hip replacement due to fracture in August 2015, following a fall. He non-union or AVN². Based on WOMAC was kept on traction and eventually total hip score, all presented patients have good replacement was done 2 weeks later. Patient outcome in total hip replacement. Moreover, was able to ambulate with walking frame on one of our patient required conversion from post-operation day 2, and subsequently internal fixation to total hip due to loosening without aid by 2 months post-operation. of screw.

CASE REPORT 2 CONCLUSION: 40 years old gentleman, had a fall in early Total hip replacement should be considered as October 2015, and sustained left NOF fracture. treatment of choice in any case of He was operated 1 week post-trauma, where it intracapsular hip fracture, regardless of was uneventful intra-operatively. Patient was displacement, age or co-morbid. able to ambulate with walking frame 2 days after operation, but developed sacral sore REFERENCES: Grade 2 due to prolong sitting during dialysis. 1. Brinker MR. Review of Orthopaedic He was then readmitted for 3 week for wound Trauma, 2001 care, physiotherapy and antibiotics. By 6 2. Kalra S, McBryde CW, Lawrence T, weeks post operation, he was ambulating Intracapsular hip fracture in end-stage renal without aid. failure, February 1st 2006 3. Femoral neck fractures in patients receiving CASE REPORT 3 long-term dialysis, November 1st 1990 29 years old lady on regular dialysis since 2012, who also has hypertension and renal hyperparathyroidism, sustained right NOF fracture in September 2015. She was initially treated with screw fixation and allowed non weight bearing ambulation with crutches upon discharge. Later, she complained of persistent right hip pain, and subsequently noted to have screw loosening. Total hip replacement was carried out in Jan 2016, where it was intra- operatively uneventful. PA03A Case Report: A Rare Case Of Femoral Artery Thrombosis Following Total Hip Replacement

Paul Suman; Gurjit Singh; Zamyn Zuki Department of Orthopaedic Surgery, Hospital Sungai Buloh, Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia

INTRODUCTION: Total hip replacement (THR) is a common thromboembolectomy was done. However, the procedure in orthopedics that relieves pain and right leg was not salvageable and right above improves function in patients that suffer from knee amputation was done. He remained arthritis of the hip. Total hip arthroplasty is stable during the post-operative period. considered a safe, elective procedure but is not without fatal complication. Vascular DISCUSSIONS: complications in the course of prothetic hip Various causes of femoral artery thrombosis surgery are extremely rare. The risk of has been postulated which include manouver vascular injury is increased in patients with of the joint resulting in direct injury by pre-existing vascular disease symptoms such vascular elongation and torsion, persistent as sensory disturbances, claudication, pressure on femoral artery from the tip of atherosclerosis, or decreased distal pulses. Hoffman’s retractor placed on the anterior acetabular wall, screws and drilling of the MATERIALS & METHODS: acetabular wall or perforation of acetabular Here, we report a patient who had serious and diaceration of vessel during reaming and complication of femoral artery thrombosis vascular complication secondary to following total hip replacement. A 47 year old exothermic reaction during cement man presented to us with right hip pain polymerization. associated with right leg shortenning. He has history of road traffic accident in May 2014 CONCLUSION: and sustained right acetabular fracture with THR is a common procedure that is done in hip dislocation. Right acetabular hospitals in Malaysia. Vascular complications reconstruction was performed with are generally rare following total hip reconstruction plate. However, the right hip replacements and incidence rates are reported dislocated over time and formed a pseudo- between 0.2 to 0.3 %. Acute occlussion of joint. There was overiding of right femoral common femoral artery is a serious event that head approximately 7 cm from the true may result in amputation or hip disarticulation. acetabulum. He underwent right total hip Vigilant monitoring of patient in post- replacement with femoral shortenning in operative period is essential to pick salient November 2015 which took 3.5 hours. signs of vascular compromise.

RESULTS: REFERENCES: Five hours later, it was noted the right lower 1. Complications following total hip limb was pulseless, insensate, cold and arthroplasty. Asim Rajpura, Tim clammy. The doppler could not detect any Board; Athroplasty-Update 2013: 381– pulse and neither the pulse oxymeter with no 419. signs of compartment syndrome. An urgent 2. Sharma DK, Kumar N, Mishra V, CT angiography was done approximately 10 Howell FR. Vascular injuries in total hours after surgery and showed filling defect hip replacement arthroplasty: a review in common femoral artery and with of the problem. Am J Orthop (Belle surrounding oedema. A diagnosis of common Mead NJ) 2003; 32:487. femoral artery thrombosis was made and 3. Nachbur B, Meyer RP, Verkkala K, urgent referral to Vascular Unit, Hospital Zürcher R. The mechanisms of severe Kuala Lumpur was done. Following an arterial injury in surgery of the hip assessment by the vascular surgeon, an urgent joint. Clin Orthop Relat Res 1979; 122.

PA03B Outcome Of Nexgen Fixed Bearing And Posterior Stabilising Total Knee Replacement

Mohammed Harris A; Ahmad Hafiz Z; Mohd Shahidan NR Department Of Orthopaedic, Kulliyyah of Medicine, International Islamic University Malaysia Bandar Indera Mahkota, 25200 Kuantan, Pahang Darul Makmur

INTRODUCTION: DISCUSSIONS: Total knee arthroplasty (TKA) represents a This study was undertaken to review the major advance in the treatment of outcome of nexgen fixed bearing and posterior degenerative joint disease, providing excellent stabilizing total knee replacement done in restoration of joint function and pain relief. By single centre. The result functional and knee definition TKA is a surgical procedure score post operatively was good and excellent. whereby the impaired knee joint is replaced Numerous literatures gave evidence on with artificial material. TKA is not a new outcome of patient after TKA, however there procedure in Malaysia, since 1970 this is lack of study on complication following procedure had been carried out nexgen fixed bearing and posterior stabilising total knee replacement. Information collected METHODS: from this study might serves as an important This study aim to evaluate the functional and tool to improve pre and post operative surgical knee score outcome (SF-36, Oxford knee methodology for nexgen fixed bearing and score and KOOS), survival analysis of the posterior stabilising total knee replacement. implant(Kaplan Meier), to evaluate radiological outcome following total knee CONCLUSION: replacement. and to identify complication This study showed that the total knee following nexgen fixed bearing and posterior replacement is a surgery for which a trained stabilising total knee replacement. Study surgeon will be able to produce excellent and population include patient from orthopaedic good results. Total knee replacement is a department, Hospital Tengku Ampuan Afzan reproducible and calculated risk procedure from year 2000 to 2015. REFERENCES: RESULTS: 1. Ahmad HZ, Masbah O, Ruslan G The study sample consisted of 150 patient. (2011). Total Knee Replacement: 12 years There are total of 360 TKA performed during Retrospective Review and Replacement. the study period. Total of 39 stage bilateral Malaysian Orthoepaedic Journal. 5 (1): 34-39. TKA was performed. Female was more than 2. Scott WN, Rubinstein M, Scuderi G male. Ethnic make up was chinese 162, Malay (1988). Results after knee replacement with a 156, Indian 39 and Punjabi 3. Female posterior cruciate substituting prosthesis. comprised the largest subgroup. Functional Journal of Bone and Joint Surgery. 70A: and knee score post operatively was excellent 1163-1173. and good. The post operative xray showed 3. Callahan CM, Drake BG, Heck DA, femoral angle and tibial angle was within Ditlus RS (1994). Patient outcomes following normal range. Complication include tricompartmental Total Knee Replacement. A superficial wound infection, deep vein metaanalysis. Journal of American Medical thrombosis, periprosthetic fracture. Most Association. 217(17): 1349–1357. patient with superficial wound infection was treated with intravenous antibiotic and dressing. Osteoarthritis knee is the most common in this study.

PA03C Case Report : Bilateral Total Knee Replacement In Severe Knee Osteroarhtritis

Mohammed Harris A; Ahmad Hafiz Z; Mohd Shahidan NR Department Of Orthopaedic, Kulliyyah of Medicine, International Islamic University Malaysia Bandar Indera Mahkota, 25200 Kuantan, Pahang Darul Makmur

INTRODUCTION: 40 years old malay gentleman with underlying gout and hyper tension presented with chief complaint of bilateral knee pain for 10 years duration. He was walking with limping gait and unable to squat or sit cross legs. Pain had been increasing for the last 5 years. He was dependent on analgesia. Since pain was Right Left Right Left worsening patient was on wheelchair ambulation. On examination patient right DISCUSSIONS: knee, no swelling, fixed flexion at 10 degree, Post operatively wound was clean. Patient was range of movement 10-100 degree flexion, discharge well with oral antibiotic. He was lateral collateral laxity and varus deformity. advised for non-weight bearing for 3 months. Left knee had fixed flexion at 5 degree, range He was referred to physiotherapy for range of of movement 5-100 degree and varus motion exercises. 1 year post operatively deformity. Blood investigation showed uric patient able to ambulate with walking stick. acid. Xray of bilateral knee showed reduced Pain score improved. Functional and knee joint space, and sclerotic bone. score is good. Range of movement bilateral knee are 0-100 degree. METHODS: Patient underwent bilateral total knee CONCLUSION: replacement. Left total knee replacement was Outcome shows that total knee replacement is done followed with right total knee a reproducible surgery for which a trained replacement after 5 months. Intraoperatively surgeon will be able to produce excellent and left knee noted intraarticular loose bodies and good results. uncontained posteromedial defect which was build up with bone (screw fixation) and bone REFERENCES: grafting. Intraoperatively right knee noted 1. Gandikota Girish, David M. Melville, Gurjit posteromedial defect over tibial articular S. Kaeley, et al., “Imaging Appearances in surface, incomplete iatrogenic fracture over Gout,” Arthritis, vol. 2013, Article ID 673401, medial tibial plateau, augmented with 5mm 10 pages, 2013. doi:10.1155/2013/673401 metal block over medial tibial plateau, bone 2. Keerati Charoencholvanich, MD, quality was good, sclerotic bone over medial Boonchana Pongcharoen, MD Oxford Knee tibia plateau and multiple holes was drill over Score and SF-36: Translation & Reliability for the sclerotic bone Use with Total Knee Arthroscopy Patients in Thailand J Med Assoc Thai 2005; 88 (9): RESULTS: 1194-202 3. Callahan CM, Drake BG, Heck DA, Ditlus RS (1994). Patient outcomes following tricompartmental Total Knee Replacement. A metaanalysis. Journal of American Medical Association. 217(17): 1349–1357.

PA03D Primary Total Hip Arthroplasty With Restoration Gap II Cage Post Fracture Dislocation Of Femoral Neck With Acetabulum Fracture

1Ong. LH; 2Ahmad Tarmuzi. N; 2Arsad. SR; 2Rutel. A; 2Kamaruddin. F 1Department of Orthopaedic Surgery, FMHS University Malaysia Sarawak, 94300 Kota Samarahan, Sarawak. Malaysia 2 Department of Orthopaedic Surgery, Hospital Umum Sarawak Jalan Hospital, 93586 Kuching, Sarawak, Malaysia

INTRODUCTION: necrosis of femoral head after 1 year of Fractures of the femoral head infrequently reduction and fixation, subsequently received accompany hip dislocations with acetabulum total hip replacement.4 Dreinhöfer KE et. al fracture, but create complex therapeutic treated all 4 Pipkin III fracture with primary dilemmas. The injury is likely due to high- total hip arthroplasty with good outcome.5 energy trauma during a motor vehicle accident Schmidt AH et. al noted that recent in a younger subject. The combination of both comparative follow-up studies have injuries results in joint stiffness and documented superior and more durable osteoarthritis.1 function in patients with displaced femoral neck fractures after total hip replacement CASE: when compared to hemiarthroplasty or Mr. L, 67 year-old laborer was involved in uncomplicated osteosynthesis. Economic road traffic accident. He sustained closed analyses suggested that the long-term cost of fracture dislocation of left femoral head and treatment favors total hip replacement due to subcapital neck of left femur fracture additional cost of treating failures of internal associated with posterior wall of acetabulum fixation and hemiarthroplasty in patients who fracture. survive 2 years or longer after their initial hip fracture.6

CONCLUSION: Primary hip arthroplasty is a reasonable treatment option with functional and financial

FIG.1: PREOPERATIVE advantage for fracture dislocation of femoral FIG.2: POSTOPERATIVE head/neck with acetabulum fracture Primary total hip replacement with restoration Gap II cage was done and postoperative was REFERENCES: uneventful 1. J. Tonetti, S. Ruatti, V. Lafontan, F. Loubignac, P. Chiron, H. Sari-Ali, et al. Is DISCUSSIONS: femoral head fracture-dislocation management Mr L. sustained Thompson-Epstein type improvable: a retrospective study in 110 cases V (Pipkin subtype III) injury of the left hip. Orthop Traumatol Surg Res, 96 (2011), pp. 623–631 Treatment options include 1) Open reduction, 1 screw fixation of femoral neck with plating of 2. Hougaard K , Thomsen PB. Traumatic acetabulum 2) Hemiarthroplasty with plating posterior fracture-dislocation of the hip with of acetabulum 3) Primary total hip fracture of the femoral head or neck, or both J 2 Bone Joint Surg Am. 1988 Feb;70(2):233-9. arthroplasty with restoration cage. Zehi K. et. 1 al noted surgical treatment with screw 3. Zehi K , Karray S, Litaiem T, Douik M. fixation, excision of fragment or prosthetic Fracture-luxation of the femur head. Apropos replacement had satisfactory functional results of 10 cases Acta Orthop Belg. 1997 3 Dec;63(4):268-73 after mean follow-up of five years. 1 Guan H. et. al used titanium cannulated screws 4. Guan H , Liu X, Su J, Zhang C, Sun J, Fu Q to fix the femoral intertrochanteric fracture in Treatment and short-term effect analysis Pipkin III in two patient. One case had

ABSTRACT TRUNCATED PA04A A Case Report On Late Presentation Of Discoid Meniscus Masquerading As Chronic Iliotibial Band Syndrome Post Total Hip Arthroplasty

Chang CW; Chan CK; Teo SH; Mohamed Ali MR; Abbas AA; Merican AM Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

INTRODUCTION: Chronic iliotibial band syndrome is one of the Discoid meniscus is usually asymptomatic diagnostic considerations for painful hip unless in the event of degenerative tear. arthroplasty. However there are many other Therefore the presentation can be later at mimickers that can contribute to the pain. We middle age. However due to insidious report a case of chronic thigh pain post total symptoms and vague signs, it leads to hip arthroplasty that turned out to be late diagnostic uncertainty that require further presentation of discoid meniscus. work up such as diagnostic arthroscopy or imaging studies. CASE REPORT: A 46-year-old lady who had left femoral head Therefore, post total hip arthroplasty patients avascular necrosis with short limb underwent who presented with hip, thigh or knee pain total hip arthroplasty. Since the surgery she require careful systematic assessment of the had chronic left hip and knee pain. It was symptoms. mechanical in nature and located along the lateral aspect of hip, thigh and knee. Clinically she had tenderness over greater trochanteric region and lateral knee joint. Her hip adduction and internal rotation was markedly limited. Ober’s test was positive. Diagnosis of chronic iliotibial syndrome was made.

Despite several months of physiotherapy and steroid injections, her symptoms remained the same. We re-evaluated her together with sports surgeons and found that she might have meniscus problems. A diagnostic knee arthroscopy was performed and we found a Fig. 1 – Incomplete discoid lateral meniscus. discoid lateral meniscus with menisco- capsular separation (Fig. 1). Therefore we REFERENCE: proceeded with saucerisation and repair of 1. Farmer, K. W., Jones, L. C., Brownson, meniscus. Subsequent follow up in the clinic K. E., Khanuja, H. S., & Hungerford, M. W. showed improvements. She is able to walk (2010). Trochanteric bursitis after total hip without pain and resume her activities. arthroplasty: incidence and evaluation of response to treatment. J Arthroplasty, 25(2), DISCUSSION: 208-212. doi: 10.1016/j.arth.2009.02.008. In this case, after excluding the diagnosis of fracture, aseptic loosening and infection, we are fairly contented with the diagnosis of iliotibial band syndrome in the beginning. This may be due to correction of short limb by total hip arthroplasty that involved the use of high offset implant but no study could verify this hypothesis (Farmer, Jones, Brownson, Khanuja, & Hungerford, 2010). PA04B Variability In Magnification Of Pelvic Radiographs In Hip Hemiarthroplasty

WH Chee; CA Low; MA Wong Department of Orthopaedic, Hospital Tuanku Ampuah Najihah, Jalan Melang, 72000 Kuala Pilah, Negeri Sembilan, Malaysia

INTRODUCTION DISCUSSIONS Accurate calibration of radiograph in It is an accepted fact that radiograph arthroplasty is essential in preoperative magnification is subject to variation. Several templating and planning. Templating of pelvic methods have been reported to improve the radiographs traditionally involved using accuracy of preoperative planning, including company-provided templates which assumed a measuring one’s own radiology department magnification of 115-120%. Knowledge of the mean magnification, using calibration true radiographic magnification is essential for markers, and using mathematical formulas. accurate templating measurement. The aim of Preoperative planning for hip hemiarthroplasty this study is to determine the variability in in our hospital should be done using a magnification of radiographs in our hospital. magnification 13.5% ± 4%, which would accurately predict the implant size in 60% of METHODS cases. Ideally, accurate preoperative Fifty hemiarthroplasty postoperative pelvic templating should include using calibration radiograph films were selected at random from marker. our patients’ records and measured using a standard 150mm ruler. The implant CONCLUSION component was measured and compared with Anteroposterior pelvic radiographs exhibits known component size from operative notes. variable amount of magnification and is Intra observer and inter observer inconsistent on repeat examinations. The use measurements were tested to obtain a more of radiographic calibration marker should be accurate reading. used to improve preoperative planning and obtain a better postoperative outcome. RESULTS Of the 50 radiographs obtained, 13 (26%) REFERENCES were males and 37 (74%) were females with 1. Zubairi A, Ahmad T: Variability of mean age of 75.5 (±10.3) years. 28 (56%) magnification on digital pelvic radiographs were Thompson hemiarthroplasty and 22 from patients with fractures of the femoral (44%) were bipolar hemiarthroplasty. Mean neck - a retrospective audit. J Pak Med implant size used was 45mm (±4mm). Assoc. 2014 Dec;64(12 Suppl 2):S158-60. Radiographic magnification ranges from 7.5% 2. SP White, J Bainbridge, EJ Smith: to 22.22%, with mean magnification of 13.6% Assessment of Magnification of Digital Pelvic (±4.1%). There were no statistically Radiographs in Total Hip Arthroplasty Using significant difference in magnification Templating Software. Ann R Coll Surg Engl. between gender (p value = 0.417), side of 2008 Oct; 90(7): 592–596. interest (p value = 0.624), nor between types 3. The B, Kootstra JWJ, Hosman AH, of hemiarthroplasty (p value = 0.95). Verdonschot N, Gerritsma CLE, Diercks RL, Preoperative planning using a template of 15% : Comparison of Techniques for Correction of magnification resulting in correct estimation in Magnification of Pelvic X-rays for Hip 13 (26%) patients. Templating using 20% Surgery Planning. Journal of Digital Imaging, magnification yields accuracy in 3 (6%) Vol 20, No 4 (December), 2007: pp 329Y335 patients. However, preoperative planning 4. Conn KS, Clarke MT, Hallett JP. A simple using a 10% magnification would result in guide to determine the magnification of correct estimation in 15 (30%) patients. radiographs and to improve the accuracy of preoperative templating. J Bone Joint Surg Br 2002; 84-B:269-72.

PA04C Tuberculous Knee Joint- Case Report

Goonasegaran AR; LH Ong Orthopaedic Department, , Jalan Hospital, 93586 Kuching, Sarawak, Malaysia

INTRODUCTION Tuberculosis is an ancient disease that is still a represents 10% of cases3, of which skeletal major morbidity worlwide1. Along with the tuberculosis may range from 1-20% of all increase in prevalence of pulmonary extrapulmonary tuberculosis. Most common tuberculosis, skeletal tuberculosis seems to be site of skeletal tuberculosis is the spine (50- on the rise too2. The complication of joint 60% cases), followed by weight bearing joints related tuberculosis can be very disabling and (hip and knee). In the present case, treatment may impede the function of an individual if was started on high index of suspicion and left untreated. diagnosed with smear negative tuberculosis with left knee tuberculous arthritis. A positive CASE PRESENTATION smear is only seen up to 16%4 of cases and a Mr Z is a 42 year old gentleman which positive culture ranges from 30.4% - 87% of presented with multiple episodes of left knee cases5. Tuberculous arthritis spares no joints swelling since September 2013. Patient was and is usually monoarticular2. Weight bearing then diagnosed with smear negative joints seem to be involved more commonly pulmonary tuberculosis with left knee than the rest. The symptoms may vary from tuberculous arthritis for which he completed 9 joint swelling, chronic pain, warmth, localised months of anti-tubercular treatment in April tenderness and gradual loss in function1-6. 2015. Sinuses, cold abscesses and presence of constitutional symptoms is not uncommon. PHYSICAL EXAMINATION Osteoarticular involvement is usually through The left knee was minimally swollen with haematogenous spread from a primary focus restriction of range of motion which is 20 – 90 likely the lungs6. In this case, the lung may be degrees of flexion with firm end points. Fixed the primary focus as reported from the chest x- flexion deformity at 20 degrees. Other joints ray. were grossly normal. In December 2015, patient proceeded with a left total knee CONCLUSION arthroplasty. Post-operative range of motion High index of clinical suspicion is needed to was 10 – 120 degrees. diagnose tubercular knee arthritis as early treatment leads to better outcome. LAB RESULTS AND IMAGING STUDIES REFERENCES The left knee x-ray, showed severe bone erosion with osteomyelitic changes of the 1. Garrido G, Gomez-Reino JJ, femur, tibia and patella. ESR 1, CRP negative. Fernandez-Dapica P, Palenque E, Prieto S. A review of peripheral tuberculous arthritis. InSeminars in arthritis and rheumatism 1988 Nov 30 (Vol. 18, No. 2, pp. 142-149). WB Saunders. 2. Mohapatra D, Sarangi G, Paty BP, Das 2014 POSTOPERATIVE P, Mohapatra A, Chayani N, Patnaik G. Tuberculous Synovitis of Knee DISCUSSIONS Joint. Tuberculosis still remains as a major health 3. Nissapatorn V, Kuppusamy I, Rohela 3 burden to the Malaysian public health . The M, Anuar AK, Fong MY. incidence of extrapulmonary tuberculosis is Extrapulmonary tuberculosis in ranging from 2- 20% and in Malaysia it Peninsular Malaysia: retrospective ABSTRACT TRUNCATED PA04D Primary Bipolar Hemiarthroplasty For Displaced Neck Of Femur Fracture In Young Patient: A Case Report

Firdaus Z; Ramesh N; ARauf A Hospital Tuanku Jaafar Seremban, Jalan Rasah, 70300 Seremban, Negeri Sembilan, Malaysia

INTRODUCTION: Figure 3: Post bipolar hemiarthoplasty Neck of femur is intracapsular and vascular is fragile. There is risk of non union and avascular necrosis is high. For young patient early reduction is required to avoid the risk of osteonecrosis.

CASE REPORT: A 28 years old male presented to us with left hip pain after involved with motor vehicle accident. Pelvis X-ray, left hip x-ray and CT pelvis show neck of femur and left acetabulum DISCUSSIONS: fracture. In view of severity and displacement The treatment for femoral neck of femur of the femoral neck fracture patient was then fracture highly debated. The current evidence plan for uncemented total hip arthoplasty and with respect to the treatment principles of plating of left acetabulum. femoral neck fractures in two distinct patient populations: “young” and “old.” The Figure 1: Pelvis X-ray controversies including surgical timing, choice of implant, arthroplasty options, nonoperative management, and capsulotomy1. For young patient whose sustain femoral neck fractures, all treatment decisions focus on preservation of the native femoral neck and head. However there is risk of osteonecrosis and non union, AVN rates of 85 % and nonunion rates as high as 60 % have been reported2. In view of

severity and displacement of the femoral neck Figure 2: CT Pelvis fracture, therefore arthropalsty was suggested for this patient. Post-operative patient was advised to avoid strenuous activity to prevent early revision of implant or total hip arthroplasty.

REFERENCES: 1. David A. Forsh and Tania A. Contemporary management of femoral neck fractures: the Patient underwent surgical intervention 2 young and the old Curr Rev Musculoskelet weeks after trauma; however intraoperative Med. 2012 Sep; 5(3): 214–221 finding show comminuted left femoral neck 2. Protzman RR, Burkhalter WE. Femoral- fracture with intact posterior wall acetabulum, neck fractures in young adults. J Bone Joint only labrum avulsed. We proceed with Surg Am. 1976;58:689–95 primary bipolar hemiarthroplasty for this patient.

PA05A

Bilateral Hip Osteoarthritis With Systemic Sclerosis : A Case Report

Anuar S; Farid FF; H Shahrul Department of Orthopedic, Hospital Selayang, Lebuhraya Selayang-Kepong, 68100 , Selangor Darul Ehsan

INTRODUCTION DISCUSSION Systemic sclerosis is a severe connective In the case of the woman described here, tissue disease which frequently involve severe erosive changes were found in the musculoskeletal and causes significant joints bilateral hip joint in keeping with functional disability due to changes of osteoarthritis features, including osteophytes, cartilage thickness or cartilage degradation. joint space narrowing and subchondral cyst and sclerosis instead of avascular necrosis of CASE REPORT the femoral head. We present a case of a 62 years old chinese The pathogenesis of systemic sclerosis is lady with underlying systemic sclerosis with complex and poorly understood. However, it coexisting polymyositis , esophagitis and lung is accepted that its pathogenesis is fibrosis. She was referred by rheumatologist to characterized by vasculopathy, immune our team as she has been complaining of activation and progressive fibrosis in multiple severe bilateral hip pain for the past 1 year organs. In patients with systemic sclerosis, which gradually worsen till an extend where cartilage damage or degradation may also she has to use walking stick. However she occur with the interaction of these pathologic denies any recent trauma previously. processes. The examination shows bilateral hip Articular cartilage is an avascular tissue and is tenderness, with limited range of movement of nourished by synovial fluid or subchondral both hips 0-100 degrees in bone. Current studies have indicated that the flexion.Radiographically shows loss of joint nutrition of cartilage could play a critical role space, bone osteopenia and subchondral in maintaining normal cartilage homeostasis sclerosis with flattening of both head of and function. In patients with systemic femurs which indicates bilateral hip sclerosis, thinner cartilage could be the result osteoathritis.These osteoathritic changes is of nutritional deficiency, which may be worse over the left hip which correspond with associated with vascular dysfunction or patient having severe pain more over the left synovial fibrosis in this disease. side.She was diagnosed to have secondary Joint involvement in systemic sclerosis occurs bilateral hip osteoarthritis with underlying frequently and may resemble rheumatoid systemic sclerosis. arthritis in the early stages but is less RESULT destructive. The occurrence of unrelated The surgery of left total hip arthroplasty was arthropathy, such as primary osteoarthritis, is successfully done on 14 July 2015 without not uncommon, intraoperative complications.The radiological outcome postoperatively showed acceptable CONCLUSION fixation.Patient was discharged well from our Systemic sclerosis is one of the factor ward with advice of walking frame contributing to osteoarthritis of the joints due ambulation. to changes of cartilage thickness or cartilage degradation.. This medical condition together with joint disease lead to devastating clinical joint condition for the patient. However this musculoskeletal manifestation was managed succesfully with total hip arthroplasty which 1. Radiograph of severe bilateral hip provide good radiological and clinical osteoarthritis outcome. 2. Postoperative Radiograph of left total hip arthroplasty ABSTRACT TRUNCATED PA05B Total Knee Replacement In Hemophiliac Knee Arthropathy: A HKL Joint Replacement Unit Experience

Bernard Cheu TL; EP Su Department Of Orthopaedics, Institute Traumatologi dan Ortopedik,Hospital Kuala Lumpur, Jalan Pahang, 50586, Kuala Lumpur , Malaysia

INTRODUCTION assessment is essential , a routine Full blood Haemophiliac arthropathy of the knee is a count , renal profile and extended coagulation common complication of long term profile are sent. Factors level are haemophiliac condition.In the recent identified.Factor levels are corrected pre decade,haemophiliac arthropathy has ceased to operatively and post operatively. delay in its manifestation due to the availability of recombinant plasma factor RESULTS started at a very young age in haemophiliac Our patients demonstrated overall patients.Severe form of INTRODUCTION improvement according to assessment with haemophilia can be converted into a moderate knee society scoring system.The scoring form.The recurrence in bleeding in the knee showed improvement on average of 37points joint causes synovium friability.In the end to 85point 3months postoperatively and at stage of disease, hyperplasia of membrane will 6months 92points.Functional scoring improves form more fibrous tissue leading to contracture from 38points to 86 in 3months and at of knees.In Malaysia,with the recent 6months average of 91points.ROM improves availability of recombinant factor plasma on average of 20degrees at 6months post provided by PDN,Patients had benefitted from operative period.No documented a thorough preoperative preparation prior to complications from 14 cases during follow up surgery addressing the issue of excessive of 31 months.No infected implant and aseptic bleeding intraoperatively. As such that the loosening cases reported. frequencies of haemarthrosis can be reduced to DISCUSSIONS less than 5 times in a year.Patients indicated Life expectancy of haemophiliac patients had for surgery are those with severe prolonged considerably now due to pain,functional reduced mobility and has a availability in treatment with plasma factor. restricted range of motion of affected knee Early transfusion will help in delaying joint.Definitive contraindications includes any degenerative changes over knee joints by form of active infections , relative reducing frequency of bleeding. However, on contraindications are skin diseases , average patients at the age of 29 , a relatively immunocompromised patients (with HIV , young age are still at risk of needing surgery. Liver diseases), patients who has history of Till now there are still no study with regards to non compliance in treatment. the life span and durability of implants to tell

METHODS us at which stage patients will have to go for revision surgery. A prospective study was carried out in HKL orthopaedic department by joint replacement CONCLUSION unit from January 2013 to December 2015. A Total knee replacement in haemophiliac total of 14 haemophiliac A patients with patients with arthropathy is a good method to average age of 29.2.All patients had Grade 5 address debilitating functions and pain to the haemophiliac arthropathy according to knees. Good support from the nearest Arnold-Hilgartner arthropathy classification. Haemophilia treatment centre is essential in The average preoperative knee score ensuring the success of surgery. Functional according to knee score society were 37 and outcomes improve drastically and it improves functional score were on the average of 38. quality of life of patients tremendously. Early Total knee replacement surgery were carried out by a single surgeon.Preoperative clinical ABSTRACT TRUNCATED PA05D Study On Prevalence Of Patella Baja In Knee Osteoarthritis Patients And Its Association With Patellofemoral Osteoarthritis

Ong TJ; Chan WH; Lee KH; Zulkiflee O Department of Orthopaedic Surgery, , Jalan Residensi, 10990 George Town, Pulau Pinang, Malaysia

INTRODUCTION: five (92.2%) patients had a normal patella Patella baja is sometimes seen in knee position. Two (1.9%) patients had patella alta. osteoarthritis (OA) patients who are planned Seventy nine (76.7%) of our knee OA patients for Total Knee Arthroplasty (TKA) surgery. It had patellofemoral OA (Stage 2-4). There is presents a challenge during TKA surgery. significant association between patella position Failure to address patella baja can lead to with severity of patellofemoral OA (p-value < decreased range of motion, decreased lever arm, 0.05). extensor lag, anterior knee pain, impingement of patella against tibial polyethylene or tibia Table 1: Comparison of Patella position with plate, and rupture of patellar tendon. The patellofemoral OA stage and gender association of a misaligned patella, leading to Merchant et al Patella Normal p-value OA of the knee, especially patellofemoral joint Patellofemoral Baja patella is unclear. Therefore in this study, we look into OA staging (n=6) (n=95) the prevalence of patella baja in our community and association of patella baja with Stage 1-2 1 81 development of knee OA. 0.001 Stage 3-4 5 14 METHODS: Study sample consisted of 103 primary knee Male 0 14 0.592 OA patients, aged 54-84 years old who Female 6 81 underwent TKA surgery at our center. Patients were randomly selected. Pre-operative knee radiographs of patients were reviewed. Patella DISCUSSIONS: height was calculated by Insall-Salvati ratio In our study, female are observed to have a (ISR). ISR < 0.8 was considered diagnostic of higher prevalence of knee OA, 87 female patella baja. ISR > 1.2 was patella alta. Severity (86.4%), compared to 14 male (13.6%). There of patellofemoral OA was staged according is no significant association between patella Merchant et al, based on the 45° skyline view. baja and gender. Neogi DS et al 2014 showed Stage 1: joint space more than 3mm. Stage 2: prevalence of patella baja in pre-operative knee joint space less than 3mm but no bony contact. OA patients was 7.46%1, in Finland. In view of Stage 3: bony surface contact over less than one the significant association between patella baja quarter of joint surface. Stage 4: bony contact and patellofemoral OA, it is interesting to throughout the entire joint surface. Statistical explore the prevalence of patella baja in general analysis, Fisher Exact test was used to find the population and its risk of developing knee OA. association between patellofemoral OA and High prevalence of patellofemoral OA in knee patella baja. OA may lead to future study the outcome of patella surfacing in TKA. RESULTS: Among the 103 patients, 89 (86.4%) were CONCLUSION: female and 14 (13.6%) were male. Mean age Patella baja is common in knee OA, 5.8%. was 70.9 ±6 years. Major ethnic group was Proper pre-operative planning can reduce Chinese 85 (82.5%). Nine patients (8.7%) were morbidity. There is significant association Malay and 9 patients (8.7%) were Indian. patella baja with severity of patellofemoral OA. Prevalence of patella baja was 6 (5.8%). Ninety

ABSTRACT TRUNCATED PA06A Intracapsular Analgesic Cocktail Injections In Total Knee Arthroplasty (TKA)

Lam AWC; Ng MG; Tan HP; A Singh Hospital Tengku Ampuan Rahimah, Jalan Langat, Taman Chi Lung, 41200 Klang, Selangor, Malaysia.

INTRODUCTION: is lower than patients given spinal epidural Total Knee Arthroplasty (TKA) is becoming analgesia without intracapsular analgesic an increasingly popular intervention in cocktail injections (1.50 versus 3.62, p value = patients with knee osteoarthritis. Shortened 0.01 <0.05). hospitalization duration, facilitated by early post-operative TKA rehabilitation, The mean value of spinal epidural analgesia significantly negates common post-operative dose required in patients receiving spinal disasters acutely associated with TKA. Such epidural analgesia with intracapsular analgesic advantages often translate to a higher patient cocktail injections is lower than patients given turnover and reduced individual healthcare spinal epidural analgesia without intracapsular costs for the administrator. However, analgesic cocktail injections (112.92cc versus competent post-operative pain management to 177.73cc, p value < 0.05). realize such objectives often remains elusive. We investigated the efficacy of locally The mean duration of spinal epidural analgesia infiltrated intracapsular analgesic cocktail in patients given spinal epidural analgesia with injections administered intraoperatively in intracapsular analgesic cocktail injections is TKA patients coupled with spinal epidural shorter compared to patients given spinal anaesthesia. epidural analgesia without intracapsular analgesic cocktail injections (22.67hours We compared the average post-operative versus 32.42hours, p value <0.05). visual analogue scale (VAS) pain score, epidural dosage, epidural duration and days to The mean value for days to ambulation in ambulation in patients receiving intracapsular patients given spinal epidural analgesia with cocktail analgesia with spinal epidural intracapsular analgesic cocktail injections is analgesia against patients receiving only spinal lower compare to patients given spinal epidural analgesia after unilateral primary epidural analgesia without intracapsular TKA in a developing country’s hospital. analgesic cocktail injections (1.92days versus 3.38days, p value <0.05). METHODS: A retrospective postoperative analysis of 38 DISCUSSION: patients who underwent TKA was performed TKA patients are subjected to immense pain in a developing country’s hospital. From this especially during the immediate post operative total, 26 patients who received only spinal period. Our aim was to evaluate if epidural analgesia were compared to 12 intraoperative intraarticular injection can be an patients who received intracapsular analgesic adjunct to pain management. cocktail injections combined with spinal Literature review showed mixed results epidural analgesia. Data concerning 48 hour regarding the efficacy of this analgesic post TKA average Vas score, total spinal cocktail. epidural dosage required, duration of spinal epidural analgesia administered and days to Our data shows reduction in pain score, ambulation post TKA are collected. epidural duration and dosage, and the time taken to ambulate. RESULTS: The average 48h post TKA VAS score in CONCLUSION: patients receiving spinal epidural analgesia We conclude that intracapsular analgesic with intracapsular analgesic cocktail injections cocktail injections reduces average 48h

ABSTRACT TRUNCATED PA06B Adolescent Primary Generalised Osteoarthritis A Case Report

Liew, Steven TW; Chua WS; Kunalan G Orthopedic Department, Hospital Queen Elizabeth, 88400 Kota Kinabalu, Sabah, Malaysia

INTRODUCTION: DISCUSSIONS: Classically, osteoarthritis has been grouped Primary or idiopathic osteoarthritis of the into primary and secondary types. Primary or joints are mainly diagnosed from middle to idiopathic osteoarthritis is believed to be a elderly aged group. This is due to the effect of sequelae of altered biomechanical stresses age-related chemical and mechanical across joints in susceptible individuals in the deterioration of hip articular cartilage present absence of any insult. in a subset of individuals for unknown reason. There is currently a lack of available literature CASE REPORT: on Primary Generalised Osteoarthritis in 19 year old lady, presented with bilateral hip Adolescents. pain and stiffness, more on the left side since the age of 13 years, and no pain prior to that. CONCLUSION: She also had similar complaints over the Primary OA is the most common type and has bilateral as well as her fingers. No no identifiable etiology or predisposing cause. history of anaemia, easy bruising, nor blood The reasons of degenerative joint disease in transfusion. There was no history of traditional the adolescent group are yet to be identified. medication, steroid, smoking, nor alcohol ingestion. There was no history of multiple REFERENCES: joint pain presenting in adolescence among 1. Kelley's Textbook of Rheumatology, her family members. She takes a mixed diet. 98, 1617-1635.e8. © 2013. Clinically, she is of average Malaysian height, 2. Hoaglund F.: Primary Osteoarthritis of and average built, No abnormal facies. There the Hip: A Genetic Disease Caused by is presence of Heberden’s nodules on both European Genetic Variants. Journal of hands, fixed flexion deformity of 20o at the Bone and Joint Surgery, 2013-03-01, elbow, and restricted range of movement of Volume 95, Issue 5, Pages 463-468 her left hip. There are no stigmata of connective tissue disorder like rashes, erythema over affected joints, nor subcutaneous nodules. Her skin appears healthy. She was referred to Rheumatology to rule out inflammatory but was subsequently referred back to orthopaedics as Primary Osteoarhritis after inflammatory markers came back negative

RESULTS: Image 1 showing AP radiograph of the hips

PA06C Ceramic Femoral Head Fracture With Metallosis And Severe Wear: A Case Report

P Devarani; CL Ooi; Lim MY; Dato Zulkiflee O Orthopedic Department, Penang General Hospital, Jalan Residensi, 10990 George Town, Pulau Pinang, Malaysia

INTRODUCTION:

An ideal joint bearing for THA would be Figure 2: intraoperative something that is able to withstand high cyclic findings showing multifragments ceramic loading for several decades, no corrosion or head, severe ceramic wear, and would possess biocompatibility and wear material stability in vivo1. Ceramic bearings ceramic components has have been shown to possess extremely low been reported to be between 0.004% for wear properties that make them suitable femoral heads and 0.013% for acetabular compared to the most commonly used bearing liners1. Defective ceramic manufacturing and couple in joint arthroplasty, which consists of errors in surgical technique may contribute to cobalt-chrome (CoCr) metal alloy articulating breakage. Trauma, high activity level and against polyethelene. However brittleness of Asian population lifestyle, including squatting, ceramics can lead to fracture of femoral heads kneeling, and sitting cross-legged, has been and liner. correlated to liner rim impingement and fracture. As for this patient, the ceramic MATERIAL & RESULTS: fracture was due to traumatic fall. With 54 years old gentleman presented with left hip repetitive loading, stress concentration at a pain for a year. He had left total hip material imperfection can start a crack that replacement done in 2008 for left hip AVN subsequently migrates, resulting in failure and secondary to traumatic accident. He was well fracture. McAuley et al demonstrated that until he had a fall last year however patient misalignment of the liner during impaction still able to ambulate and perform daily into the acetabular component does activities. Patient claims there is a sound from significantly increase the risk of liner the hip joint upon movement. On examination, fractures2. Diffuse metallosis is noted in this there was limitation over the range of case due to the femoral stem articulating with movement of the left hip and tenderness on the damaged ceramic after the ceramic head movement. Pelvic Xray showed broken liner has fracture to multiple pieces. Revision and head of the total hip replacement. Patient surgery for fractured ceramic components was planned for revision of left total hip should be carried out urgently in order to replacement. Intraoperatively, the ceramic reduce the risk that ceramic particles further heard broken into many pieces and multiple damage the metal taper leading to metallosis. scratches of the ceramic liner. There was Complete elimination of ceramic fragments is presence of metalosis and the neck of the of paramount importance to increase the femoral stem was deformed. There was no survivorship of the new articulation in the sign on infection or loosening of the femoral revision surgery. Allain et al reported a 5-year stem and acetabular cup. Metallotic tissue was survival rate of 63% for revision following excised, ceramic debris was carefully fracture of a ceramic femoral head2. He also removed, and wound was well irrigated. We reported that a 17% incidence of repeat inserted a new ceramic on ceramic total hip revisions when a ceramic head had been used2. implant for this patient. Post op 3 months CONCLUSION: later, patient is ambulating with no hip pain. Fracture of a ceramic component in total hip replacement is rare but can happened like in DISCUSSIONS: this patient due to a fall. Prompt diagnosis and Revision of THA due to fracture of a ceramic revision surgery is essential in order to prevent component is rare. The fracture rate of catastrophic outcome.

ABSTRACT TRUNCATED PA06D Minimally Invasive Lateral Approach In Total Hip Replacement

Bernard Devadasan Mawar Medical Centre, 71, Jalan Rasah, 70300 Seremban, Negeri Sembilan

INTRODUCTION: CONCLUSION: Mini-incision total hip arthroplasty seeks to This minimally invasive approach preserves eliminate some complications of traditional anatomy and injury to the artery with a extensile exposure and also facilitates more generous skin incision, the gluteus medius is rapid post-operative rehabilitation. Posterior repaired anatomically. In this modified approach has been associated with increased approach with variability as an extensile risk of posterior dislocation. Thus, a modified approach the incidence of Trendelenburg gait mini-incision lateral approach of Hardinge and heterotrophic ossification was neglible . was described not only to overcome this The postoperative strength of the abductors of problem by preserving the posterior capsule, the operated side was the same as that on the but also allows adequate access for orientation non-operated side and functionally, this direct of the implant. The author has modified the lateral approach is a safe alternative to other Hardinge approach by a V-shaped incision approaches and reproducible where the apex is centered over the tip of the greater trochanter with the one limb extending proximally along the fibers of the gluteus . medius muscle and the distal limb extending across the proximal part of vastus lateralis.

METHODS: Prospective selective clinical study. 97 patients: Age 37 to 87 years, follow-up of 1 year. Assessment was made of Trendelenburg gait and functional result.

RESULTS: No significant differences in functional result at 6 and 12 months after surgery and the mean Harris hip score at 6 months & 1yr was 99 points. Gender 97 females, OA 83n, RA 8n , AVN 3n, SLE 2n and CDH 1n. Operative time average 2hrs. Head size: 28 35%, Large .Bearing 65%,. Cementless 86% and 14% hybrids. Average acetabular angle 40° Femoral component, neutral in 97%, valgus in 3%.  0 1 PF01C A Rare Midfoot Injury Pattern: Open Navicular-Cuneiform And Calcaneal- Cuboid Dislocation

Lingeshwaran R.Arunasalam; Leow VC; Abdul Aziz Department of Orthopaedic Surgery, Hospital Seberang Jaya,Penang, Jalan Tun Hussein Onn, 13700 Penang

INTRODUCTION: DIAGRAM Fracture and dislocation of the midfoot are uncommon because of the highly constrained configuration of the midfoot bones, which are secured by extensive ligaments. The navicular– cuneiform and calcaneal–cuboid joints play important roles in maintaining the arch of the foot and in weight-bearing during locomotion.Severe and high-energy traumatic DISCUSSIONS: injury patterns usually involve multiple Midfoot injury involving navicular–cuneiform anatomical structures,complicating and calcaneal–cuboid dislocation can result in 1,2 treatment. . Fracture–dislocations of the a global shortening and collapse of the midfoot Chopart and Lisfranc joints are the most through both the medial and lateral 3 common midfoot injuries. This report present columns.Delay in diagnosis and treatment can a extremely rare case of midfoot injury pattern lead to persistent instability, deformity or (open navicular-cuneiform and calcaneal- arthritis4,5.Avascular necrosis or nonunion can cuboidal dislocation) and discusses the occur, because of excessive soft tissue stripping mechanism of injury, diagnosis and therapy, at the time of fixation 6,7,8.Early anatomical based on our experience. reduction and stable fixation can decrease the occurrence of post-traumatic arthritis and the CASE REPORT: need for salvage arthrodesis, and improve the NW, 58 years old Male, was involved in clinical results. industrial injury.His left foot was trapped by a falling cargo approximately 3 ton from 3 feet CONCLUSION: height.Plain xray(Anterior-posterior,lateral and Navicular-Cuneiform and Calcaneal-Cuboid oblique) of his left foot shows dislocation of dislocation relatively uncommon Lack of left Navicular-Cuneiform and Calcaneal- knowledge of the abnormality seems to be the Cuboid dislocation. He was operated in supine main factor for misdiagnosis. position under spinal anesthesia.Initial wound extended vertically (medial aspect- from REFERENCES: proximal aspect of navicular till distal aspect of 1.Pylawka T, Andersen LB: Midfoot trauma. medial cuneiform) and another vertical incision CurrOrthop Pract 2008; 19: 228 – 233. laterally(from calcaneum to distal aspect of 2. Richter M, Wippermann B, Krettek C, et cuboidal).Reduction of Navicular-Cuneiform al:Fractures and fracture dislocations of the and Calcaneal-Cuboid dislocation done and midfoot: occurrence, causes and long-term dislocation stabilized with multiple Kirschner results. Foot Ankle Int 2001; 22: 392 – 398. wires size 2.0 (embeded).Post operative 3. Lawrence SJ: Midfoot trauma, bony and fixation stable and protected with full cast ligamentous: evaluation and treatment. Curr immobilization for 8 weeks.At 8 week follow Opin Orthop 2002; 13: 99 – 106. up, mobilization of foot and ankle was 4 .Gallino RM, Gray AC, Buckley RE: The permitted and patient was allowed full weight outcome of displaced intra-articular calcaneal bearing. Patient walks with no any form of pain fractures over left foot with no stiffness and foot arch that involve the calcaneocuboid joint. Injury maintained. K wire removed post trauma 12 2009; 40: 146 – 149. weeks.

ABSTRACT TRUNCATED PF01D

Knowledge Assessment Of Medical Officers On Ankle Impingement Syndrome. A Cross-Sectional Study.

Thinesh VS1; Kularaj S1; Michael DB1; Mathavan G2; Abdul Rauf1 1Orthopedic Department, Hospital Tuanku Ja’afar Seremban, Jalan Rasah, 70300 Seremban, Negeri Sembilan, Malaysia 2Orthopedic Department, Hospital Port Dickson, Jalan Pantai, 71050 Port Dickson, Negeri Sembilan, Malaysia

Introduction: Figure 1: Medical officers in Klinik Kesihatan claim Ankle impingement syndrome (AIS) is a aware of AIS common ankle pathology seen in outpatient unit IMU Students although inadequately documented in the past two decades. AIS is caused by overuse and Hospital Seremban trauma, affecting individuals in middle age House Officers group requiring extreme movement. Patients Medical Officers in require early treatment to maintain their Klinik Kesihatan productivity in sports and work. The aim of this study is to test the understanding of medical Figure 2: Percentage of scores obtained by each group officers (front liners) from primary center in A total 50 IMU students, 60 house officers from outpatient unit on AIS using 20 point Hospital Seremban, 110 medical officers from questionnaire. Klinik Kesihatan and 30 medical officers from Materials and Methods: Orthopedic Hospital Seremban took part in the -First stage is the development and validation of study. The maximum score possible is 20. the questionnaire. The questionnaire covering Medical officers from Klinik Kesihatan has the etiology, clinical features and investigations of lowest average score of 9.0, IMU students and AIS was created based on literature review and House officers scored average of 9.6 and 9.2 validated by orthopedic specialist. respectively and highest score by medical -Second stage involves testing the officers from orthopedic department with questionnaire. Pilot study using the validated average of 12.4. questionnaire was done among 30 house Discussion: officers and the readability, reliability and AIS is a clinical diagnosis, done through history reproducibility were evaluated by direct taking and clinical examination further interview upon completion of the questionnaire. supported by relevant investigations. In anterior -Third stage assesses medical officer’s AIS, anterior pain is felt after lengthy activity knowledge on AIS. Medical officers from all and relieved by rest [1]. Examination findings Klinik Kesihatan in Negeri Sembilan who fulfill include tenderness over the anterior ankle joint the inclusion and exclusion criteria were and positive anterior impingement test. Oblique evaluated using the validated questionnaire. anteromedial impingement X-ray view plays an Their average marks were compared with important role in detecting the osteophytes [2]. results of medical students from International In posterior AIS, symptoms include posterior Medical University (IMU), house officers and ankle pain and swelling [2]. Pathognomonic medical officers from orthopedic department of sign is pain on forced hyperplantarflexion. Hospital Tuanku Ja’afar Seremban. Lateral radiographs with the foot in 25° of Results: external rotation will improve the visualization of posterior talar process or os trigonum[2]. 7% Conclusion: This study provides insight regarding the need Yes for better understanding among front liners on No 93% AIS due to their role in identifying and referring patients for further management.

ABSTRACT TRUNCATED PF02A

Outcome Of Endoscopic Calcaneoplasty In Retrocalcaneal Bursitis. A New Prospective Study.

Thinesh VS1; Kularaj S1; Mathavan G2; Michael DB1; Ramesh N1; Abdul Rauf1 1Orthopedic Department, Hospital Tuanku Ja’afar Seremban, Jalan Rasah, 70300 Seremban, Negeri Sembilan, Malaysia 2Orthopedic Department, Hospital Port Dickson, Jalan Pantai, 71050 Port Dickson, Negeri Sembilan, Malaysia

Introduction: Pre Op 3 Months 6 Months Achilles tendon related disorders are more SK 43 55 69 recognized following better understanding of TCE 48 79 88 CWY 52 67 75 foot and ankle pathologies over the past decade. MN 72 84 79 Retrocalcaneal bursitis involves the bursa in the CKL 61 72 78 recess between anterior inferior side of Achilles MA 57 81 88 tendon and posterosuperior aspect of calcaneum MEAN 55.5 73.0 79.5 leading to pain, swelling and impaired P value - 0.028 0.028 performance. This study analyzes the outcome Table I: Results of AOFAS Hind Foot Scoring of Endoscopic Calcaneoplasty (EC) among 6 SF-36 subscale Pre Op 3mths 6mths P Value patients with Retrocalcaneal Bursitis using Physical functioning 55.0 62.5 68.3 0.040 American Orthopaedic Foot and Ankle Society Physical role limitations 41.7 54.2 66.7 0.035 (AOFAS) hind foot score, Short Form (SF 36) Mental Role limitations 58.3 55.6 61.1 0.725 Health Survey and Ogilvie Harris scores for 6 Energy/ Fatigue 52.5 54.2 59.2 0.184 months duration. Emotional well-being 55.0 64.5 73.3 <0.005 Social functioning 60.4 67.9 68.8 0.058 Material and Methods: Pain 42.9 58.3 77.5 0.003 6 patients (3 men, 3 women) with mean age of General Health 59.2 63.3 63.3 0.188 45.2 years underwent EC between September Table II: Mean pre- and post-operative SF-36 scores 2014 and January 2015. The inflamed Pre Op 3 months 6 months retracalcaneal bursa and superior part of SK 5 8 10 calcaneum were removed with shaver under TCE 7 13 15 fluoroscopy guidance. All the patients were CWY 7 11 15 discharged on the following day of operation MN 8 11 14 and allowed weight bearing as tolerated. CKL 6 12 16 MA 7 13 15 Preoperative and postoperative (3rd month and th Table III: Results of Ogilvie Harris score 6 month) AOFAS, SF-36 and Ogilvie Harris scores were calculated and analyzed using Discussion: SPSS. EC has several advantages such as early return Results: to work and sports due to quick post-operative Wilcoxon signed rank analysis of AOFAS score recovery with minimal rehabilitation, small documented significant improvement with p rd th incision, minimal scar, less surgical site value of 0.028 at 3 and 6 months. Repeated infection and osteomyelitis, less morbidity and ANOVA measures of mean SF-36 score showed no wound breakdown compare to open significant changes for physical functioning technique [1]. (p=0.04), physical role limitation (p=0.035), emotional wellbeing (

PF02B Doctor… I Cannot Wear Shoes

M Ashri M Azhar; J Samuel; Han C S; Aziz M Yusof Department of Orthopaedic, Hospital Sultan Haji Ahmad Shah, 28000 Temerloh Pahang, Malaysia

INTRODUCTION: trabeculae,section of skin show minimal A 30 year old man with no medical illness scattered chronic inflammatory cells presented with enlargement of left big toe correlated with features of osteochondroma. since childhood. Initially,the size of the left big toe was small and slowly increasing DISCUSSIONS: associated with pain and has difficulty to do Osteochondroma is a benign tumor,usually daily life activity . He also unable to wear occur about the knee, proximal femur and slipper or shoes and difficult to walk. There proximal humerus. It may have a narrow stalk was no history of trauma. On examination of or broad base and typically occur at the site of left big toe, the size was 7cm x 7cm,hard in tendon insertion and affected bone is consistency, curved upward. There was no abnormally wide and underlying cortex is skin changes, not warm and non tender. covered by a thin cap of cartilage. This lesion is asymptomatic but can be presented with pain due to soft tissue irritation or bursitis. If it is asymptomatic it can be treated conservatively but need to excise if symptomatic. The development of sarcoma fewer than 1% and prognosis is excellent.

CONCLUSION: By doing Rays Amputation and debulking surgery of left big toe ,this patient resolve in pain and after one month post-operative he able to walk without difficulty and wear shoes properly.

REFERENCES: METHODS: 1. Review of Orthopaedics 6th edition, Mark D. Case was presented in Casualty department Miller,Stephen R. Thompson, Jennifer A. Hart and refered to Orthopaedic team for further 2. Robin Basic Pathology 7th edition, Vinay evaluation and treatment. Patient was Kumar, Ramzi S. Cotran, Stanley L. Robbins examined clinically and planned for Rays 3. Appleys Orthopaedic textbook Amputation of left big toe with debulking surgery.

RESULTS:

Histopathology result shown outer layer cartilage cap with underneath enchondral ossification continuous with underlying bony PF02C Juvenile Tillaux Fracture: A Case Report

SM, Faisal Amir; AO, Normawathy Department of Orthopaedic, Hospital Sultanah Nur Zahirah, Kuala Terengganu, Malaysia.

INTRODUCTION: Antero-lateral part of distal tibia epiphysis is the last to fuse during transitional period, making it vulnerable to fracture in adolescent ankle injury. Fracture of the antero-lateral aspect of distal tibia due to avulsion force by anterior-inferior tibio-fibular ligament is known as Tillaux fracture1.

CASE REPORT: Figure 3: Post-operative radiograph shows A 13-year-old girl sustained roller skating anatomical reduction of the fracture related injury to the left ankle. Patient had inability to bear weight with swollen and DISCUSSIONS: painful left ankle. Radiographic examination Transitional period refers to fusion time of revealed Tillaux fracture (Figure 1). epiphysis from adolescent to skeletally mature bone. Closure of distal tibia epiphysis occurs in specific pattern – first at central, then at medial and lastly at antero-lateral part2. As antero-lateral part is still open and last to fuse, it is most susceptible to fracture and behaves as Salter-Harris III physeal injury. This injury is usually attributed by external rotation force of foot on the leg. It is mostly displaced type that needs internal fixation.

Figure 1: Fracture fragment of antero-lateral distal tibial epiphysis (white arrow) CONCLUSION: Identifying the specific fracture pattern of Closed manipulative reduction was attempted, Tillaux fracture and attempting to achieve but was unsuccessful with intra-articular step precise anatomical reduction is essential as in off deformity more than 2mm. Patient had other intra-articular fractures in order to yield undergone open reduction and internal good functional outcome. fixation. (Figure 2). Intra-operatively, we managed to bring the fracture fragment back REFERENCES: to its anatomical position and fix it with half 1. Sharma B, et al. The adult Tillaux fracture: threaded cancellous screw (Figure 3). one not to miss. BMJ Case Rep 2013. 2. Davies P.A & Parson F.R.G (1927) The age order of appearance and union of normal epiphyses as seen by X-rays. Journal of Anatomy 64, 58-71.

Figure 2: Open reduction and screw fixation was done via antero-lateral approach PF02D A Rare Case Of Septic Arthritis Of Talonavicular Joint: A Case Report

S.Shyful; M.Azhar; R.Mohan; S.Jasvindar Department of Orthopaedic Surgery, Hospital Taiping, Jalan Taming Sari, 34000, Taiping, Perak.

INTRODUCTION: of Kocher’s criteria, an elevated ESR and Septic arthritis is an inflammation of synovial inability to bear weight which means 50% membrane with purulent effusion into the joint likelihood of septic arthritis. The diagnosis of capsule due to bacterial infection which can septic arthritis was also supported by the occur via heamatogenous spread, direct imaging study. The principle management of inoculation, or contiguous spread from adjacent acute septic arthritis includes adequate site of infection.1 2 Delay in diagnosing and drainage of the joint, appropriate antibiotic and failure to begin treatment early are the most splitting the joint in resting position.2 Empirical common cause leading to complications in antibiotic should be given once culture is septic arthritis. obtained. However, in up to 75% of the case, the culture will yield no growth. In such cases, CASE REPORT: antibiotic treatment is still a must.2 We present a rare case of primary septic arthritis in 9 year old Malay boy with no known CONCLUSION: medical illness. He presented with history of Primary septic arthritis involving the alleged blunt trauma to his right foot while talonavicular joint is extremely rare.1 The playing football with complaints of pain, purpose of this case report is to highlight the swelling and unable to weight bear on the importance of proper history taking, clinical affected foot for a month. His right foot examination and relevant investigation and appeared erythematous, swollen and tender on imaging in detecting this condition. Early palpation. He had low grade fever upon diagnosis and prompt treatment with regular admission and though the white blood cell interval follow ups with infective markers such count was within normal range, his ESR and as ESR is vital to prevent complications. CRP were elevated. X ray of the foot showed sclerotic changes over the right navicular bone REFERENCE and ultrasound detected fluid collection in the 1. Hosam E Matar, Karthikeyan P Iyengar, right foot involving intertarsal space. Eugene M Toh. Primary septic arthritis of Subsequently, he underwent wound talonavicular joint. A case report 2014. debridement and joint washout over the right doi:10.1136/bcr-2013-203346. talonavicular joint. Intra-operatively noted pus 2. S.Terry Canale, James H. Beaty. 20cc drained out and erosion of the navicular Orthopaedic champbell. Volume I. page bone. A rewound debridement and secondary 749-772 suturing was done later. Tissue culture and sensitivity showed no growth and he was empirically started on cloxacillin for 6 weeks. During his follow ups, noted the child was active and able to weight bear. The ESR trend was reducing and x ray shows no progressive changes.

DISCUSSION: Incidence of septic arthritis of the talonavicular joint is rare which accounts approximately 3- 7% of all septic arthritis reported.1 A thorough history and examination with relevant investigation is required to diagnose septic arthritis especially in children. He fulfilled two PF03A Meliodosis And Tuberculosis Co-Infection In A Health Care Worker In Pahang, Malaysia

Rao Muhindra; Rahimawati Nur; Yusoff Muhammad Department of Orthopaedics, Hospital Sultan Haji Ahmad Shah, 28000 Temerloh, Pahang, Malaysia

INTRODUCTION: Images of the Burkholderia pseudomallei causes Melioidosis left wrist and is endemic in South East Asia.1 In and right ankle Malaysia, the state of Pahang is endemic for -consent taken Melioidosis.1,3,4 Mycobacterium Tuberculosis on the other hand causes Tuberculosis which causes significant morbidity and mortality DISCUSSIONS: throughout the world with a rise in developing Melioidosis is caused by a gram negative countries. Both these organisms are bacilli, Burkholderia Pseudomallei, which is a intracellular and share similar predisposing saprophyte found in the water and soil.4 In a factors.3 Generally both organism affect and country rich with moist and rice paddy fields, thrive in immunocompromised patients. Co- this saprophyte thrives.3 Data from 2003 show infection of both this pathogens, albeit rare has an incidence rate of 6.1 /100000 population in been previously reported in Malaysia.1 Musculoskeletal Melioidosis would immunocompromised patients.3, 4 However, to comprise a much lower rate than this.1 Major our knowledge this is the first case in a healthy risk factors for melioidosis are diabetes young immunocompetent patient. mellitus, excess alcoholism and renal disease.3 CASE PRESENTATION: Tuberculosis infection has been reported as a In January 2014, a previously healthy 33 years risk factor for Meliodosis.2 Our patient was a old lady presented to us with complaints of young fit healthy lady with no previous prolonged painful swelling of the dorsum of medical illnesses or high risk behaviors. From her left wrist and over the lateral aspect of our report, we postulate that the patient could right ankle. Pain progressively worsened have sustained the bacteria most likely due to leading to stiffness and limitation of function inhalational as occupational hazard as she of the aforementioned joints. She works as a does come into contact with foreign nationals. nurse in a district clinic in Pahang. All We were unable to ascertain as to whether the connective tissue work up were reported as Melioidosis or tuberculosis appeared first in negative. this patient. Aspirate from these swelling grew CONCLUSION: Mycobacterium Tuberculosis. However in In an endemic setting, a high index of view of non-improving initial symptoms, suspicion is needed in identifying these further workup was done and Meliodosis pathogens. Although not serology came back as positive titre on 3 immunocompromised, high risk occupations occasions. There were no radiological in contact with patients harbouring these evidence of dissemination. Targeted pathogens do play a role as a risk factor to management were started for both the acquire these diseases infection. REFERENCES: As of 30th December 2015, the patient has had 1. Guidelines for clinical and public health 2 follow up to orthopedic clinic Hospital management of meliodosis in Pahang Temerloh, She reports reducing of pain in both 2. Kanai K et al; Serosurveillance for double her wrist and ankle with slight regaining in infection with pseudomonas pseudomallei in joint function. Patient is also able to start to tuberculous patients; Pubmed id: 1284880 bear weight. 3. S.D.Puthucheary; Meliodosis in Malaysia 4. S.H How; Meliodosis in Pahang.

PF03B Case Report Of A Rare Heel Swelling: Calcaneal Osteosarcoma

Cheong KH; Gurmeet. S; Azuhairy.A; Zulkiflee.O Department of Orthopaedic Surgery, Hospital Pulau Pinang, Jalan Residensi, 10450, Georgetown, Pulau Pinang.

INTRODUCTION: Osteosarcoma is the most common primary malignancy of bone. It usually affects the metaphyses of long bones and the presentation in calcaneum is rare.

CASE REPORT: Figure 2a Figure 2b A 12 years old Indian boy presented with right ankle painful swelling for three months We noted the swelling rapidly enlarged and duration. The swelling rapidly increasing in had doubled in size within six weeks (Figure size and pain was accentuated at night. There 3a &3b). Skin overlying lateral aspect of ankle were no fever and no constitutional symptoms. was ulcerated with tumour content sprouting He had antecedent history of fall and sprained out from the skin. Due to the rapid progression his right ankle which was mistaken to be soft of disease, below knee amputation was tissue injury by local clinic. performed.

Examinations revealed a diffuse swelling over Figure 3a right ankle, measuring 10 X 12cm. The swelling has regular border, warm, tender, firm in consistency and immobile. There was restricted movement of right ankle.

Figure 3b Figure 3c

Histopathological examination (Figure 3c) revealed it was a chondrocytic osteosarcoma of right calcaneum. We can see pleomorphic spindle cells that produce abundant osteoid, Figure 1a collagen and cartilage in varying proportions.

After the surgery, patient was started on adjuvant chemotherapy Protocol AOST 0331 (doxorubicin, cisplatin and methotrexate) for Figure 1b total duration of 3 months. However, CT thorax, abdomen and pelvis showed worsening Figure 1a and 1b – Appearance of the right of metastasis involving bilateral lungs and also heel swelling at first presentation to our center bilateral inguinal nodes. Subsequently,

chemotherapy regime was revised to ST JUDE Plain radiograph of right ankle and foot OS99 (Carboplatin, Ifosfamide and (Figure 2a) showed densely sclerotic lesion Doxoribicin). involving the entire right calcaneum with periosteal reaction. MRI (Figure 2b) showed a DISCUSSION: heterogenous mass of the calcaneum reaching The calcaneal location of osteosarcoma is very articular surface with talus and infiltration into rare, representing less than 1% of all adjacent soft tissues. Haematological and osteosarcoma. [1] Delay in diagnosis is biochemical investigations were within normal attributed by lack of clinician familiarity with range. Serum lactate dehydrogenase (LDH) these rare lesions and low index of suspicious. and alkaline phosphatase were not raised. ABSTRACT TRUNCATED PF03C Dysplasia Epiphysealis Hemimelica (Trevor’s Disease) Of Medial Cuneiform And Navicular Bone Right Foot: A Case Report

Low, Weng Kong; Chua YP Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

INTRODUCTION: DISCUSSIONS: Dysplasia epiphysealis hemimelica (DEH), Dysplasia epiphysealis hemimelica is a rare also known as Trevor’s Disease is a rare osteochrondromatoses disease with the skeletal developmental disorder characterized prevalence is reported to be 1 in 1 000 000(1- by asymmetrical overgrowth of cartilage in the 3). The etiology of this condition is still unclear epiphyses. This rare entity was first reported by until today(2-4). 4 most common locations of Mouchet and Belot in 1926. We are reporting a involvement were the talus-calcanurm (22%), case of Trevor’s Disease involving the distal tibia-fibula(22%), distal femur(21%), navicular and medial cuneiform bone. and proximal tibia(11%)(3). To our best knowledge, no similar case of DEH involving CASE REPORT: the cuneiform or navicular has been reported A 2-year-old Chinese boy, presented to our before. In our case, surgical removal and clinic for right flat foot with progressive deformity correction was warranted despite prominent bony swelling over the medial knowing that the recurrence rate is high as the aspect of his right foot noted since patient was patient is long yet to achieve skeletal maturity. 6-month-old. Examination of his right foot revealed a hard bony swelling arising from the CONCLUSION: medial aspect of his right foot, extending into In conclusion, DEH is a rare but debilitating the plantar surface. The forefoot was in fixed disease especially if they caused significant abduction. limb deformity and limb length discrepancy. In Plain radiograph revealed medial cuneiform the management of symptomatic intraarticular and navicular hypertrophy. Intraoperatively, lesion, the surgeon need to balance between the there was a gross hypertrophy of his right benefit of correcting the deformity against the cunieform and navicular bone with a 1cm x risk of early osteoarthrosis of the involved 1cm exostosis arise from cuneiform, extending joint. distally toward the base of 1st metatarsal bone. Wedge osteotomy and resection of the medial REFERENCES: cuneiform bone was done, with the osteotomy 1.Douira-Khomsi W, Louati H, Mormech Y, site secured with a compression bone stapler. Saied W, Bouchoucha S, Smida M, et al. Post operatively his right foot was immobilized Dysplasia epiphysealis hemimelica: a report of in a fiberglass cast for 4 weeks. four cases. Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons. 2011;17(1):37-43. 2.Arealis G, Nikolaou VS, Lacon A. Trevor's Disease: A Literature Review regarding Classification, Treatment, and Prognosis apropos of a Case. 2014;2014:940360. 3.Mann SA, Andrews G, Forster BB, Malfair D, Figure 1: Intraoperative images showing the Prasad N. Answer to Case of the Month #160. hypertrophied medial cuneiform bone with its Dysplasia epiphysealis hemimelica (Trevor's exostosis on the inferior aspect (left), and the disease). Canadian Association of Radiologists post osteotomy image with the compression journal = Journal l'Association canadienne des bone staple in situ (right) radiologistes. 2010;61(1):58-61.

ABSTRACT TRUNCATED PF03D Plantar Plate Rupture Of Second Metatarsophalangeal Joint: Repair Or Let It Be?

Daun E; Bajuri MY; Shukur MH Department of Orthopaedics & Traumatology, Faculty of Medicine, Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia.

INTRODUCTION: RESULTS Plantar plate rupture is one of the most common causes of metatarsalgia, yet often missed due to spectrum of signs and symptoms at presentation1. It is fibrocartilaginous structure and the most important stabilizer to prevent hyperextension at metatarsophalangeal joint (MTPJ) 2. If it is (G) (H) Figure 3: Photograph G and H showed post-operative not treated promptly it will progress to correction achieved. overriding of second toes on great toe and dislocation of MTPJ. DISCUSSION: Plantar plate repair had been advocated CASE REPORT: entities in management hallux valgus with A 58 year old lady with long standing history overriding of lesser toe 3. Advancement of of bilateral hallux valgus, presented with imaging technique such MRI helps to improve progressive metatarsalgia of right second and the diagnosis and management become more third toes associated with subluxation of objective and systematic3,4. second MTPJ and overriding of second toe over great toe. She had undergone right hallux CONCLUSION: valgus and lesser toes deformity correction Thorough evaluation of lesser toes deformity with plantar plate repair of second MTPJ. with repair of plantar plate tear minimized the Dorsal approach combined with a Weil’s risk of recurrent deformity and subluxation of metatarsal osteotomy used for plantar plate MTPJ after deformity correction. repair. REFERENCES: 1. Bavarian B, Thompson J, Nazarian D. Plantar Plate Tears:A Review of the Modified Flexor Tendon Transfer Repair for Stabilization. Clin Podiatr Med Surg 2011;28:57-68 (A) (B) 2. Bhatia D, Myerson MS, Curtis MJ, Cunningham BW, Figure 1: Photograph A and B showed patient’s right Jinnah RH. Anatomical restraints to dislocation of the foot before surgery. Noted hallux valgus with second metatarsophalangeal joint and assessment of a overriding of second toe over great toe deformity Grade repair technique. J Bone Joint Surg Am. 1994;76:1371- 4 III 1375 3. Coughlin M, Baumfield D, Nery C,. Second MTP joint instability:grading of the deformity, description of surgical repair of capsular insufficiency. Phys Sport Med 2011;39:132-141 4.Nery C, Coughlin MJ, Baumfeld D, Mann TS, Yamada AF, Fernandes EA. MRI Evaluation of the

(C) (D) (E) (F) MTP Plantar Plates Compared With Arthroscopic Figure 2:Serial photograph C to F, demonstrated Findings: A Prospective Study. Foot Ankle Int intraoperative procedure in plantar plate repair. 2013;34:315-322 Transverse Plantar plate rupture noted (C). Detachment from attachment prior repair (D ).Two Fibrewire suture size 2/0 was used to catch the most proximal part of plantar plate (E). Suture was attached back to the base of proximal phalanx after completed the Weil osteotomy procedure. (F). PF04B Non-Traumatic Foot Pain And Deformity In Elderly Within Klang Valley

Chan HZ; Chua YP AA; Rukumanikanthan S Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

INTRODUCTION: foot deformities. This followed by bunions Nontraumatic foot pain and foot deformities (10.3%), nails dystrophy/onycomycosis are very common public health problems as (9.3%), Pes planus (8.8%), Skin hypercallosity the elderly population rapidly increases due to (7.8%), and others rare deformities such as improving geriatric health care. Most of the hammertoes, clawed toes, and prominent literature related to footwear and foot health is metatarsal head. based on either Western society. There are obvious differences between Western and DISCUSSIONS: Asian countries with regard to social, cultural Only less then one quarter (20.25%) of and ethnic compositions, as well as shoe- subjects experienced non-traumatic foot pain. wearing habits. This was relatively lower then the Western prevalence of foot pain, which accounted from METHODS: 21% to 45%. This might be due to majority of This study was a cross-sectional survey with the elderly in this study were assumed to have specific target population. The target relatively well-educated, finantially stable, and population was elderly Malaysian gentlemen expected to have healthy feet in view of the and women with following inclusion criteria: optimal body weight control and greater elderly above 65 years old staying in Klang awareness of the importance of foot health. Valley, presented with symptoms of recurrent The study result to a certain extent was a par foot pain and deformity for more then 6 with our assumption. months. Foot deformities derived from congenital, trauma or underlying medical CONCLUSION: illness that change the foot biomechanics This study displayed a significant positive would be excluded. Sample size was estimated relationship between Manchester Foot Pain with online Raosoft sample calculator. Non- and Disability Index (MFPDI) and visual probability convenience sampling method was analog scale pain score. We also found that used from 1st April to 30th July 2015. relation between development of hallux valgus and shoe wear was significant. RESULTS: We successfully gathered information from REFERENCES: 210 male (52.5%) and 190 female (47.5%) 1. Ambigga, K. S. et al. Bridging the gap in subjects for the survey. The racial distribution ageing: Translating policies into practice in of the subjets in this study were 40.8% Malay, Malaysian Primary Care. Asia Pac Fam Med 36.5% Chinese, 20.8% Indian and 2.0% other 2011: 10(2). races. Only about one fifth of them (81 2. Abdullah et al. Common nail changes and subjects; 20.25%) reported having recurrent disorders in older people: Diagnosis and non-traumatic foot pain in the past 6 months. management. Can Fam Physician, 2011:57(2), 60 subjects, which is about 74.1 percent of 173-181. elderly with recurrent foot pain reported having pain more then 5 days a week and majority of them (38 subjects, 46.9%) having moderate pain score range from 4 to 6. There were 167 subjects (41.8% of total) were found to have foot deformity at least at one side of the foot with different level of severity. Hallux valgus (17.0%) was the most common type of PF04C Modified Bridle Procedure With Achilles Tendon Lengthening For Acquired Spastic Equinovarus

A. Azamuddin; I. M. Izani; D. Melvin; A. Asni Department of Orthopaedics and Traumatology, Hospital Raja Permaisuri Bainun, Jalan Raja Ashman Shah (Jalan Hospital), 30450 Ipoh, Perak, Malaysia

INTRODUCTION: ambulation without needing an ankle foot Head Injuries are commonly associated with orthosis. Under spinal anasthesia we Acquired Spastic Equinovarus Deformity of performed an Achilles tendon Z-plasty to the Feet. It is caused by Gastrocnemius-Soleus lengthen and allow ankle dorsiflexion up to 20 Complex overactivity, contributing to equinus, degrees. The TPT was then transferred and tibialis anterior tendon (TAT), Posterior through the interosseous membrane and tibialis tendon (TPT), Flexor Hallucis Longus passed anteriorly through the TAT via the (FHL) and Flexor Digitorum Longus (FDL) Pulvertuft technique before attaching it to the overactivity causing Varus. This is often lateral cuneiform using an anchor suture with associated with difficulty in shoe wear, the ankle in slight dorsiflexion and the standing, transfers and walking.Various forefoot in neutral position. A below knee surgical techniques have been described to backslab applied for 6 weeks. Postoperative correct this problem which includes one or a outcome was favorable, the patient was able to combination of Split Anterior Tibial Tendon ambulate after 2 months with a walking aid. Transfer (SPLATT), TPT transfer, Peroneus The right ankle was stable in plantigrade Longus (PL) transfer, FDL transfer, Extensor position and the foot in neutral. She is Hallucis Longus (EHL) transfer, Achilles currently on walking frame ambulation, tendon lengthening and in more severe cases, stepping on the right foot with a better gait. corrective osteotomy and gradual correction She is on regular physiotherapy to reestablish with an Illizarov external fixator. We would lower limb muscle strength, and does not like to describe a case of Acquired Spastic require any ankle orthoses to maintain a Equinovarus Deformity of the right foot, neutral foot. following a traumatic Subarachnoid Postoperative outcome was measured using Hemorrhage using a modified Bridle the AOFAS functional Score and the VAS at 1 procedure. month and at 3 months post-op. The patient’s surgical wounds healed without complications. CASE REPORT: Overall functional outcome scores shows good Madam W is a 41 year old lady with no prior improvement at the 3rd month. illnesses. She had an unfortunate accident in 2011 that rendered her incapacitated for 4 Scoring 1st Month 3rd Month years. She sustained a Bifrontal Contusion System with Traumatic Sub Arachnoid Hemorrhage AOFAS 35 68 that required a decompressive lobectomy. She VAS (pain) 5 1 subsequently developed a spastic equinovarus deformity over the right foot that made it DISCUSSIONS: difficult for her to ambulate. She was able to Achilles Tendon Lengthening with tendon ambulate with a walking frame but needed to transfer, corrective osteotomies with hindfoot drag the right leg and steps on the outer border fusion or correction using external fixators are of the right forefoot due to the foot deformity. among the commonly employed procedures X-ray of her right foot and ankle revealed no for correction of Acquired Spastic arthritis or bony abnormalities. We proceeded Equinovarus Deformities of the Ankle. The with a modified Bridle procedure with Bridle procedure is recommended procedure Achilles Tendon lengthening, aiming to get a for foot drop and flail foot stabilization. stable plantigrade foot for better gait and The standard Bridle procedure consists of

ABSTRACT TRUNCATED PF04D Early Functional Outcome Of Tibiotalocalcaneal Fusion With Intramedullary Nail: HRPB Foot And Ankle Unit Experience

Azammuddin A; KS Yap; Yong-Jia Tan; Asni A; M.Izani; VC Leow; Manoharan K Department of Orthopedic, Hospital Raja Permaisuri Bainun, Jalan Hospital, 30990 Ipoh, Perak, Malaysia

INTRODUCTION: operation, traumatic and non-traumatic group, Tibiotalocalcaneal arthrodesis with diabetes and non diabetes group, age above intramedullary nail was 1st reported in year and below 50, gender. 1948 by using Steinman pins and external fixators (1). For the past 50 years, surgical RESULTS: technique and design for intramedullary In general, all the patient who underwent devices have been markedly improved. surgery, show significant improvement in foot Currently, IM nails available are specifically and ankle outcome questionnaire post op. We designed for hind foot fusion. further divide patients into few groups Tibiotalocalcaneal arthrodesis is used for (traumatic / non traumatic, diabetic/non- patient with changes in the subtalar junction of diabetic group, gender and age) for statistical the tibiotarsal joint. The indications for this analysis. In the traumatic and non-traumatic procedure include post traumatic arthrodesis, group, there are no significant difference in rheumatoid arthritis, neuromuscular disease. term of pre and post operative score. However Pathology above often causes deformity and in the diabetic and non diabetic group shows causes The deformities are often associated significant difference in terms of less joint with chronic ulceration and osteomyelitis, stiffness; less swelling of joint; better which may eventually require amputation.(2) ambulation; less interference in work and less Reconstruction may be undertaken with the interference in life post operatively . There is aim of reducing the risk of ulceration by also improvement noted in terms ambulation creating a stable plantigrade foot allowing the when comparing patient according to age patient to bear weight and mobilise, thereby group. No significant difference in terms of decreasing the morbidity and the risk of gender. amputation. The intramedullary (IM) hindfoot fusion nail offers stable fixation and weight- DISCUSSION: bearing, allowing fusion and correction of the Tibiotalocalcanel fusion using intramedullary deformity. Although rates of fusion of > 70% nail is a technically demanding procedure. Not have been described using this technique, many center practices this method routinely. there is a high rate of complications including In our center,we reported 24 patients nonunion, failure of fixation, infection and underwent this procedure. Only 1 patient amputation. (3) develop superficial surgical wound infection which resolve after 1 course of antibiotic, no METHODS: any other complications was noted in our Starting from year 2012 until 2015, total of 24 patients. With high union rate and low risk of patients underwent tibiotalar and subtalar complications, if done properly it is a good fusion surgery using intramedullary nail. The surgical option to consider in patient with end only exclusion criteria are those patients who stage hind foot arthritis. refuse to give consent. All patients were followed up since surgery till year January CONCLUSION: 2016 with questionnaire of Foot and ankle Tibiotalocalcanel fusion using intramedullary outcome questionnaire and numeric pain nail is a good choice in the treatment of end rating scale in 3rd, 6th, 9th and 12th month post stage hind foot arthritis. Patient who operation. Using Wilcoxon signed-rank test underwent the surgery in our center shows and Mann-Whitney u test in SPSS 20.0. we significant improvement post operatively. analyzed the outcome for all patients after

ABSTRACT TRUNCATED PF05A Case Report On A 9 cm Defect Chronic Achilles Tendon Rupture: An Alternative Repair Technique

KS Yap; Azammuddin A; M.Izani; Mohd Asni; VC Leow; Manoharan K Department of Orthopedic Hospital Raja Permaisuri Bainun, Jalan Hospital, 30990 Ipoh, Perak, Malaysia

INTRODUCTION: flexor hallucis longus by dividing the tendon Achilles tendon is the thickest and strongest at the knot of Henry and introduced it in front tendon in the body. In treating chronic of Achilles tendon to come out at insertion of Achilles tendon rupture with defect, TA and sutured to the distal part of TA.Post- autogenous tendon grafting is preferable to operation, patient put on anterior slab in avoid allograft related problems. However, in plantar flexion 20 degree. Patient was treating chronic Achilles tendon rupture with followed up at 3rd week, 6th week, 3 months large defect, allograft is needed.1Due to the and 6 months post-op. patient shows good large defect in chronic Achilles tendon functional outcome with improve range of rupture, allograft has always been the choice movement as well as improvement of Achilles of treatment.We are reporting a case with a tendon total rupture score of 91. large defect in chronic Achilles tendon rupture, with no allograft used. Functional DISCUSSION: outcome is good with improvement of In neglected TA rupture, large gap between Achilles tendon total rupture score. tendon ends often makes end to end repair impossible. The use of allograft has been CASE STUDY: recommended when significant segmental A 23-year-old Nepalese male, was diagnose defect is encountered, such as greater than 10 with chronic rupture of Achilles tendon. He cm when fascia advancement or tendon was planned for V-Y flap, KIV flexor hallucis transfer is not able to provide sufficient longus transfer.A posteromedial incision was bridging between the tendon ends. In a series done, exposing the Achilles tendon. Plantaris of patients treated 4 to 12 weeks from the time was found to be still intact. Initial gap was of injury, Porter and colleagues found an about 5cm in length. The gap increased to 9cm average gap of 3 to 5 cm between the tendon after debridement of the ruptured Achilles ends after removal of the fibrous scar tissue.In tendon ends. V-Y plasty done, reducing the our case, after removal of fibrous scar tissue gap to 4cm. 1 cm wide and 10cm length of created a gap around 9 cm. We were aponeurosis was taken around 3 cm from the successful to repair a chronic tear with large end to perform Achilles tendon turn down, defect without the use of allograft, with filling up the remaining 4cm gap. The 10cm combination of fascia advancement, FHL turn down has 3cm sutured respectively to the transfer and augmentation with plantaris proximal and distal end of the ruptured augmentation. tendon. All repairs were done by non- absorbable suture size 2. CONCLUSION: For the past, standard practice for chronic Achilles tendon rupture with large end to end tendon defect would require allograft for the surgery. However, our case report does give another option of surgery in treating chronic

Achilles tendon rupture, with good functional The intact plantaris tendon was divided as outcome and improvement in Achilles tendon proximal as possible and was used to further total rupture score(35 to 91). augment the repair by introducing it into a sewing needle which is passed through the repaired tendon using the pulver-tuft suture technique.Final step involved harvesting of the ABSTRACT TRUNCATED PF05B Case Series In 3 Different Method Treating Chronic Ankle Syndesmosis Injury

Mohd Asni; Azammuddin A; KS Yap Department of Orthopedic, Hospital Raja Permaisuri Bainun, Jalan Hospital, 30990 Ipoh, Perak, Malaysia

INTRODUCTION RESULT The ankle syndesmosis is the joint between the After surgery, all patients was follow up until year distal tibia and distal fibula. Motion at this joint 2016 and by using AOFAS score, foot and ankle includes translation and rotation during tibiotalar functional outcome qustionaire and numeric pain dorsiflexion and plantar flexion accommodating the rating scale, 3 patients who underwent different asymmetric talus while maintaining congruency. surgery shows promising functional outcome, and Three main structures provide stability at the pain improve. All patients satisfied with the surgery. syndesmosis: the interosseous tibiofibular ligament, the anterior inferior tibiofibular ligament, and the DISCUSSION posterior inferior tibiofibular ligament. With a Syndesmosis ankle joint injury is common complete syndesmosis disruption the ankle joint is especially when associated with lateral malleolus left unstable with significant negative consequence fracture (Danis-Webber type B/C). Syndesmosis is if not repaired. disrupted when an external rotation torque is applied to the ankle. In most cases, a CASE SERIALS pronation/external rotation injury occurs when an In our case serials, total of 3 patients with the external rotation force is applied to the leg with the diagnosis of chronic ankle syndesmosis joint foot firmly planted. The injury force starts through injury, at least 7 moths and above of injury, either the medial malleolus or Deltoid ligament, underwent 3 different type of surgery: travels laterally through the joint, tears the 1. 1/3 tubular plating of fibula+ syndesmotic syndesmosis structures, and exits through the fibula suture Few surgical methods in treating acute syndemosis 2. 1/3 tubular plating + syndesmotic screw +open ankle joint injury have been described e.g scew debridement+Fusion of distal1/3 tibia/fibula and fixation, suture button method with good clinical with bone graft outcome1.However, there are not much of literature 3. 2 syndesmotic screw + open debridement review in the outcome of treating chronic syndesmotic fusion+with bone grafting from left syndesmosis ankle joint injury, 1 of the operative proximal tibia. repair consisted of arthroscopic debridement with reduction and suture button fixation with significant improvement2. while compare to single method used the surgery, our center carry out a pilot study with 3 different method of surgery for chronic Syndesmosis ankle joint injury with promising oucome with no complication.

CONCLUSION Our center shows good clinical outcome in treating chronic syndesmosis ankle joint injury with 3

different type of surgical intervention. Further exploration of the result should be carried out with larger population/sample size to determine which surgical method is more superior.

REFERENCE : 1. Treatment of Syndesmotic Injuries of the Ankle, Clifford B. Jones, MD; Alex Gilde. MD, Debra L. Sietsema, PhD, JBJS 2. Outcomes and Return to Activity after Operative Repair of Chronic Latent Syndesmotic Instability, LTC Paul M. Ryan, MD, Foot and Ankle International

PF05C The Challenge In Management Of Plantar Foot Ulcer: Early Intervention Of Advance Dressing With Modified Off-Loading To Reduce Healing Time

M.K, Maizatul; A.R, Syahrizal; A.A, Zubair; F, Omar; W, Fareez; A.R, Amiruddin; M.S.K, Andrew; K.H Kew Department of Orthopaedic Surgery, Hospital Slim River, Slim River, 35800, Malaysia.

INTRODUCTION: patients requiring another session excision of The management of plantar foot ulcer healing callus. has proven to be very challenging. Callous formations are commonly seen, at times DISCUSSIONS: requiring for multiple excision. Callous will Patient compliance to use the modified disrupt the progression of wound healing, offloading cast plays a major role to prevent leading to chronicity. There are many total callous formation thus promoting wound contact cast methods readily available, healing. The removable of modified however cost and patient compliance offloading cast may attribute to patient’s complicates the healing. In this case study, we willingness to use it as compared to the would like to compare the healing time in conventional full cast methods. The usage of newly debrided plantar wounds versus chronic advance dressing: sodium polyacrylate beads non healing ulcer post excision callus, using to manage exudates, and hydrolyzed collagen advance dressing and modified offloading with glycerin lotion over the periwound cast. promotes a faster healing rate.

MATERIALS & METHODS: CONCLUSION: A prospective study was conducted throughout Early intervention in the management of March 2015 until January 2016. Total of 8 plantar foot ulcer using advance dressing such patients with plantar foot ulcer (clinical as polyacrylate beads and hydrolyzed collagen Wagner grade 2) was recruited. They were with glycerin based lotion, in combination divided into two groups: group A consists of 4 with patient’s compliance to use offloading patients new cases post operation one week cast, contribute to significant reduction of wound debridement. Meanwhile in group B, healing time. consist of 4 patients with chronic non healing ulcer post operation 1 week excision callus. REFERENCES: Both groups of patients were then applied with 1. Harikrishna K.R. Nair et al, Efficacy of advance dressing every other day, using Collagen and Glycerine Based Lotion in sodium polyacrylate beads with hydrolyzed Treating Diabetic Skin Disorders in Two collagen plus glycerin lotion applied over Wound Care Units, International Wound periwound. A modified total contact cast using Conference 2013 a fibre-glass backslab was used, customized according to patient’s wound shape. The wound was then reviewed every 3 weekly in clinic using TIME concept.

RESULTS: Significant clinical improvement was observed in group A as compared to group B. In group A, healing can be seen as early as 14- 18weeks. Meanwhile in group B took approximately 27-34 weeks to show clinical improvement. Callous edge re-occurrence was observed in group B, in which two of the PF05D A Rare Presentation Of A Growing Calcaneum Osteochondroma In Adult: A Case Report

1IM Izani; 2B. Bilal; 1A. Azamuddin; 2T. Nahulan; 1M. Asni. 1Orthopaedic Department, Hospital Raja Permaisuri Bainun, Jalan Hospital, 30450 Ipoh, Perak, Malaysia 2Orthopaedic Department, Hospital Queen Elizabeth, Karung Berkunci No. 2029, 88586 Kota Kinabalu, Sabah, Malaysia

INTRODUCTION: DISCUSSIONS: Osteochondromas are benign osseous neoplasms Osteochondroma can easily be diagnosed with a distinct hyaline cartilage cap originating radiographycaly. It is usually asymptomatic. If from the physis and cease growing with skeletal symptomatic patient usually complains of pain due maturity. They are the most common benign bone to compression of soft tissues (tendons, nerves, tumour and usually involves long bones. vessels), fracture through the stalk,bursa Calcaneum osteochondroma is a rare condition. formation, pseudo aneurysm formation, infection, Foot and ankle osteochondroma consist only 10% ischaemic necrosis and also malignant of all ostechondroma. We are reporting on a rare transformation. Malignant transformation is seen case of osteochondroma of the calcaneum in an in less than 1-2% of patients of solitary adult. osteochondroma and in 5-25% of patients with multiple osteochondroma. Even though plain xray CASE REPORT: is diagnostic, other modalities such as CT scan and 30 year old lady presented with bony swelling MRI may be necessary for surgical planning and to associated with pain over the right heel for past 10 exclude sarcomatous degeneration.Cartilage cap years. However for the past 1 year the swelling thickness greater than 1-2cm in adults or 2-3cm in gradually increases in size and the pain become children suggest malignant transformation. worse hence she seek medical attention. The pain Osteochondromas around the foot region can was so severe that it affected her daily activities. usually be treated conservatively if it is small and Plain x-ray showed a large bony growth from the asymptomatic. In this patient however the tumor anterior-inferior part of the right calcaneal has increase in its size causing significant pain. tuberosity. CT scan of the right calcaneum Surgical excision was done to relieve the pain and showed the bony swelling arises from the to rule out malignant transformation. metaphyseal part of the right calcaneum tuberosity Histopathological examination showed no extending from lateral to medial (buffalo horn like malignant findings and there was no recurrence shape). Upon weight bearing the patient walks on after 2 years surgery. the bony lesion thus causing pain. This patient eventually underwent surgical CONCLUSION: resection via a lateral approach. The resected bony This case report demonstrates that mass measured 10cm3. The cartilage cap measure osteochondromas may occur in the foot, 5mm in thickness. Post operative xray showed particularly the calcaneum. This also confirms that most of the lesion was excised. Histopathological benign osteochondroma growth may occur in report showed no evidence of malignancy and adulthood. confirmed of osteochondroma. Patient recovered uneventfully and started weight bearing without REFERENCES: pain 1 month after surgery. Currently patient is 1.Blitz NM, Lopez KT. Giant solitary pain free and without any recurrence 2 years after osteochondroma of the inferior medial calcaneal excision. tubercle: a case report and review of the literature. J Foot Ankle Surg.2008;47:206–212. 2.Nogier A, De Pinieux G, Hottya G, Anract P. Case reports: enlargement of a calcaneal osteochondroma after skeletal maturity. Clin Orthop Relat Res.2006;447:260–266. 3.Greger G, Catanzariti AR. Osteochondroma: review of the literature and case report. J Foot Surg. 1992;31:298–300. Preoperative xray Postoperative xray PF06A An Underlying Soft Tissue Infection In A Bilateral Closed Calcaneal Fracture

Danappal, Selvan; Vincent, J; Nadia, MK; KMS, Kadir Department of Orthopaedic, Hospital Tengku Ampuan Rahimah, Taman Chi Lung, Jalan Langat, 41200 Klang, Selangor, Malaysia

INTRODUCTION: However the swab culture grew 2 gram Calcaneal fractures are rare fractures with an negative and one gram positive organisms. annual incidence of 11.5 per 100000(1). They are debilitating injuries that have a DISCUSSION: predisposition in the young and usually occur Functional outcome on conservative and after a fall from height (1). These fractures are operative fixation mainly depend on good treated conservatively with the exceptions of fixation by experienced surgeon (2). The soft those extending into articular surfaces. The tissue infection may be postulated with surgical decisions on operative management can be with delay, however there is no correlation (2). The using the Bohler and Gissane angles. In this usage of external fixation for calcaneal case we report a Nepalese male who sustained fractures are generally accepted as a salvage a bilateral calcaneus facture. A decision for a procedure and in open fractures (4). In this case, locking plate was made however the external fixation was used to avoid internal intraoperatively converted to external fixation fixation after open reduction with k-wires. and k wiring due to a soft tissue Infection. CONCLUSION: METHODS: Soft tissue infection commonly occurs either We report a case of a 35 years old Nepalese preoperatively or postoperatively. In such rare man who had a fall from a forklift at a 5 meter occasions, intraoperative findings may suggest height. Patient was not able to ambulate after such and prompt decisions need to be made on the fall due to severe pain at both the heels. internal or external fixation. The decision made Examination revealed swelling over both the for this case for external fixation was right heels with no signs of compartment syndrome. given the positive swab culture and sensitivity. X-rays of bilateral calcaneus showed fractures involving subtalar joints. Right Bohler’s angle REFERENCES: was 5 and Gissane’s angle was 100. Left 1. McKinley JC, Robinson CM. The Bohler’s angle was 20 and Gissane’s angle was epidemiology of calcaneal fractures. Foot 130. His injuries were stabilized with bilateral (Edinb). 2009 Dec;19(4) Robert Jones and admitted to the ward for 2. Schmied M, Schutte BG, Factors affecting observation and planned for operation the infection after calcaneal fracture fixation. following day. Injury. 2009 Dec;40(12):1313-5. 3. Magnan B etal, External fixation for RESULTS: displaced intra-articular fractures of the At day 14 of trauma, the patients was brought calcaneum. J Bone Joint Surg Br. 2006 to the operating theater for locking plate of the Nov;88(11):1474-9. left calcaneus. The right calcaneus treated 4. Kenwright J. Fractures of the calcaneum. J conservatively due to financial constraints. The Bone Joint Surg [Br] 1993;75-B:176–7. patient was placed in a lateral position and a lateral approach was used for reduction and fixation. During the reduction and manipulation there was hemopurulent discharge darning from the subtalar joint that was foul smelling. A decision was made to abandon plating and proceed with external fixator and k wiring after washout. The tissue sample taken intraoperatively did no grow any organisms after 48 hours of incubation. PF06C A Missing Navicular

Shankari S; Ariffin M.A; VS.Naveen; Afifi M; Sajali H Department of Orthopaedic, Hospital Tawau, KM1 Jln Tg Batu, 91007, Tawau, Sabah, Malaysia.

INTRODUCTION: The navicular bone is a midfoot structure the HPE showed a Diffuse Large B cell located on the medial side of the foot. The Lymphoma, NOS of ABC type.CT Thorax and posterior tibialis is the USG abdomen was normal. only muscle which attaches to it. It is a rare DISCUSSIONS: occasion to develop any Lymphomas arise from lymphoid tissues, and fractures, bony are diagnosed from the pathological findings on infections or tumor to biopsy as Hodgkin and non-Hodgkin this bone.7 percent of lymphoma. Primary Lyphomas to the the population presents Navicular Bone is a rare occurrence.Cases have with an accessory shown occurrence in the Talus and also navicular. cutaneous manifestations of the foot.This Pic1: Medial View Of the Left Foot patient has been subjected to Chemotherapy under theHeamatologist.He is currently on a Case Report ankle foot orthosis due to instability of the foot A 50-year-old man, presented with pain and after the excision biopsy swelling after a fall in the toilet. Previously never gave any history of trauma or swelling to CONCLUSION: the foot. Examination of the foot revealed a A proper general history must be taken and mildly tender 3cm x 5cm firm hematoma like clinical examinations should be carried out in swelling. Initial diagnosis was non other than patients.A bone cement or tricortical bone graft either a fracture or a soft tissue trauma. Foot can be used after excision biopsy for stability xrays were done and much to our surprise, the of the foot. NAVICULAR WAS MISSING. He gave REFERENCES: further history of dull pain about 4months ago 1.Primary malignant non Hodgkin Lymphoma of with 5 kilograms weight loss. the Talus.Foot and Ankle Journal 08/2005;26(7) 2.Cutaneous Non-Hodgkin Lymphoma of the Foot.A rare Case report.Crystal Ramanujam,The Journal of Ankle and Foot Surgery. 09/2009 3.Metastatic Bone Involvement of the Hallux and Cuboid. Lara Allman Foot And Ankle Journal 12/2008

Pic 2: AP and Lateral View Of The Left Foot

INVESTIGATIONS: All blood parameters seemed to be normal. Chest x-rays were normal for age. Initial differential diagnosis was Tuberculosis and osteonecrosis of the Navicular. An MRI of the foot was done. A solid irregular mass with enhanced soft tissue collection over navicular bone with extension into inferior border of talus suggestive of mycobacterial infection. A excision biopsy was done.To our very surprise, 2 * PH01A Radiographic, Functional And Patient-Rated Outcome Of AO Type-C Fracture Of Distal Radius Treated Primarily With Volar Locking Plate In A District Hospital - A Case Series

Liew HC1; Siek IM1; Sem SH2; Mohd Sallehuddin H3; Kamarulzaman MA1 1Department of Orthopaedics, Hospital Enche Besar Hajjah Khalsom, Kluang KM 5, Jln Kota Tinggi 86000 Kluang Johor, Malaysia 2 Department of Orthopaedics, Hospital Tengku Ampuan Rahimah, Taman Chi Lung, Jalan Langat, 41200 Klang, Selangor, Malaysia 3Department of Orthopaedics, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia

INTRODUCTION: Functional Maximum and Mea It has been shown that the comminuted Parameters minimum Range n (°) fracture fragments of distal radius can be fixed of Motion (°) well by a volar locking plate without crossing Flexion 0 to 30 - 50 41.1 the wrist joint. However, in district setting, the Extension 0 to 30 - 60 38.1 option of volar locking plate is often insisted Supination 0 to 80 - 85 83.3 only in severe comminution instead of being Pronation 0 to 65 - 70 68.3 used across the board due to several Radial deviation 0 to 20-40 32.2 limitations. Ulnar deviation 0 to 30-80 42.2 METHODS: Functionally,grip strength 1 year after surgery This case series was carried out by identifying tested on both hands using Jamar patients who has been admitted due to closed dynamometer reveals that the operated hand comminuted intra-articular distal end radius has at least 66% of the contralateral grip fracture and treated primarily with a volar strength with a mean of 88.4% if compared to locking plate. Their records and radiographs the patients’ contralateral uninjured hand. are reviewed. Exclusion criteria were set as Range of motion of the wrist joint measured 1 patients who had previous trauma to the limb year after surgery is shown in the table. with residual deformity or dysfunction and When assessed at 1 year after operation, more open fractures. 9 patients were identified. than half of the patients report no functional Radiographic outcomes taken includes radial disability (mode=0, n=5). It has a range height, radial inclination, articular step or gap, between 0 to 16.38 out of a total of 100 points ulnar plus or minus and volar tilt. The with a mean of 3.77 in the DASH disability radiographic outcome was based on immediate score. post-operative check radiograph taken before DISCUSSIONS: Radiological Rang Mean Volar locking plate of the distal radius is a Parameters e popular method of fixation for intra-articular Palmar tilt (+ °) +25 5 and unstable distal radius fracture. However, a Dorsal tilt (- °) -12 significant impediment to the selection of this Radial Height (mm) 6-12 9.4 option is the cost involved. Alternative form Radial Inclination (°) 10-20 15.3 of fixation is often used. In severe Articular step (mm) 0 0 comminution, radiological outcome may not Ulnar plus (+ mm) +2 +0.11 always fall in acceptable range. Articular step Ulnar minus (-mm) -2 is the most consistant outcome in this study. discharge. None of the subjects has any intra-articular RESULTS: step. Radiological parameters based on the CONCLUSION: immediate post-operative radiographs assessed It has been shown that the comminuted by a qualified Orthopaedic surgeon revealed fracture fragments can be fixed well by a volar as such: locking plate and should be applied across the board for Type C Distal radius fractures. ABSTRACT TRUNCATED PH01C Flexor Tendon Injuries: Delayed Single Stage Reconstruction

Ezainy MA; Teo PC; Sa’adon Ibrahim Department of Orthopaedic, Hospital Sultan Ismail, Jalan Persiaran Mutiara Emas Utama, 81100 Johor Bahru, Malaysia.

INTRODUCTION: RESULTS: Chronic neglected or failed primary repair of Patient is able to flex the little finger actively flexor tendon injuries are mostly treated with and hold object after 4 months. Range of two-stage reconstruction1. Here, we extend the motion MCPJ full, PIPJ 45’-90’ and DIPJ 45’- indications of delayed single stage 80’. He is satisfied with the final outcome. reconstruction which are normally recommended for young age, clean cut wound injury, intact pulley, injury less than a month and yet we still achieved satisfactory functional outcome2.

METHODS: This is a case of 64 years old, healthy malay Figue 2: 4 months post operative review in male who had neglected total cut of FDS and clinic FDP tendon at zone 2 of left little finger. Patient refused 2-stage reconstruction. Thus, DISCUSSIONS: single-stage reconstruction of FDP with Delayed single stage reconstruction of flexor palmaris longus was done 3 months after the tendon is possible to achieve good functional injury. Grafting was done using pull-out outcome in selected patient with chronic zone technique secured with button distally and 2 flexor tendon injury. Reconstruction of the pulvertaft technique proximally. While A4 A4 pulley is feasible by using the remnant pulley was reconstructed using the insertion stump of FDS insertion. Compliance to stump of flexor digitorum superficialis3. intensive post operative rehabilitation is the key to final success.

CONCLUSION: Delayed single-stage reconstruction of chronic neglected flexor tendon injuries can still provide acceptable functional outcome in selected and motivated patient.

REFERENCES: 1. J reconstr Microsurg 2014; 30 - A002

Two Stage Flexor Tendon Reconstruction George Zaher 1, Raafat Gohar 1, Ashraf El- Sebaie 1 2. [Single-stage flexor tendoplasty in the treatment of flexor tendon injuries]. Acta Orthop Traumatol Turc. 2004;38(1):54- 9.Aydin A1, Topalan M, Mezdeği A, 3. J Bone Joint Surg Am. 1986 Jun;68(5):752- 63.Two-stage flexor-tendon reconstruction. Ten-year experience. Wehbé Figure 1: Intra-operative view

PH01D Feasibility Of Full Length Phrenic Nerve Transfer Via Video Assisted Thoracoscopic Surgery (VATS) To Restore Elbow Flexion In Post Traumatic Brachial Plexus Injury

Embun, Denny; TS Ahmad Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

INTRODUCTION: of paediatric endotracheal tube size 4mm Full length phrenic nerve transfer via video which was slotted , this is served as a tunnel to assisted thoracoscopic surgery to restore retract the intrathoracic component of phrenic elbow function in post traumatic brachial nerve. The controlled rotatory movement was plexus injury is relatively new if compared to vital as to avoid injury to surrounding traditional method. Previous studies show this structure such as great vessels. No method considered to be safe, minimally complication was observed. The length of invasive and early motor reinnervation without phrenic nerve is vital for the success of morbidity. We present a case of left neurotization as previous study [3] showed preganglionic complete brachial plexus injury average length of phrenic nerve is range who underwent full length phrenic nerve between 24cm to 30cm. In this case 23cm of transfer to motor branch of biceps to restore phrenic nerve was harvested and was adequate elbow function. for neurotization to motor branch to biceps of musculocutaneous nerve. METHODS: A 17 year old Malay male college student who CONCLUSION: was right hand dominant was involved in In conclusion full length phrenic nerve motor vehicle accident and sustained a left transfer via video assisted thoracoscopic preganglionic complete brachial plexus injury. surgery is safe and viable option for At 6 months post trauma, he underwent restoration of elbow flexion. neurotization of the left brachial plexus injury, which involved Spinal Accesory nerve to REFERENCES: Suprascapular nerve and left Phrenic nerve to 1. Xu, W.-D., et al., Full-Length Phrenic Motor branch to Biceps (branch of Nerve Transfer by Means of Video-Assisted Musculocuteneous nerve). Left phrenic nerve Thoracic Surgery in Treating Brachial Plexus was harvested by cardiothoracic surgeon via Avulsion Injury. Plastic and Reconstructive VATS. Post procedure a 23cm long phrenic Surgery, 2002. 110(1): p. 104-109. nerve was harvested and then neurotized 2.Lijie, T. and X. Zhenglang, Mobilization of directly to the motor branch to biceps the phrenic nerve in the thoracic cavity by (musculocutaneous nerve). Patient was well video-assisted thoracic surgery. Surgical post operatively without any complication. Endoscopy, 2001. 15(10): p. 1156. 3.Jiang, S., et al., An anatomical study of the DISCUSSIONS: full-length phrenic nerve and its blood supply: Phrenic nerve transfer or neurotization uses clinical implications for endoscopic cervical part of the phrenic nerve which is dissection. Anatomical Science International, short, and a nerve graft is needed, resulting in 2011. 86(4): p. 225. a long period of regeneration and donor related morbidity. Full length phrenic nerve transfer via VATS is believed to be superior in term of safe and minimally invasive [1], [2]. Besides, it also shortens the time required for nerve reinnervation and preferred method for patients with long interval from injury to operation [1]. In this case we used 4cm length PH02A A Rare Case Of Pigmented Vilonodular Synovitis Of The Elbow

1, 2Ramalingam, K; 1Sivanoli, R; 1Farid, M; 1Kamil MK ; 2Jamari S 1Department of Orthopaedics and Traumatology, Hospital Tengku Ampuan Rahimah Klang, Klang, Selangor, Malaysia 2Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia

INTRODUCTION: REFERENCES: Pigmented villonodular synovitis or PVNS is a 1. Byers PD, Cotton RE, Deacon OW, benign disease of synovium. It is a Lowy M, Newman PH, Sissons HA, et al. The proliferative disease usually presenting with a diagnosis and treatment of pigmented swellling in the knee or the hand. It was first villonodular synovitis. The Journal of bone described by Chassaignac in 1852, (1) .There and joint surgery British volume. has been many reports of PVNS in other 1968;50(2):290-305. Epub 1968/05/01. regions such as the knee and elbow, with 2. Lin J, Jacobson JA, Jamadar DA, Ellis incidences of 2 case per million people. (2) JH. Pigmented villonodular synovitis and Literature review shows that it is quite a rare related lesions: the spectrum of imaging occurance in the elbow, with about 20 cases findings. AJR American journal of reported so far. (3) roentgenology. 1999;172(1):191-7. Epub 1999/01/15. DISCUSSIONS: 3. Pimpalnerkar A, Barton E, Sibly TF. We presented a case of a 47-year-old lady, Pigmented villonodular synovitis of the elbow. who presented to us with a slow growing mass Journal of shoulder and elbow surgery / over the anterior aspect of the left elbow for American Shoulder and Elbow Surgeons [et the past 4 years. Clinical examination of the al]. 1998;7(1):71-5. Epub 1998/04/03. elbow showed a 4 by 4 cm swelling at the 4. Koto K, Murata H, Sakabe T, Matsui T, volar aspect of the forearm. It had well defined Horie N, Sawai Y, et al. Magnetic resonance margins, not multilobulated and was non imaging and thallium-201 scintigraphy for the pulsatile. diagnosis of localized pigmented villonodular Magnetic resonance imaging showed a soft synovitis arising from the elbow: A case report tissue mass of the biceps tendon over the and review of the literature. Experimental and anterior proximal left forearm, measuring therapeutic medicine. 2013;5(5):1277-80. 4.5cm x 3.0cm x 2.2 cm. Epub 2013/06/06. An excisional biopsy was performed under 5. Yoon HJ, Cho YA, Lee JI, Hong SP, general anaesthesia using standard aseptic Hong SD. Malignant pigmented villonodular techinques utilizing the anterior approach. synovitis of the temporomandibular joint with Pigmented vilonodular synovitis (PVNS) is a lung metastasis: a case report and review of rare proliferative disease of the synovium with the literature. Oral surgery, oral medicine, oral an incidence around 2 in 1 million people pathology, oral radiology, and endodontics. worldwide. It has a higher occurance in the 2011;111(5):e30-6. Epub 2011/03/30. 2nd to 4th decades of life (young adults) and usually has an unknown etiology.(2) Treatment for PVNS is achieved by surgical excision, as it was with our case report.

CONCLUSION: PVNS especially around the elbow has to be considered as a differential diagnosis for slowly growing swellings in the region. Surgical excision is the treatment of choice for these swellings.

PH02B Giant Cell Tumor Of The Bone Of The Hand In Children

Idris, Ristiman; Ruban Sivanoli; Tiew; Sam Department of Orthopaedic Hospital Tengku Ampuan Rahimah Jalan Langat, 41200 Klang, Selangor, 41200, Malaysia.

INTRODUCTION: no obvious deformity seen at his middle The Giant cell Tumor of bone is a benign but finger. Biopsy comeback as Giant Cell Tumor. locally aggressive bone tumor.. It constitutes of 4-5% of all bone tumor and and about 18% DISCUSSIONS: of all benign bone tumor. The tumor presents The Giant cell tumor is was first described in as a large lytic mass of the epiphysis of long 1818 by Cooper and Travers. Its local bones The presence in the small bones of hand aggression has been highlighted by Nelaton is rare. Unni1 reports and incidence of 1.7% , and its malignancy by Virchow. Initial Mirra et al. 2 report an incidence of less than presentation mimic malignancy bone tumor. It 4% and Huvos3 reports an incidence of 3.7%. is a rare tumor, essentially benign, but it may In the past, these tumors were treated with behave unexpectedly, regardless of the result amputation or large resection with ulterior of radiological or histological examinations. It reconstruction. is usually located in the long bone meta- epiphysis and rarely, into diaphysis. Giant cell CASE REPORT: tumor in hand is very rare especially in This is a 9 year old malay boy presented with children The variables related to the tumor, right hand middle finger middle phalanx such as size, location, biological activity, swelling since 3 months ago. Initially started cortical bone destruction or pathologic fracture as peanut size and gradually increasing in size. evidence, determine the treatment. No history of insect bite or history of infection Reconstruction option are very limited in such as fever, erythematous or pus discharge. children No history of loss of weight or loss of appetite. Claimed by mother that patient had CONCLUSION: history of fall at school on august 2015. On Futher studies are needed to gain data for examination, right hand middle finger middle successfully of range of motion post phalanx swollen 6cm x 6cm (hard and well operatively in which joint are not circumscribe). Range Of Motion Right middle reconstructed . finger at proximal interphalangeal joint (PIPJ) and distal interphalangeal joint (DIPJ) is restricted. Otherwise, metacarpophalageal joint of middle finger is able to flex and extend fully (0-90degree). He underwent operation large resection of right middle finger middle phalanx and was replace with cortical graft from medial aspect of contralateral of Fig. 1: (Left) – Plain AP radiograph of right middle tibia. This graft was hold by 2 k-wire axially. finger pre-operatively, showing aneurysmal bubbly The middle finger proximal interphalangeal bony lesion seen in the middle phalanx . (Right) – Plain joint (PIPJ) and Distal Interphalangeal joint Lateral view of right middle finger. (DIPJ) is not reconstructed. Post-Operative 7 weeks noted his hand function regained with Range of Motion of his right middle finger Proximal Interphalangeal Joint (PIPJ) is 0-45 dergree and his Distal Interphalangeal Joint (DIPJ) is 0-10 degree. He is also able to Fig. 2: Swollen of the right middle finger at middle perform his daily routie activities. In term of phalanx area and involving the proximal cosmetic appearance, he is very satisfied and interphalangeal joint (PIPJ) and distal interphalangeal joint (DIPJ)

ABSTRACT TRUNCATED PH02D Rupture Of The Flexor Tendons Of The Index Finger After Distal Radius Fracture

Chung WH; Randhawa SS; Norsaidatul AS; Suhaeb AM; Jayaletchumi G; Ahmad TS Department of Orthopaedic Surgery, NOCERAL (National Orthopaedic Centre of Excellence in Research and Learning), University of Malaya, Lembah Pantai, Kuala Lumpur, Malaysia.

INTRODUCTION: Flexor tendon rupture following distal radius fracture is a rare complication. In most reported cases, there was a delay between the fracture and the rupture of the tendon. The case reported here, is rupture of both long flexors of the index finger which occurred immediately after a fracture of the distal Figure 1 Figure 2 Figure 3 radius. Figure 1: Bruises and loss of finger cascade

Figure 2: Comminuted fracture and anterior MATERIALS & METHODS: bony spike A 50-year-old male civil servant presented Figure 3: FDS and FDP tendon cut with fractures of both radii after a road traffic accident. On physical examination, besides the mechanism is delayed tendon rupture was the wrist deformities, there were bruises over attrition by anterior bony spur or other the volar aspect of the right wrist and loss of structures, such as displaced ulnar head or normal finger cascade of the right hand hypertrophic distal radioulnar joint. The (Figure 1). He was unable to flex both second mechanism is acute flexor tendon interphalangeal joints of the right index finger. rupture at the time of injury as a result of Neurovascular examination was severe mechanism of injury and fracture unremarkable. Radiographs showed a displacement. This mechanism applies in our comminuted distal radius fracture with marked case. dorsal displacement (Figure 2). A volar locking plate fixation of the right radius and tendon exploration were performed. CONCLUSION: Acute flexor tendon rupture following distal Intraoperatively, both flexor digitorum radius fracture is rare. However, one should superficialis (FDS) and profundus (FDP) have a high index of suspicion and examine tendons of the index finger were totally the active motion of each digit in distal radius lacerated which was due to a bony fragment fracture, especially in the presence of bruises, (Figure 3). Both tendons were repaired end-to- abnormal finger cascade and severe fracture end. He was able to follow an intensive comminution. rehabilitation protocol.

REFERENCES: RESULTS & DISCUSSION: 1. Suppaphol S, Woratanarat P, Channoom T. He recovered uneventfully. Flexor tendon Flexor tendon rupture after distal radius rupture after distal radius fracture is rare. fracture. Report of 2 cases. J Med Assoc Thai Although the flexor tendons lie in close (2007); 90 (12): 2695-8. proximity with the fracture site, the high 2. Southmayd WW, Millender LH, Nalebuff tensile strength of the tendon and its flexibility EA. Rupture of the flexor tendons of the index often protect it from rupture. Supaphol et al. finger after Colles’ fracture. Case report. J proposed two mechanisms of tendon rupture Bone Joint Surg Am (1975); 57 (4): 562-563. following distal radius fracture based on onset of rupture, severity of initial injury, and presence of attritional cause. The proposed PH03A Transligamentous Variant Of The Recurrent Motor Branch Of The Median Nerve

SS Toyat; CK Chuah; Rashdeen F Department of Orthopaedics & Traumatology, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Malaysia.

CASE HISTORY: branch to the thenar muscles. Most commonly, A 52 year-old right-hand dominant female the recurrent motor branch follows an nurse presented with numbness over the radial extraligamentous course, whereby the branch digits of her right hand for 5 months, with originates distal to the transverse carpal positive Tinel’s sign over the carpal tunnel ligament, then bends back to innervate the region. No loss of hand function was noted. thenar muscles. However, there are anatomical She underwent open right carpal tunnel release variations in the course of the recurrent motor for her right carpal tunnel syndrome. Intra- branch, classified by Lanz as operatively, a transligamentous recurrent extraligamentous, subligamentous, and motor branch of the median nerve was transligamentous.1 encountered and protected during division of the transverse carpal ligament. The median In the transligamentous variant, the recurrent nerve itself was normal in appearance with no motor branch pierces the transverse carpal abnormalities within the carpal tunnel. Post- ligament on its course towards the thenar operatively, there was relief of her muscles. This puts it at high risk of being paraesthesia, with no complications. injured during incision of the transverse carpal ligament, which can result in loss of opposition of the thumb, and consequently, loss of ability to grip and pinch. Furthermore, in this group of patients, the motor symptoms may be a result of compression of the recurrent motor branch as it passes through the transverse carpal ligament, rather than increased pressure within the carpal tunnel.2 Therefore, the standard carpal tunnel release will not alleviate the motor symptoms, unless the foramen through which the recurrent Fig. 1 Transligamentous variant of the motor branch passes is explored and released. recurrent motor branch of the median nerve However, this procedure was not necessary in the case of this patient, as she did not present DISCUSSION: with any motor symptoms. The carpal tunnel is a fibro-osseous tunnel at the wrist through which the median nerve CONCLUSION: passes with 9 tendons. The transverse carpal Recognition of the anatomical variations of ligament forms the roof of the tunnel. Carpal the median nerve and its branches is important tunnel syndrome results from compression of to prevent iatrogenic injury during carpal the median nerve in the tunnel, causing tunnel release. symptoms such as paraesthesia over the median nerve distribution, weakness and REFERENCES: atrophy of the thenar muscles. Treatment is 1. Lanz U. J Hand Surg Am. 1977; 2(1):44– either conservative or surgical via carpal 53. tunnel release. Carpal tunnel release involves 2. Stosic A, Eskinja N, Stancic MF. division of the transverse carpal ligament to International Orthopaedics (SICOT) 1995; 19: relieve pressure on the median nerve. From 30-34. the median nerve arises the recurrent motor

PH03B A Black Finger Does Not Mean A Dead Finger

Hau, William; Belani, Levin Kesu; Selvanathan, Nanchappan; Abdullah, Shalimar Department of Orthopaedics, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaakob Latiff, 56000 Kuala Lumpur, Malaysia.

INTRODUCTION: DISCUSSION: Revascularisation and replant surgery Replant and revascularization surgery can occasionally produces sub-optimal results. have unexpected regenerational capacity. Two cases of near total amputation of the There is a possibility of either arterial (pale or digits which underwent revascularization. At dusky finger, low pulse oximetry and one week post-surgery, the fingers were temperature readings, decrease pulp turgor and discoloured black but had good pulp turgor absence of bleeding on needle-prick) or with arterial bleed on pin-prick. Inexperienced venous obstruction (blue, purple and swollen surgeons may view this as gangrene and finger with excessive bleeding from the amputated the fingers. However we continued wound edges). observation and at 1 month post-surgery, the black skin had desloughed and the underlying skin was pink.

MATERIALS & METHODS: Figure 1: The Case 1 – An 11-year-old boy had his right black dorsal skin and nail plate (top) middle finger caught in a washing machine had changed to sustaining an avulsion near total amputation healthy, pink skin injury. The finger was attached by only the by 7 weeks post- FDP tendon. One digital artery was surgery (bottom). anastomosed. Other vascular structures were injured and unable to be repaired. Case 2 - A 42-year-old male sustained a machete attack with near total amputation of his right small and ring finger attached only by 2cm of dorsal skin. Only one digital artery to Figure 2: The each finger was anastomosed. No digital veins black tip of the were repaired due to presence of the skin left ring finger bridge and time was a factor. and discoloured skin (top) had turned to healthy RESULTS: pink skin by 16 Case 1 – At 1 week post-anastomosis, the days post-surgery finger tip and dorsal skin was all black. with good arterial However pulp turgor was good. At 7 weeks bleed (bottom). post-op, we were delighted to see new pink skin. Case 2- At post-op Day 9, the finger seemed to blister, the wound looks wet and the skin CONCLUSION: appeared unhealthy. The pulp was black Pulp turgor and not discolouration is an although turgor was maintained. At 16 days important factor in assessing viability of the post-op, the pulp is still black but the skin over finger. The benefit of the doubt should always proximal and middle phalanx was pink and be given in replant surgery. healthy. REFERENCES: 1. Morrison WA, McCombe D. Digital replantation. Hand Clin. 2007;23(1):1–12 PH03C Unusual Locked Trigger Finger Due To Tophaceous Infiltration Of Wrist Flexor Tendon

Hau William; Abdullah Shalimar; Sapuan Jamari Department of Orthopaedic and Traumatology, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia

INTRODUCTION: Tophi can present as a first sign of hyperuricemia but reports on the involvement of the flexor tendons of the hand is rare. Although tuberculous tenosynovitis is a more common etiology for swelling over the wrist, gout must be among the differentials Figure 1: The ring finger in flexed position irrespective of hyperuricemic status. Because Figure 2: The arrow shows tophaceous gout in of its low frequency, gouty involvement of the the FDP of the left ring finger flexor tendons is not often considered in the differential diagnosis of tenosynovitis. DISCUSSION:

Gout is a disorder of purine metabolism that CASE REPORT: predisposes to hyperuricaemia, leading to A 37-year-old male presented to our out monosodium urate crystal depositions in patient clinic 8 months after a failed trigger joints. In addition to joints, uric acid crystals finger release operation with the complaint of are reported to deposit in soft tissues such as inability to extend the ring finger of his left tendons, median nerve, bursae and intrinsic hand. The left trigger finger release was done muscles. Gout at the wrist as the initial at another hospital. The patient did have appearance of the condition occurs between symptoms of triggering. However 2 weeks 0.8 to 2% of all gout cases. Gout patients who after the operation, patient was unable to are not treated have a 19–30% chance of extend his left ring finger. On physical developing gout in the wrist during their examination a firm – hard mass around 2*2 lifetime. Gouty tenosynovitis can induce cm was found over the volar aspect of the flexion contracture of the digits by forearm just proximal to the flexor involvement of the flexor tendons at the wrist, retinaculum when the patient flexes his as in our patient, or at the digital canal. fingers. On finger extension, the mass Surgical intervention like tenotomy or disappears. He had a flexion contracture of the tenosynovectomy are required to debulk left ring finger. Our working diagnosis was tophaceous deposits, improve smooth gliding TB tenosynovitis followed by soft tissue of tendon and decompress nerves but primarily neoplasm and subsequently surgical medical management to treat gout remains the exploration was performed. We noted that the gold standard. Short-term outcomes are A1 pulley has been completely released. consistently good but the risk of rupture or However his finger was still in the flexed recurrence remains if medical control is not position. An extended carpal tunnel incision achieved. noted whitish chalky infiltration of the tendon of the FDS, synovial adhesion to other tendons CONCLUSION: and hypertrophy of the flexor tendon. Surgery This is an uncommon and unusual case of confirmed with synovectomy and complete tophaceous infiltration of the flexor digitorum excision of the tendon of FDS to the ring superficialis of the ring finger. This case finger. Histo-pathological evaluation demonstrates several issues that clinicians confirmed the diagnosis of gout. should keep in mind when assessing patients with a history of gout. Early diagnosis based on a high index of suspicion is paramount to the initiation of proper surgical management. ABSTRACT TRUNCATED PH03D Carpal Tunnel Syndrome With Abnormal Lumbrical Muscles

Benny Ewe; A. Shalimar; S. Jamari Department of Orthopaedics and Traumatology, Faculty of Medicine, University Kebangsaan Ma- laysia, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Wilayah Persekutuan Kuala Lumpur, Malaysia

INTRODUCTION: Carpal tunnel release surgeries are considered DISCUSSIONS: straight forward and delegated to junior sur- Lumbrical muscles originate from the FDP geons. However it is not uncommon to en- tendon, distal to the carpal tunnel, and the counter anatomical anomalies. We report a muscle belly moves proximally on finger flex- patient with carpal tunnel syndrome (CTS) ion. Several authors reported that lumbrical ofleft hand resulting from hypertrophy of the muscle intrusion is a potential cause of CTS lumbricals to the ring finger with origin prox- [1]. There have been a few reports of CTS as- imal to the carpal tunnel, and arising from sociated with lumbricals. There are various both flexor digitorum profundus (FDP) and underlying causes of this condition, such as superficialis (FDS) tendon to the ring finger. anomaly of the muscle, tumor-related condi- The patient had numbness with night pain and tions, and hypertrophy from overuse. In this clumsiness. case, there is lumbrical muscle anomaly, as well as hypertrophied muscle with possible METHODS: history of hard labour. CTS associated with A 73-year-old retired army veteran presented occupations in which overuse induces lumbri- with numbness, pain, night pain and clumsi- cal hypertrophy are characterized by the fol- ness in his left hand for 1 year. There was the- lowing aspects: most patients being young or nar muscles atrophy and numbness over the middle-aged males, worsening symptoms on median nerve area, together with a soft tissue finger flexion, positive fist test results, and fullness proximal to wrist crease. Numbness resistance to conservative treatment. was aggravated by active flexion fingers. Operative treatment is preferred for CTS asso- Tinel’s sign and Phalen’s test were positive. ciated with lumbrical muscle anomaly, rather MRI revealed muscle tissues in carpal tunnel. than conservative management [2]. Carpal The median nerve was compressed between tunnel release is usually performed, as well as the transverse carpal ligament and the anoma- resection of the abnormal muscle belly. It is lous muscle. preferred to be done under general anesthesia Open carpal tunnel release was performed un- due to the extent of surgical exposure. The der general anesthesia. Hypertrophied lumbri- prognosis is good after operative treatment, cal muscles were noted inside the carpal tun- because the overcrowding of the carpal tunnel nel, with an abnormal origin from tendons of by the abnormal muscle is resected, and also if both FDP and FDS of ring finger, proximal to it is performed at an early stage before the ir- the wrist. No median nerve abnormality were reversible pathological changes occurs to the noted (Figure 1). The abnormal lumbrical median nerve. muscle belly was excised. CONCLUSION: Figure 1: The medi- Carpal tunnel release surgeries are not straight an nerve (yellow ar- forward easy operations. Occasionally anoma- row) and lumbrical lies such as hypertrophy of the lumbricals can muscles (blue arrow) be a confounding factor and orthopaedic sur- arising from both geons should be aware of this possibility. FDP and FDS ten- don (green arrow) of REFERENCES: the ring finger in 1. M. E. Jabaley, “Personal observations on carpal tunnel. the role of the lumbrical muscles in carpal tunnel syndrome,” The Journal of Hand Sur- ABSTRACT TRUNCATED PH04A Multiple Carpometacarpal Joint Fracture Dislocation

Mohd Faizal Nazir; Lingeshwaran R.Arunasalam; Wong KA; Narinder Singh Gill; Abdul Aziz Department of Orthopaedic, Hospital Seberang Jaya, 13700 Prai, Pulau Pinang, Malaysia

INTRODUCTION: Hand fracture is one of the most common fracture in general population1, however carpometacarpal joint dislocation is a rare injury. Carpometacarpal joint dislocation are missed and misdiagnosed especially in poly- [Fig-2] : Ct Of Hand, Showing Fracture Dislocation Over 2nd Until 5th Carpo- trauma in up to 70%2. These injuries account 3 Metacarpal Joint And Fracture Of The Base Of less than 1% injury of the hand . We present 3rd And 4th Metacarpal Bone to you a rare case of hand injury post motor vehicle accident.

CASE REPORT: A 33 years old left handed malay male, alleged motor vehicle accident, he landed with full extension of wrist and hit his mid palmar [FIG-3]: Antero-Posterior And Lateral Radiograph Of Wrist Showing POST OP X- area. On review in emergency department, his Ray left hand mild swelling, tender, range of movement reduced and no neurovascular DISCUSSIONS: compromised. Plain x-ray of left hand and nd th Carpometacarpal joint fracture dislocation are wrist done showed 2 to 5 carpometacarpal rare injuries which amount less than 1% of joint fracture dislocation. CT of left hand, also 1 nd th hand trauma , multiple carpometacarpal joint showed fracture dislocation over 2 until 5 fracture joint dislocation are extremely carpo-metacarpal joint dislocation and fracture rd th isolated. A direct impact trauma is the of the base of 3 and 4 metacarpal bone. An commonest mechanism of injury. attempt of closed manual reduction done but Carpometacarpal fracture dislocation usually failed .Under general anesthesia, closed occur in high energy trauma motor vehicle reduction and Kirschner wires was done over nd rd th th accident. The downfall is late diagnosis either 2 , 3 , 4 and 5 carpometacarpal joint ,post in poly-trauma cases or lateral view of wrist op x-ray acceptable. Wound inspection done was not taken. It is important to do a proper on day 3 and STO on day 14, K-wire removed view x-ray (AP and lateral) in casein 6 weeks post operation. Patient was referred to suspicious cases of carpometacarpal occupational therapy and active physiotherapy injuries.These injuries can be treated by of the wrist and hand was started, currently different methods either closed reduction or still under our follow up. open reduction and internal fixation with K- wire. The choice of treatment depends on severity (multiple carpometacarpal fracture joint dislocation) and stability of the joint.

CONCLUSION: This type of injuries is extremely rare (<1% of [Fig-1] : Antero-Posterior And Lateral hand trauma). In daily practice only AP and Radiograph Of Wrist Showing Fracture oblique views of the hand are taken, in order Dislocation Over 2nd Until 5th Carpo- to avoid this pitfall, lateral view of the hand Metacarpal Joint should be taken in case which suspected carpometacarpal joint fracture dislocation. Late recognition of this injury likely to result in morbidity.

ABSTRACT TRUNCATED PH04B Case Report: Bilateral Radial Head Replacement - A Deed Or Sin??

Paul S; Gurjit Singh; Zamyn Zuki Department of Orthopaedics, Hospital Sungai Buloh, Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia

INTRODUCTION: The results of elbow dislocations with DISCUSSION: associated radial head and coronoid fractures There is no consensus about the treatment of are often poor because of recurrent instability an unstable elbow injury associated with and stiffness from prolonged fracture of the radial head.The options include immobilization.These injuries are usually early or delayed excision,reconstruction and managed with a standard surgical replacement.Early excision of the radial head protocol,postulating that early requires immobilization for several weeks to intervention,stable fixation and repair would allow the soft tissues to heal.There is a risk of provide sufficient stability to allow motion at redislocation and of stiffness.Reconstruction seven to ten days postoperatively and enhance of the radial head is possible only when there functional outcome. are two or three main fragments and may be technically difficult.Delayed excision of the CASE REPORT: radial head is sometimes performed several A 32 year old Malay gentleman,presented with weeks later when necessary.Residual stability pain,swelling and deformity of bilateral elbow may be poor and there is risk of myositis following a MVA.He had no other injuries and ossificans after delayed surgery. sustained closed comminuted right olecranon and radial head fracture(Mason IV) with CONCLUSION: posterior elbow dislocation and closed An arthroplasty with a modular metallic radial comminuted left olecranon and radial head head is safe and effective option for the fracture(Mason III) with coronoid process treatment of unreconstructible radial head fracture.CT scan was done for preoperative fractures associated with other elbow planning and we proceeded with ORIF on day injuries.However,risk of elbow instability and 8 post trauma once the soft tissue condition stiffness is always a possibility especially had improved.He underwent bilateral locking following delayed surgery. reconstruction plate of olecranon,screw fixation of coronoid process and bilateral REFERENCES: radial head replacement in the same setting. 1.Comminuted radial head fractures treated RESULTS: with a modular metallic radial head Post-operatively,patient had no neurological arthroplasty,Journal of Bone and Joint Surgery deficit and was immobilized with above elbow Am,2006 Oct;88(10):2192-2200 backslab for 14 days,started on T.indomethacin to prevent myositis ossificans 2. Arthroplasty with a metal radial head for and his antibiotics were continued for a unreconstructible fractures of radial duration of 10 days.He was discharged on post head,Journal of Bone and Joint Surgery op Day 3 and started on physiotherapy on Day Am,2001 Aug;83(8):1201-1211 14.The fractures took a total duration of 11 weeks for radiological union and after 3 months of aggressive physiotherapy,his left elbow had regained full range of flexion and extension but his right elbow ROM was 10-80 degrees of flexion.

PH04C Whitmore's Disease Manifestation As Septicaemic Melioidosis, Septic Arthritis Right Elbow And Osteomyelitis Right Humerus: A Case Report

Muhammad Firdaus; Abdul Muttalib AW; Suhana SB; Richford J; Department of Orthopaedic, Hospital Segamat, 85000 Johor, Malaysia.

INTRODUCTION: arthritis right elbow was made, she started on Whitmore's disease, also called melioidosis is intravenous Unasyn to cover the broad an enviromental saprophytic infection caused spectrum. Sputum samples were sent for acid- by gram-negative soil-dwelling bacillus fast bacilli to rule out active pulmonary Burkholderia pseudomallei. It affects mainly tuberculosis and came back negative. She adults with underlying predisposing condition underwent washout right elbow such as diabetes. The range of symptoms and intramedullary flush right humerus with varies from benign and localized abscesses, to intra-op findings of 30 cc pus at posterior severe community-acquired pneumonia to compartment of right arm, cheesy white thick acute fulminating septicaemia with material flow at humerus midshaft, sloughy multiple abscesses often leading to death.1 elbow joint, and destroyed articular surface. MATERIALS & METHODS: Two days after operation, temperature still Case report spiking up to 40 oC with persistant Mrs WK, a 55-year-old Malay housewife, tachycardia, metabolic acidosis and deranged with underlying diabetes, admitted to hospital renal profile. Patient was admitted to ICU on January 26, 2015, complaining of a one- and underwent second look wound week acute onset painful swelling of her right debridement of right elbow. Antibiotic elbow associated with high-grade fever, chills, escalated to Tazosin. Five days later, tissue rigors, and night sweats. She denied any culture grew Burkholderia Pseudomallei, recent trauma, or travelling outside and no leading to the diagnosis of melioidosis. She contact with active pulmonary tuberculosis was started on intravenous Fortum 1 g three patient. On admission, her temperature was times daily. Treated as inpatient for two 38.50C. Her right elbow warm, tender, weeks for the intensive phase of antibiotic swollen, erythematous and limited range of therapy without any complications. She was motion due to pain. Investigations showed a discharged with continuation of oral white cell leukocytosis(16.3x109/L) with doxycycline and bactrim for another 20 weeks neutrophilia (83.2%), ESR:111, CRP:3.49 and and outpatient follow-up at 4-6 weeks VBG showed metabolic acidosis. Other blood intervals. Latest review in clinic, the elbow investigations are normal. MRI of right elbow functioning well with full range of motion. reported presence of right elbow septic DISCUSSIONS: arthritis with multiple intercommunicating Melioidosis has a wide array of clinical signs rim-enhanced abscess locules in the triceps and symptoms. Septic arthritis and and brachialis muscles. Associated with osteomyelitis, which was the principal extentensive myositis of right arm and presentation of our patient are rare presenting subcutaneous cellulitis. features, with only 4% of cases having such manifestations.2 Over half of patients have bacteraemia on presentation, and septic shock develops in approximately one fifth. Internal- organ abscesses and secondary foci in the lungs, skin and soft tissues, bones and joints, 2 or any other organ may occur. Figure 1: MRI right elbow of Mrs WK CONCLUSION: Chest X-ray showed patchy opacities in the Septic arthritis only occurs in 4% of patients right upper zone suggestive of peumonic with melioidosis. This case is relevant for changes. Ultrasound of her abdomen are medical literature as melioidosis is emerging normal. A working diagnosis of septic and is expanding its territories worldwide. It

ABSTRACT TRUNCATED PH04D Excision Of 4th Metacarpal Bone Giant Cell Tumour With Fibula Strut Graft Reconstruction And Metacarpophalangeal Joint Soft Tissue Arthroplasty

Lau, L.Q; Raghavan, S; Sivanoli, R Department of Orthopaedic Surgery, Hospital Tengku Ampuan Rahimah, Jalan Langat, 41200 Kelang, Selangor, Malaysia

INTRODUCTION: HPE findings were consistent with our Giant cell tumour is a benign locally diagnosis of giant cell tumour. aggressive tumor which commonly occurs in long bones, especially lower limbs. Only 2% DISCUSSIONS: of giant cell tumor occurs in metacarpal The goal of treatment is to obtain local tumour bones1. It commonly occurs in adults between control and preserve hand function. Various ages of 20-40 and has high rate of recurrence. treatment options have been presented in We present a case of giant cell tumor of the literature including curettage, curettage with left 4th metacarpal bone, which was treated addition of bone graft or bone cement, wide with extensive enbloc excision and resection with reconstruction or ray reconstruction with fibula strut graft. amputation2. In this case, we decided for wide resection of the tumour with fibula strut graft METHODS: reconstruction. We found that even without A 20 year old gentleman presented to our reconstruction of head of 4th metacarpal, clinic with progressive painful swelling over patient was able to achieve good range of the dorsum of left hand. There was a history of motion of the 4th MCPJ and function of the injury to the left hand 2 years ago while hand as a whole via pseudoarthosis. playing sports. Examination revealed a non mobile, tender diffuse swelling of 3 x 3 cm CONCLUSION: along the 4th metacarpal. A radiograph of the GCT of the bone in hand remains a rare but hand showed a large expansile lytic lesion aggressive lesion. Hence, early diagnosis and over the 4th metacarpal bone from the base up treatment is paramount to preserve as much to the head of metacarpal. MRI of the left hand function. Based on this case, we are able hand was done and it showed a well defined to highlight that periarticular lesions can be expansile lesion involving the meta-diaphysis effectively treated with bone grafting and of left 4th metacarpal bone, suggestive of giant healing via pseudoarthosis or soft tissue cell tumor. arthroplasty which eventually gives acceptable functional results. RESULTS: Patient was subsequently planned for excision REFERENCES: biopsy of the mass with fibula strut graft. 1. Averill et al. "Giant-cell tumors of the Intraoperatively, we noted a grayish bony bones of the hand." The Journal of tissue measuring about 3 by 4 cm extending hand surgery 5.1 (1980): 39-50. from base of 4th metacarpal up to the head. 2. Matev et al. "Giant cell tumor of the The mass was removed en bloc hence fourth metacarpal: case report and sacrificing the 4th MCPJ. The defect was then literature review." J Radiother Med filled with fibula strut graft taken from the Oncol 18 (2012): 73-77. ipsilateral leg and fixed with one axial K-wire from the base of the proximal phalanx of the ring finger to the base of 4th metatacarpal. The K-wire was removed after 6 weeks at clinic and follow up xrays showed incorporation of the graft to the base of the metacarpal. The wound healed well and patient had range of motion of the MCPJ from 0-80 degrees. The PH05B The Effects Of Hypnoanaesthesia On Carpal Tunnel Release Procedure

1Choong, CL; 2Soh AH; 1Tay, Terence; 1Ahmad, TS 1Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia 2London College of Clinical Hypnosis Therapy Centre, Pantai Hospital, Jalan Bukit Pantai, Kuala Lumpur, 59100, Malaysia.

INTRODUCTION: demonstrated that the experimental group Carpal tunnel syndrome (CTS) remains a showed a significant improvement in role disabling condition which causes upper limb functioning, role physical, pain, social discomfort associated with median nerve functioning, emotional health and mental compression. Carpal tunnel release (CTR), a health category but not in physical health and treatment for CTS often performed under local vitality. anaesthesia (LA). However, LA may cause complications such as allergic or LA systemic DISCUSSIONS: toxicity. The present study aimed to Pain is often associated with surgical investigate the effects of hypnoanaesthesia as procedures, injuries and diseases [1]. Prolong an alternative to LA on patients undergoing pain often leads to excessive uneasiness, CTR. A randomized, quantitative and delayed recovery, incompliance to qualitative pilot study was conducted. rehabilitation, and more use of health care resources [2]. In this study, the improvement METHODS: in pain intensity evaluated via VAS between A randomized, quantitative and qualitative control and hypnosurgery experimental group pilot study was conducted. Eight patients were was encouraging. In addition, the treatment randomized into the control (received local gains in pain intensity were maintained even anaesthesia) and the experimental group up to six weeks post-treatment. Most (hypnoanaesthesia group). All subjects’ importantly, we are the first to report the progress was evaluated according to multiple reduction in analgesic medication dependent variables which include: i) Short requirements post operatively in experimental Form 36 (SF36), ii) Modified Boston Carpal group. In different condition, hypnotherapy Tunnel Syndrome Questionnaire (mBCTQ), has shown a reduction in the usage of iii) Visual Analogue Scale (VAS), iv) State- analgesia during labour [3], gastroscopy [4], Trait Anxiety Inventory (STAI) and v) amount cervical endocrine surgery [5] and pregnancy of analgesic medication used for the control termination [6]. Hypnosurgery has also been group. effective in controlling patients' pain and anxiety during excisional breast biopsy [7] and RESULTS: dental procedures [8]. The results revealed that the experimental group showed a reduction of VAS scale in a CONCLUSION: shorter duration of time compared to control In conclusion, hypnoanaesthesia used in CTR group post operatively, thus reduced the intake shown a significant reduction in pain score in of analgesic medications. Control and a shorter time, reduces intake of analgesic experimental groups showed a significant medications, improved recovery of carpal improvement in patients’ symptoms severity tunnel symptoms, reduced the anxiety and scale (30.7% and 32.9% respectively) and minimised complications post-operatively. In functional status scale (24.5% and 54.5% the future, hypnoanaesthesia can be used as an respectively) post operatively as evidenced via mBCTQ. The experimental group revealed alternative analgesic tool for carpal tunnel that the anxiety score improved after the surgery and would investigate its effects operation significantly from STAI towards high risk patients undergoing carpal questionnaires. The SF36 questionnaire tunnel releast.

ABSTRACT TRUNCATED PH05C Rice-Body Formation And Tenosynovitis Of The Wrist: A Case Report

Loi KW; TS Ahmad Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia.

INTRODUCTION: Though rice-body forming lesions have been articular synovial inflammation and ischaemia, widely reported, we find little records in our with subsequent synovial shedding and local journal and documentation. We report an encasement by fibrin derived from synovial interesting yet treatable case of rice-body fluid2. De novo formation and progressive forming lesion in the wrist in our center. enlargement by fibrin and an alteration in fluid viscosity and fibrinogen content of the CASE REPORT synovial fluid has been implicated. The A 72-year old lady, with underlying retroviral differential diagnoses include pigmented disease, presented with 3 years history of villonodular synovitis (PVNS) and giant cell progressive painful swelling over the dorsal tumor of the tendon sheath3. aspect of the right wrist. It was multi-lobulated and soft in nature spanning from distal forearm to the dorsal aspect of the right hand. Magnetic resonance imaging revealed extensive tenosynovitis with rice bodies consistent with chronic tuberculosis. Laboratory test results were normal, except for an elevated erythrocyte sedimentation rate (109mm/h) and C-reactive protein (3.1mg/dl). Mycobacterium intra-cellulare was cultured from the fluid aspirated from the swelling. Figure 1: Intraoperative well encapsulated Surgical exploration and excision of the lesion rice bodies. was performed. Large mass of soft tissue mass encapsulated the common extensor tendons CONCLUSION: deeply adhered to the extensor retinaculum, It is always good to be aware that tuberculosis which contained several hundred small 0.5cm is a common cause of chronic tenosynovitis. rice bodies were found. Histopathological Combines surgical and medical therapy give examination was consistent with necrotizing good result and prevent recurrence of disease. granulomatous inflammation. Tissue section staining for acid fast bacteria (Ziehl-Neelsen REFERENCES: stain) and tissue cultures for mycobacteria 1. Berg E, et al., On the nature of rheumatoid were however negative. Patient completed a 9- rice bodies: an immunologic histochemical month anti-tuberculous therapy and currently and electron microscope study. Arthritis doing well with no sign of recurrence. Rheum. 1997; 20(7): 1343-9. 2. Matsumoto K, et al., Massive nonspecific DISCUSSION: olecranon bursitis with multiple rice bodies. J Rice bodies occurring in joints affected by Shoulder Elbow Surg. 2004; 13: 680-83. tuberculosis were first described in 1895. Rice 3. Chen A, et al., Distinguishing multiple rice bodies are a common finding in many body formation in chronic subacromial rheumatic disease as well as infectious subdeltoid bursitis from synovial diseases such as nonspecific arthritis, chondromatosis. Skeletal Radiol. 2002; 31: tuberculosis, atypical mycobacterial infections 119-21. and even osteoarthritic joints1. The cause of rice body formation remains obscure. Some suggested micro-infarctions after intra- PH05D A Case Of Madura’s Hand. Devastating Mycetoma Infection

Harkeerat Singh; Ariffin M.A; K.Hariharan; VS.Naveen Department of Orthopaedic Surgery Hospital Tawau, Sabah, Malaysia

INTRODUCTION: INVESTIGATIONS: Mycetoma is an uncommon chronic infective Blood investigations did not reveal much as disease of the skin and subcutaneous tissues white cell counts were within normal range, characterized by the triad of tumefaction, ESR: 110ml/hr. HPE revealed skin ulceration, draining sinuses and presence of colonial granulation tissue and mixed inflammatory grains in the exudates. It is a disease infiltrate with colonies of organisms with commonly seen in tropical countries and is Splendor Hoeppli phenomenon and basophilic named after the region Madurai in Southern staining suggestive of Mycetoma. No evidence India where it was first described in 1842. The of atypical cells seen. Gram Stain shows Gram most common site of infection is the foot positive staining suggestive of (70%) thus “Madura’s Foot” followed by the actinomycetoma. Zeihl Neelson & Perodic hand. Most infections are preceded by minor Acid-Schiff stains were negative. Cultures trauma allowing organism to breech into the from the lesion also did not yield any growth. subcutaneous layers. Infections can be caused X-rays of the hand showed density changes in by true fungi 40% - eumycetoma or by the 4th and 5th metacarpal bones with cortical filamentous bacteria – actinomycetoma in 60% scalloping and periosteal reaction of the 4th of cases. Treatment of the two etiologies differ metarcarpal bone accompanied with cystic thus it is necessary to differentiate prior to changes with sclerosis of the 4th n 5th commencement of treatment. metacarpal bones.

CASE REPORT: DISCUSSIONS: A 17-year-old Suluk girl presented with This patient was subjected to oral Grisofulvin multiple painless crusted papular lesions over 375mg daily for six weeks. Upon review in the dorsum of her left little finger for the past 8 two weeks her crusted lesions had shrunk, months. Upon further inquiry she admits being papules reduced in numbers and her lesions pricked by a fish hook 2 years ago and dried up. Unfortunately she had defaulted presented with a small papule over the dorsum follow-up thereafter. According to literature of her left little finger. She has had multiple Actinomycetoma infections can be cured with visits to private GP’s where she had been surgical debridement and appropriate given multiple doses of oral and IM antibiotics antibiotic therapy while eumycetoma is only with different concoctions of ointments. To partially responsive to antifungal agents and her dismay the lesion had spread to both the high rate of recurrence may require amputation dorsum and volar aspects of her hand. CONCLUSION: Image 1: Left hand dorsal and volar views Due to the slow and painless progression of the disease, patients with mycetoma usually present late. We suggest determining the etiology prior to commencing therapy as their treatment differs.

REFERENCES: 1. Linchon V, Khachemoune A, Mycetoma A rewiew, Am J Clin Dermatol. 2006;7:315-21 2. Davis JD, Stone PA, McGarry JJ. Recurrent mycetoma of the foot. J Foot Ankle Surg. 1999;38:55-6

PH06A Bilateral Hypoplastic Flexor Pollicis Longus Diagnosed As Congenital Locked Trigger Thumb

Allaudeen, MA; Sapuan J; Abdullah S Department of Orthopaedic and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latiff, 56000 Cheras, Kuala Lumpur, Malaysia

INTRODUCTION: The human thumb is opposable and prehensile. The thenar muscles are responsible for complex movements of the thumb. Congenital anomaly of the thumb and/or the thenar muscles can be quite disabling1. Most of the articles documented a unilateral absence of FPL tendon2,3; bilateral absence is extremely rare as exemplified in this case. Figure 3. Intraoperative findings showing Keywords: congenital anomaly of the thumb, ‘thin-out’ (hypoplastic) FPL tendon (arrow) hypoplastic flexor pollicis longus tendon with absence of A1 pulley.

CASE REPORT: An 8-year-old Malay girl DISCUSSION: Thumb hypoplasia represents with underlying global developmental delay a spectrum of deficiencies from slight was brought by her parents who noticed that hypoplasia to a completely absent thumb. she kept both of her thumbs constantly straight Most cases are reported in the pediatric age whilst playing on mobile devices. Clinically, group. Isolated minor hypoplasia (Blauth type there was absence of skin creases over the 1) can manifest as only an absent FPL. In our interphalangeal joint (IPJ) of both thumb case, we have an attenuated FPL with an (Figure 1(A)). She was unable to perform absent A1 pulley. An absent FPL tendon active flexion at the IPJ but able to achieve 0- o without other associated anomalies of the 90 passively. She picked up objects using a thumb is the rarest variation1. FPL anomaly is lateral grip (Figure 1(B)). an important differential diagnosis in a patient who is unable to flex the IPJ of the thumb. Clinically, the affected thumb shows absent or less evident dorsal wrinkles and flexion creases with loss of normal thumb function1,2,3. Surgical reconstruction with FDS tendon of ring finger transferred to the thumb is an option. Nevertheless, post-operative physiotherapy is difficult in children and the AB results are unlikely to be satisfactory1,3. Figure 1. Clinical pictures (A) showing absence of interphalangeal creases of the CONCLUSION: Paediatric patients who thumb and (B) the patient using her lateral unable to flex the IPJ of the thumb should pincer grip to pick up small objects (coin). have a differential diagnosis of an absent/ hypoplastic FPL tendon. Ultrasound reported both FPL as attenuated. Her parents consented for exploration of both REFERENCES: thumbs. Intraoperatively, there was hypoplasia 1. Demirseren ME, Afandiyev K, Durgan M, of the flexor pollicis longus tendon (Figure 3) Kilicarslan K, Yorubulut M. Congenital and an absent A1 pulley. We did not proceed absence of flexor pollicis longus tendon to operate the other thumb. Parents are not without associated anomalies of thumb keen for reconstruction of the thumb as the hypoplasia; a case report and review of the patient has adapted to the condition well. literature. Hand. 2007;2: 184–7. ABSTRACT TRUNCATED PH06B Non-Specific Rice Body Formation In Tenosynovitis Of The Hand – A Mystery

A Ithnain; S Abdullah; J Sapuan Department of Orthopaedic, Faculty of Medicine, University Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Wilayah Persekutuan Kuala Lumpur, Malaysia

INTRODUCTION: of the hand2 and tibialis anterior tendon5. Rice Inflammatory diseases such as rheumatoid body are free particles that have a cartilage- arthritis and tuberculosis are among the most like shiny appearance and are of synovial common conditions that can produce rice origin. No concencus have been made bodies1. Resembling rice, the lesion was first regarding the aetiology and it is believe to described in 1895 by Riese and called as ‘rice develop from a non specific response to body’3. In tuberculosis-endemic countries, rice synovial inflammation. body tenosynovitis is almost always related to Clinical judgement with additional medical tuberculosis until proven otherwise2. background provides useful information on the investigation plan and definitive treatment. METHODS: Ultrasonographic evaluation is very useful to We report a rare case of non specific rice body determine the nature of the mass B and can tenosynovitis in the left hand of a healthy 66 detect foci of echoic lesion that represent rice year old gentleman. He presented with a body. painless swelling over the dorsum of his left Malaysia is a country endemic for hand for 6 months and was increasing in size. Tuberculosis and we suspected TB from the There was no history of trauma, tuberculosis history and the numerous rice body seen contact or any systemic inflammatory event during surgery. We were surprised when both such as rheumatoid or gouty attack to the PCR TB and culture (Zeihl-Nielsen) were hand. negative. Physical examination revealed a soft mass over the dorsum of left hand measuring 5cm x A B 5cm and non tender. Flexion of the fingers produced a slight movement. Plain radiograph of the hand as well as the chest are normal. An ultrasound reported suppurative granulomatous inflammation. Rheumatoid, tuberculosis and infective markers were unremarkable. Intraoperatively there was a A: The mass over the dorsum of the left hand mass overlying the common extensor tendon B: Numerous rice body around the mass and at the level of zone VI. It was dark red in color fluid from the ruptured mass and contains clear fluid. There were numerous rice bodies around and inside the mass. The CONCLUSION: mass was completely removed and the wound The occurrence of non specific tenosynovitis was closed primarily. No growth was found is under reported. Good clinical evaluation from the culture of the mass includeing no with supportive laboratory and radiological acid fast bacilli, fungal or any organism. It was assessment is important to provide safe negative for malignancy. TB PCR was also treatment for non specific tenosynovitis. negative. REFERENCES:

RESULTS: 1. Teo S C, George J, Kamarul T. Tubercular Patient was discharged well and further Synovitis Mimicking Rheumatoid evaluation in clinic noted no recurrence. Nodules. Med J Malaysia 2008 June:Vol 63:159-161

DISCUSSION: 2. Seung E H, Ji-Hyun P, Hyun S S, So-Ra A few cases have been reported as non K, Bo Y P. Rice Body Tenosynovitis specific tenosynovitis with rice body of flexor without Tuberculosis Infection after ABSTRACT TRUNCATED PH06C Painful ‘Ingrown Nail’ That Is Not Responding to Treatment

TMFairuz TI; Azfan C.Y.; Kamil MK; Suzanah K Department of Orthopaedic Surgery, Hospital Sultanah Nur Zahirah, Kuala Terengganu.

Introduction: defect filled in with bone graft (Granumas size Glomus tumours are benign hamartoma derived 0.1mm-0.2mm). Nail bed graft sutured tightly from normal Glomus body. It accounts for 1- to prevent bone graft migration. 5% of tumour in hand and commonly occurring at subungual tissues, typically presenting as Histology finding: triad of severe pain, point tenderness and cold Section show tissue lined by stratified insensitivity (1, 2). Diagnosing it remains a squamous epithelium. There is a nodular challenge. We describe a patient with a long proliferation of uniform, round cells with oval history of undiagnosed glomus tumour, falsely nuclei and pale cytoplasm. Some of them labeled as ingrown nail. As the size of tumour surrounded the blood vessels. No increase in was big, and had been around long enough to mitotic activity. No nuclear atypia or evidence cause pressure effect on the surrounding of malignancy (Impression: Glomus tumour). phalanx, we report our surgical approach and treatment decision for this patient. Post-Operative Patient reported symptom relief after operation. Case report: At 3 weeks follow–up, patient expressed her A 32-year-old female patient presented to satisfaction with the treatment. Patient was Orthopaedic HSNZ with 4 years history of planned for further follow-up to look for swelling under the nail of right middle finger. symptom recurrence and nail deformity at The swelling did not increase in size but started operative and donor site. becoming more painful for the last 2 years. She described the pain as throbbing in nature which Discussion was precipitated by cold weather and contact This benign condition is difficult to diagnose. with cold water. The pain had since limited her Hence, awareness of this medical problem is activity of daily living. Upon examination essential to reach early diagnosis and patient was noted to have bluish coloured prevention of repeated wrong diagnosis which subungual growth over her right middle finger. can lead to patient frustration. A classical Patient was also noted to have pin point history of severe pain, point tenderness and tenderness to palpation. X-ray showed cold insensitivity should raise a suspicion of scalloping of distal phalanx of right middle glomus tumour and referral for expert opinion finger. Differential diagnosis of glomus tumour should be made at the earliest possible time. was made, and patient was planned for excision Transungual approach had been described by biopsy. Prior to this presentation, patient has Jawalkar et al (1), to provide good access to the sought treatment at three different nearby entire lesion and facilitates complete excision. General Practices and was wrongly diagnosed Recurrence of symptoms is usually due to as ingrown nail and had the nail avulsed each incomplete excision of the lesion rather than visit. The symptoms however persisted. true recurrence of the tumour (1). Significant nail bed loss from the excision of this tumour Intraoperative finding: can result in nail growth disturbance which in Subungual growth over the radial side of the turn can give rise to an irregular, hooked or nail of right middle finger measuring 0.8cm x thickened nail (3). Partial thickness nail bed 0.8cm x 0.5cm. Nail of the right middle finger grafting has been described to have success rate was avulsed. Transungual approach was chosen of preventing this and reported to have no to excise the tumour (1). Cystic and untoward effect to the donor site (4) and was multinodular swelling excised until normal therefore chosen for this case as the treatment tissue seen. Noted scalloping of bone. Partial of choice. thickness nail bed graft was taken from right big toe as the nail bed defect was big. Bone References: ABSTRACT TRUNCATED 33 PL01A A Multicentre Study: The Outcome Of Femoral Reconstruction Using Ilizarof External Fixator

1Mustapa Nadia; 1Ganaisan, P; 1Manickam, T; 2Towil, MB; 1Vincent, J; 1Danappal, S 1Department of Orthopaedic Surgery, Hospital Tengku Ampuan Rahimah, Jalan Langat, 41200, Klang, Selangor, Malaysia. 2Department of Orthopaedic Surgery, Hospital Serdang, 43400, Serdang, Selangor, Malaysia.

INTRODUCTION: outcomes do not necessarily reflect the The techniques of Ilizarof reconstruction has functional outcomes. far developed and progressed since its humble As evident in this study, the bony outcome is beginnings. Despite the modification of constantly better than the functional outcome. techniques and improvement of instruments, the results yield has yet to resemble the field’s CONCLUSION: advancement. Overall the outcome for femoral reconstruction with IEF has been fairly METHODS: satisfactory. There are multiple modifiable and A retrospective analysis of 30 patients who non -modifiable factors that are affecting the underwent femoral reconstruction with Ilizarof outcome. External Fixator (IEF) at our centre (HTAR) from January 2013-December 2015 was REFERENCE: performed. The cases included infected and 1. Marsh JL et al. Supracondylar fracture of non- infected cases. The exclusion criteria femur treated by external fixation. J.Ort were ipsilateral lower limb neurovascular trauma 1997; 11:405-11 injury and patients who were less than 18 2. M.Arazi et al. Illizarov fixation for years of age. severely comminuted supracondylar fracture femur.J of Bone and Joint surgery The results were compared to the study that 2001: 66-667 was previously done in Hospital Serdang, Malaysia. The outcomes were measured using the External Fixation Index (EFI) and Association of Study and Application of Ilizarof (ASAMI) Classification. RESULTS: The mean EFI is 1.73. For the infected and non- infected cases, it was 1.91 and 1.53 respectively. Based on the ASAMI classification, 44% of patients had excellent outcome while the other 44% and 12% were good and fair respectively. The percentage differs in terms of function as only 12% had excellent outcome while 44% were good 38% were fair and 6% had a poor outcome. There were no failures documented.

DISCUSSION: This study of 2 centres has shown a similar result in terms of the outcome based on the ASAMI classification. A striking difference between the bony and functional outcome is seen in a particular patient. The bony PL01B Integra Bilayer Matrix Wound Dressing Closure Of Large Crushed Injury Wound Of Tibia

Izham K; Lau HY; M Thirumal Department of Orthopaedic Surgery, Hospital Tengku Ampuan Rahimah, Taman Chi Lung, Jalan Langat, 41200 Klang, Selangor, Malaysia

Introduction granulated.Subsequently, she underwent Traumatic crushed injuries to the tibia with Illizarof External fixator application on 5th of injury severity score of more than 7 will Octobre 2015 and Integra® Dermal usually end up with amputation. Due to Regeneration collagen application on the same combination of soft tissue, osseous, vascular date. and nerve involvement, this type of injury Figure 2. This normally requires prompt and precise decision picture shows after to salvage the limb (Huh, Stinner et al. 2011). application of Integra Patients that sustained this type of injury will Bilayer Matrix normally risk themselves having wound dressing complications such as infection, non-union, limb ischemia and chronic pain (Giannoudis, Harwood et al. 2009). While the goal is to The Integra dressing was removed after 3 salvage the limb, these injuries carry high weeks followed by split skin graft (SSG) morbidity and amputation rate. application.

Report Of A Case Results We reported a case of 27 years old Malay lady The patient had done remarkably well with the who was involved in a hit-and-run motor- reconstruction (Figure 3) . The skin texture vehicle accident while riding a motorbike on and compliance over the wound area was 7th of September 2015. She presented to the cosmetically good with no area of contractures casualty with grade 3 Hypovolemic Shock noted like normally seen in large wound and cerebral concussion. On Orthopaedic side, treated with split skin graft alone. she sustained severe open fracture right tibia Figure 3. Post and fibula with ankle dislocation which put application of split skin graft after removal of the her on injurity severity score of more than 7 Integra collagen which with high probability that the right lower limb shows good taking up of would be amputated. The crushed injury led to the graft with a large area of degloving injury to the skin cosmetically good texture together with an extensive area of severely without evidence of muscle contusion. contractured wound. Figure 1. Preoperative photograph showing Good cosmetic appearance together with severe crushed injury stable fixation of the tibia bone successfully wound extending the stave this patient off amputation as normally whole length of the required in this type of crushed injury. tibia with degloved skin overlying a severely Discussion contused muscle area. Integra Bilayer Matrix Wound Dressing is a The ankle was bilaminar membrane that acts as a scaffold for dislocated. cellular invasion and capillary growth. It is compose of a dermal-like layer ( cross-linked Because of the severity of the injury, she was bovine tendon collagen and subjected to multiple wound debridements and glycosaminoglycan) and an epidermal-like several applications of Vaccum Assisted layer ( synthetic polysiloxane polymer). After Closure until the wound was fully placement the dermal layer becomes ABSTRACT TRUNCATED PL01D Activity Of Daily Living For Patients With Lower Limb Reconstruction Using External Fixator

Zamri.Shazwani1, Abdul.Malik 2, Mohd.Suhaili 3, Aik.Saw4 Department of Rehabilitation Medicine, University Malaya Medical Centre, Jalan Universiti, 59100 Kuala Lumpur, Malaysia Department of Orthopaedic Surgery, NOCERAL University Malaya Medical Centre, Jalan Universiti, 59100 Kuala Lumpur, Malaysia

INTRODUCTION: them spend their time at home and do not Limb lengthening and reconstruction surgery involve themselves is social, recreational is a effective treatment option for severe limb activities. deformities irrespective of underlying pathology. It involved prolonged application REFERENCES: of external fixator frame and the correction 1. Martin, L., Farrell, M., Lambrenos, K., will be mostly performed at home. We & Nayagam, D. (2003). Living with the conduct this study to evaluate the activities of Ilizarov frame: Adolescent perceptions. J Adv daily living for a group of patients during their Nurs Journal of Advanced Nursing, 43(5), period of treatment. 483.

METHODS: We have designed a questionnaire to conduct this study based on pts’ activities daily living during period of their treatment. We included 31 patients (23 males / 8 females) with mean age of 44 (youngest – oldest) in this survey. About 40% of the patients had external fixator frame limited only to the tibia bone, while others have frames extending to ankle, knee and femur.

RESULTS: On clothing, most patients (19/61%) do not have problem wearing socks but (11/39%) will need minimal assistance. Some patients (6/19%) require minimal assistance for cleaning, drying and transferring when taking bath. For toileting, 5 patients need some assistance for transferring, and 3 need assistance for cleaning the perineum. For social activities, only 8 of them regularly going for meals in restaurants, and 6 would go to park or other public areas for recreation area. Only 2 went out for movie after application of frame. Most of them (23/74%) perform daily dressing change themselves, and none rely on clinic or hospital services.

CONCLUSION: Most of our patients were able to take care of themselves for ADL either independently or with minimal assistance. However, many of PL02A Quality Of Life Assessment Following Limb Deformity Correction Surgery

Zamri Shazwani1, Mohd Suhaili2, Abd Malik1, Aik Saw2 1Department of Rehabilitation Medicine, University Malaya Medical Centre, Jalan Universiti, 59100 Kuala Lumpur, Malaysia 2Limb Lenthening and Reconstruction Unit (LLRS), NOCERAL, Department of Orthopaedic Surgery, University Malaya Medical Centre, Jalan Universiti, 59100 Kuala Lumpur, Malaysia

INTRODUCTION: while for those above 16 years it was 73.8. The Lower limb deformity will not only affects the only significant difference was noted between the gait and posture of an individual, but will also two genders. Mean score for female patients was increase energy expenditure and cause premature 86.1, while for males it was 61.9. osteoarthritis of the major joints. With advance treatment like distraction osteogenesis, and new Figure 1: SF-36 mean score for 15 patients implants including fixed-angle plates, restoration comparison between etilogy group of length and alignment of the limb has been (Trauma/Infection) and possible. However, there are very few Congenital/Development)/Age/Gender publications reporting functional outcome of these patients. We conducted this study to SF-36 mean score evaluate the quality of life as treatment outcome for patients who have undergone limb deformity 100 correction surgery for various types of lower limb 50 age deformities. scores 0 type METHODS: Gender We studied 15 patients who had undergone lower category limb deformity correction (minimum follow up 1 year). Following general evaluation, patients DISCUSSIONS: were required to fill up validated short form-36 The mean scores of all patients were generally (SF-36) that consists of 36 items measures three good considering the severity of deformity during major parameters (functional status, well-being their presentation. For some of them the and overall health). SF-36 scores included treatment was considered as salvage procedure to Physical functioning (PF), Role Physical (RP), avoid limb amputation. Female patients have emotional role (ER), vitality (VT), mental health higher mean score compared to male patients. (MH), social functioning (SF), bodily pain (BP) With more patients, we may be able to provide and general health (GH). Scores ranges from 0 to more detailed analysis based on individual 100 where poorest state of health represent from pathology and methods of treatment. 0 and the best is 100.

CONCLUSION: RESULTS: Quality of life outcome were relatively good for Out of 15, 40% were Indians, 33% were Malays patients undergoing lower limb deformity and 27% were Chinese. There were 53% male correction surgery. The scores were not affected patients and 47% female patients, aged between by age and type of underlying pathology, but we 13-68 (mean age: 30.8). For underlying etiology, noted that female patients recorded higher score. 46.7% were trauma /infection while 53.3% are congenital / development. Mean scores for all patients were 72.5. Mean REFERENCES: 1. McKee MD et.al. JBone Joint Surg 1998; score for 8 categories are between 63-79. Mean 80(2):360-361 score for patients with trauma / infection problem was 71.2, while for those with congenital/ developmental problems was 73.9. Mean score for patients age 16 years or below was 63.5,

   4/ PO01A A Rare Case Of Primary Synovial Osteochondromatosis Of The Elbow: A Case Report

LL Loh; KA Wong Department of Orthopaedic and Traumatology, Hospital Seberang Jaya, 13700 Prai, Pulau Pinang, Malaysia

Abstract months history of pain, swelling, intermittent We report here a rare presentation of a primary locking and loss of range of motion of right synovial osteochondromatosis of the elbow. elbow. The right elbow had a fix flexion Clinical presentation and radiological findings deformity of 15° and had a range of motion of were suggestive of synovial 150 - 100o. However, pronation and supination osteochondromatosis. Arthroscopic were complete; crepitus was appreciated synovectomy, debridement, excisional biopsy throughout elbow motion and upon superficial and loose body removal was performed and and deep palpation. (fig. 1, 2 and 3 ) Other histopathological examination of the tissue joints were normal. A plain radiographic sample is consistent with the diagnosis of diagnosis and computerized tomography were synovial osteochondromatosis. This article made. (fig. 4 and 5) highlights the method of operation choosen for Fig 1, Patient’s the removal of synovial osteochondromatosis right elbow in for better outcome and prognosis. extended position (anterior view) Key word: Synovial osteochondromatosis

Fig 2, Patient’s Introduction right elbow lateral Primary Synovial osteochondromatosis is an view unusual, rare, benign, chronic, and progressive metaplasia associated with the formation of cartilage in the synovial membranes of joints1- Fig 3, Patient’s 3, tendon sheaths or bursae4. The cartilaginous right elbow tissue undergoes calcification and ossification lateral view (The producing multiple osteochondral nodules. The right elbow cause of the metaplasia is still unknown. The lacked 45° of full disease is characteristically monoarticular, flexion) most commonly involving the knee5.

A site in the elbow was first reported in 1918 by Henderson6, but any joint may be involved. Despite frequent mention of elbow involvement in various texts and articles, the most comprehensive documentation of synovial osteochondromatosis was published almost 25 years ago. We wish to review the clinical, radiologic and surgical treatment in a rare case of synovial osteochondromatosis of the elbow. Fig 4, Plain radiographs of right elbow shows

numerous radiopaque round and oval loose Case Report bodies within the right elbow joints. Note the Mr M, a 49 Indian male with underlying large loose body within the coronoid fossa hypertension, hypercholesterolaemia, had a 6 region. ABSTRACT TRUNCATED PO01C A Rare Occurrence Of Cholesterol Granuloma Over Humerus Mimicking Malignant Bone Tumor

Chan Han Zhe; Salim Al-busaidi; Azura Mansor; Vivek Ajit Singh Orthopedic Surgery Department, Faculty of Medicine, University of Malaya 50603 Kuala Lumpur, Malaysia . INTRODUCTION: pathology such as myositis ossificans or Cholesterol granuloma is a benign tumor-like osteosarcoma. When features of cholesterol lesion that forms in response to foreign-body. granuloma or myositis ossificans are suspected It affects the middle ear, skull, facial skeleton, on imaging, short-term follow up is preferable and jaw and only very few literature reviews and biopsy is required to confirm the describe its occurrence in other parts of body diagnosis. (1). REFERENCES: CASE PRESENTATION: 1. Luckraz H, Coulston J, Azzu A. Cholesterol We present a case of 16 years old boy, granuloma of the superior mediastinum. Ann presented with 6 months post-traumatic left Thorac Surg 2006;81:1509–10. mid-shaft humerus painless (5 x3cm) hard swelling with no significant related history and 2.Kransdorf M, Meis J. Extraskeletal Osseous clinical findings. and Cartilaginous Tumors of the Extremities. Radiographics 1993; 13: 853-884. The plain x-ray revealed a well-circumscribed bony mass overlying anterolateral aspect of mid-shaft humerus with incomplete peripheral rim of calcification with suspicious of periosteal reaction. The radiological diagnosis of paraosteal osteosarcoma was made and needle biopsy carried on.

Histopathological analysis report was consistent with the features of cholesterol granuloma and no malignant cells were detected. The patient was started on non- steroidal anti-inflammatory drug and currently under clinic follow up with serial plain radiography monitoring.

DISCUSSION In view of cholesterol granuloma is extremely rare condition that occur at distal extremities, a bony hard mass with calcification differential diagnosis ought to include benign and malignant etiologies, such as myositis ossificans and parosteal osteosarcoma. Indeed, these entities have overlapping clinical and magnetic resonance imaging findings (2).

CONCLUSION: Cholesterol granuloma is rarely described affecting the peripheral extremities and most of the time; it radiologically resembles other PO01D Two Scapular Tumor Cases Managed With Scapulectomy And Humeral Suspension Reconstruction

Wan Khong Lee; Salim Al-busaidi; Azura Mansor; Vivek Ajit Singh Orthopedic Department, University of Malaya, 50603 Kuala Lumpur, Malaysia.

INTRODUCTION: shoulder function, the remaining elbow, wrist Scapula is third common site in for upper limb and hand function is adequate for their musculoskeletal tumors. The reconstructions activities of daily living supported by normal options vary from humeral suspension, contralateral upper limb. recycled tumor bone autograft, allograft and endoprothesis(1). REFERENCES: 1. Bickels, J., Wittig, J. C., Kollender, Y., CASE PRESENTATION: Kellar-Graney, K., Meller, I., & Malawer, M. We present 2 cases of scapula sarcomas M. (2002). Limb-sparing resections of the managed by humeral suspension as a shoulder girdle. J Am Coll Surg, 194(4), 422- reconstruction with total scapulectomy using 435. cerclage wire. First, is 38 years old male diagnosed as (MPNST) of left scapula and 2. Nakamura, S., Kusuzaki, K., Murata, H., managed by wide resection and left subtotal Takeshita, H., Hirata, M., Hashiguchi, S., & scapulectomy with the remaining acromion Hirasawa, Y. (1999). Clinical outcome of total was tagged to the resected proximal third scapulectomy in 10 patients with primary humerus using circlage wire. malignant bone and soft-tissue tumors. J Surg Second, is 18 years old male diagnosed as Oncol, 72(3), 130-135. osteosarcoma of right scapula managed by wide resection and right total sacpulectomy with the resected distal end clavicle was attached to the resected proximal humerus using cerclage wire. In both cases, the deltoid muscle was preserved. Post operatively, both required arm sling and shoulder ROM was limited to abduction and flexion. Their MSTS score was 40%. Their elbow, wrist and hand functions remained full.

DISCUSSION: All classification systems demonstrated that the shoulder had better function with more preservation of gleno-acromio-humeral complex structures. However, that intention may not be possible in all cases as a clear margin of resection remains to be the utmost priority for long term survival outcome. Humeral suspension was a simple technique of connecting the remaining humerus to clavicle or ribs with a range of materials from tendon grafts to prolene mesh(2).

CONCLUSION: Humeral suspension using cerclage wire is a simple and inexpensive reconstruction option for scapula tumor resection. Despite loss of PO02A Pathological Fracture Of Proximal Femur In Peadiatric Age Group, A Variant Presentation Of Bone Cyst

Ganapathy,Sharveen; Nanchappan Selvanathan; Haryati Binti M Yusof Department of Orthopaedic & Traumatology, Hospital Sultanah Bahiyah, Km 6, Jln Langgar, 05460 Alor Setar, Kedah Darul Aman, Malaysia.

INTRODUCTION: Unicameral or simple bone cyst(UBC) are relatively common condition. 85 percent are involved during the first two decades of life. Most common sites are the proximal femur and humerus. The cause of this condition remains unknown, however the widely accepted pathogenesis would be that a focal Figure 1: Left sided proximal femoral, well defect in metaphyseal remodeling blocks the defined lytic lesions sparing the growth plate interstitial fluid drainage. This leads to with subtrochanteric fracture. increased pressure, which leads to focal bone necrosis and accumulation of fluid. They can grow large enough to weaken bone and cause fracture.

METHODS: 7 year old boy had a trivial fall and sustained closed suntrochanteric fracture over left femur. Figure 2: 8 months post op Based on history, examination, and investigations, a diagnosis of pathological DISCUSSIONS: fracture of subtrochanteric region of left femur Treatment of UBC depends upon the site that secondary to possible UBC with a differential is affected. Most of the time upper extremities diagnosis of Aneurymal Bone Cyst(ABC) was are treated conservatively without surgical made. Patient was planned for bone curettage, intervention. Only when there is a fracture and synthetic bone grafting (NORAIN) and involving lower extremities, commonly used proximal femur locking plate of left femur technique were curettage, bone grafting and with bone biopsy. Both parents consented and internal fixation. he was placed on a skin traction until the surgery was done. CONCLUSION: Lower extremity UBC which present as RESULTS: pathological fracture, have good outcome with Intraoperative, neither fluid nor hematoma was curettage , bone grafting and internal fixation. identified, except necrotic tissue. Post operatively was uneventful, he was advised REFERENCES: not for weight bearing for at least 2 months. 1. Canale ST, Campbell WC. Campbell’s In the 3rd month he was completely weight Operative Orthopaedics.9th ed. St. Louis: bearing, Histopathological report revealed Mosby; 1998 network of osteoid, woven bone, cartilage and 2. Simple bone cyst treated with percutaneous granulation tissue with osteoblast and autologos bone grafting by F. Lokie et al, osteoclast and there is no evidence of ©1996 British Editorial Society of Bone and neoplasia. Joint Surgery

PO03A How Unlucky Can You Be? A Case Report: Spinal Metastases To The Posterior Element Of Vertebra In Double Malignancies

Zakhiri MR, Dzulkarnain A, Manmohan S, JH Goh, ZA Norazlin, Fazir M Jabatan Ortopedik dan Traumatologi, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia

ABSTRACT However, metastases typically involve the The occurrence of another malignancy in a vertebra body and predominantly posterior patient with a known malignant tumour is element lesion is rare1. In case of pain and known as double malignancy. It is rare and can neurology caused by spinal instability, surgery be missed as disease progression or is more effective than other methods1. recurrence. Spinal metastasis is common in patients with malignancy, the third most common site following lung and liver. Metastases usually involve vertebra body first and a small sized lesion can be identified only when osteolysis progresses to 30-50%1. Identifying primary tumours is very important in determining the management of spinal metastases.

CASE REPORT We report a case of a 63-year-old lady with history of treated lymphoma 10 years ago, presenting with back pain with incomplete neurology. MRI suggested a mass at the posterior element of T11 with spinal cord compression. CECT thoracic-abdomen-pelvis noted lesions on left lung, left pleura, left 5th rib and T11 with multinodular goitre. Pleural Figure 1 showing T11 posterior element lesion biopsy reported as metastatic follicular thyroid with spinal cord compression. carcinoma. Laminectomy of T11 with posterior spinal instrumentation was done. REFERENCES Intra-operatively, 4X3cm mass was noted 1. Metastatic Spinal Tumor ;Chong-Suh Lee, over posterior element of T11 spine et al. ; Asian Spine J. Mar 2012; 6(1): 71–87. encroaching the spinal cord and causing 2. What is the lifetime risk of developing stenosis.. cancer?: The effect of adjusting for multiple primaries; Sasieni PD, et al.; Br J Cancer, DISCUSSIONS AND CONCLUSION 2011. 105(3): p. 460-5. Double malignancy can be divided into synchronous and metachronous malignancies. The incidence has increased in recent years possibly secondary to improve survival in cancer patients2. Around 5% of people can get two or more primary diagnoses of cancer2. However, double malignancies involving different organs is rare and the etiology is not clear. Patients with malignancy may presented with spinal metastases as the initial presentation. PO03B Radiofrequency Ablation: A Safe, Effective And Minimally Invasive Method For The Treatment Of Osteoid Osteomas In Children- A Case Report And Review Of The Literature

Randhawa SS, Mansor A, Singh VA Department of Orthopaedic Surgery, University of Malaya, Jalan Universiti, 50603 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia

Introduction Discussion Osteoid osteoma is a benign bone forming The natural history of osteoid osteoma is such tumour with an incidence of 10% of benign that left untreated, it eventually becomes neoplasms of bone. Pain is usually the only asymptomatic and do not undergo malignant symptom that patients present with and is change. Treatment options for oeteoid described as intermittent initially, only later to osteomas include conservative, surgical and become more constant and typically worse at percutaneous techniques. The morbidity night relieved effectively with nonsteroidal related to open surgery especially in the anti- inflammatory drugs (NSAIDs). paediatric age group has made radiofrequency Treatment of this tumour is aimed at the ablation (RFA) a most desirable alternative. removal of the nidus either by the traditional Having similar success rates to open surgery, surgical manner or less invasive methods such it is therefore the treatment of choice as it is a as radiofrequency ablation (RFA). The use of minimally invasive procedure with limited RFA for osteoid osteoma was first reported in morbidity. In this child, the site of the osteoid 1992 and has since been widely reported in the osteoma was at the proximal tibia metaphysis adult population. However there are scant which was adjacent to his epiphyses; hence reports of its use in the pediatric age group. treatment with RFA was the most suitable option. Its advantages are rapid pain relief Case Report seen as soon as 2-3 days after the procedure, An eight year old boy was referred to the short hospital stay, quicker return to school orthopaedic oncology unit here at University and normal activities, and minimal trauma to Malaya Medical Center with a 1 year history surrounding bone and muscle with no of left knee pain and swelling. His pain was significant structural weakness. typically worse at night and he had been limping for 6 months prior to presentation. On examination he was ambulatory with an antalgic gait and mild tenderness at the posterior aspect of his left leg situated slightly distal to his popliteal fossa. Plain radiographs revealed a rim of sclerotic bone surrounding a radiolucent nidus measuring about 1.5cm at Figures 1 and 2: AP view of proximal tibia the metaphyseal region of the proximal tibia. (left) and lateral view (right). Subsequent MRI of the left knee and tibia Conclusion showed a 1.1cm enhancing lesion thus This case report highlights the superiority of confirming our diagnosis of an osteoid RFA for the treatment of osteoid osteoma in osteoma. He then underwent radio frequency paediatric patients in that it is safe, precise, ablation under general anaesthesia. Post and highly effective with significant ablation there were no complications advantages over surgical excision. encountered and the patient was discharged References the following day with full weight bearing 1.Carnesale, P.G., Benign tumours of bone. permitted. Histopathological examination Campbell's operative orthopaedics. Mosby, confirmed the diagnosis of osteoid osteoma. Philedelphia. 18. At 6 weeks follow up, his symptoms had completely resolved and he was pain free.

ABSTRACT TRUNCATED PO03C An Unusual Cause Of A Soft Tissue Tumour. Churg-Strauss Syndrome Revisited.

1Lim CY; 1Narhari P; 1Duski S; 2Jamny Mahmood M; 3Mohd Dusa N; 1Chye PC 1Department of Orthopaedic Surgery, Kuala Lumpur Hospital, Jalan Pahang, 50586 Kuala Lumpur, Malaysia, 2Department of Radiology, Kuala Lumpur Hospital, Jalan Pahang, 50586 Kuala Lumpur, Malaysia, 3Department of Pathology, Kuala Lumpur Hospital, Jalan Pahang, 50586 Kuala Lumpur, Malaysia.

INTRODUCTION: Churg-Strauss Syndrome (CSS) is a very rare disease characterised by asthma, hypereosinophilia, fever, and vasculitis of various organ systems. It is even rarer for the patient to present with a tumour mass. Asthma is one of the cardinal features of CSS and may begin long before the onset of vasculitis. This is followed by marked eosinophilia in the blood or in tissues. The third phase of the illness is vasculitis, which involves the skin, lungs, nerves, kidneys, and other organ systems. We report a case of CSS in a 37-year-old gentleman, who presented to us with left upper back swelling and chronic fatigue. At presentation, he was on dialysis due to kidney failure and was on anti-tubercular drugs for “bilateral tuberculosis of the lungs” a diagnosis made by the previous treating hospital based on his diffused chest X-rays changes mimicking tuberculosis and chronic respiratory symptoms. MRI of the upper back swelling revealed a well defined heterogeneous lobulated mass which was reported histologically as eosinophilic inflammatory process. Biopsy of the lungs and a haematology review confirmed our diagnosis. He was stopped from taking the anti-tubercular drugs and started on prednisolone. He had a dramatic relief from all his chronic fatigue and respiratory symptoms.

CONCLUSION: This case is highlighted to share our experience so that all of us as treating orthopaedic surgeons are vigilant about various manifestations of CSS, in addition to the other common differential diagnoses of soft tissue tumour when patient presented with trunk swelling.

PO03D Brown Versus White. Tales Of Two Fatty Tumours.

1Lim CY; 1Narhari P; 1Duski S; 2Jamny Mahmood M; 3Mohd Dusa N; 1Chye PC 1Department of Orthopaedic Surgery, Kuala Lumpur Hospital, Jalan Pahang, 50586 Kuala Lumpur, Malaysia, 2Department of Radiology, Kuala Lumpur Hospital, Jalan Pahang, 50586 Kuala Lumpur, Malaysia, 3Department of Pathology, Kuala Lumpur Hospital, Jalan Pahang, 50586 Kuala Lumpur, Malaysia.

INTRODUCTION: Lipomatous tumours such as lipomas, atypical lipomas and liposarcomas are familiar diseases to most surgeons and clinicians. Lipomatous tumours of fetal fat origins, such as lipoblastomas and hibernomas, however, are very rare and many are not aware of their existence.

Lipoblastoma is a benign lipomatous tumour of fetal white fat origin, and occurs in the paediatric age group, while hibernoma is a benign lipomatous tumour of fetal brown fat origin, and occurs mainly in adult patients, each with different cytogenetic changes.

We present a short series of these cases focusing on epidemiological presentations and histopathological differences. PO04A An Uncommon Presentation Of A Common Tumour: A Rare Case Report

Yong-Jia Tan; KS Yap; Vicknesh A; Manoharan K Department of Orthopedic, Hospital Raja Permaisuri Bainun, Jalan Hospital, 30900 Ipoh, Perak Darul Ridzuan.

INTRODUCTION: Post- operative course was uneventful. Lipomas are the most common soft tissue tumour of adulthood1 which account for approximately 16% of soft tissue mesenchymal tumours3. Histologically, lipomas are nearly indifferent from normal adipose tissue. They are derived from mesenchymal preadipocytes1. They are usually surrounded by thin, fibrous capsule which may Fig.1 MRI image showed huge lipoma allow the mass to be shelled-out in toto. The displaces the hypothenar muscles medially location of lipoma varies and they are uncommon in hand and those which involve the fingers are very rare, with reported incidence of 1%3. Here, we are presenting an unusual case of giant palmar lipoma at left hypothenar space of a 45 years old gentleman.

CASE REPORT:

A 45 year-old male presented with swelling at Fig. 2 Elliptical incision made over hypothenar the palmar aspect of his left hand for the past eminence 10 years. The swelling has progressively increases in size to approximately 7cm x 5cm. DISCUSSIONS: He denied history of trauma, family history of Hypothenar space is a small enclosed space malignancy and constitutional symptoms. He which contains hypothenar muscles. Huge complained of occasional throbbing pain at the mass in this area may endanger the swelling. However, no weaknesses or surrounding structures including the palmar numbness felt over his fingers. arch and ulnar nerve which fortunately did not On examination, a 7cm x 5cm swelling was happen in this case. In Leffert’s series of 141 noted over the left hypothenar area (Fig. 2). lipomas of the upper extremity, 6 were On palpation, the swelling has a smooth reported to have parasthesia secondary to surface and a well-defined margin, non-tender, nerve compression1. Lipoma in the hand not erythematous and it doesn’t typically presents as painless swelling and transilluminate. Further examination showed usually attains a large size by the time patient no neurovascular deficits. seeks medical attention. MRI is highly MRI of his left hand showed a mass measuring sensitive and specific tool in diagnosing 3.4cm (AP) x 4.8cm (Width) x 4.3cm (Ht) lipoma. It can be used to detect early (Fig. 1). It is situated in between the palmar presentation of lipoma at the hand. fascia and hypothenar muscles and it displaces the fibers of hypothenar muscles medially. REFERENCES: Intra-operatively, the mass is removed en-bloc. 1. Menaka M. Nadar, BSJ Journal of Plastic Gross measurement of the excised mass Surgery Vol 10, 2010; 549-556 revealed a 5cm x 4cm x 3cm tumour which 2. Brian Allen MD, Can J Plastic Surgery Vol has a smooth and lobulated surface. It weighed 15, No 3 Autumn 2007; 141-144 34g. Histopathological examination showed a 3. Hemlata T. Kamra. Journal of Clinical and well-circumscribed lesion composed of mature Diagnostic Research. 2013 Aug, Vol-7(8): adipocytes arranged in lobules and no 1706-1707 evidence of malignancy. PO04C Tale Of A Late Presentation Of Malignant Peripheral Nerve Sheath Tumour : A Case Report

Lee KW, Yasser AK, N Shakirah AH Department of Orthopaedics, Hospital Duchess of Kent, KM3.2 Jalan Utara, 90000 Sandakan, Sabah

INTRODUCTION: Malignant Peripheral Nerve Sheath Tumour neurofibromatosis type 1 (NF-1) for the 20-40 (MPNST) is also known as "malignant age group 2. Our patient presented to us with schwannoma, neurofibrosarcoma and features suggestive of Neurofibromatosis 1, neurosarcoma 1 . It arises from a peripheral correlating with the common age group for nerve or neurofibroma 2. Neurosarcoma associated with NF1. A 5-year survival rate for lesion associated with NF 1 is CASE REPORT: 30% while solitary lesion is 75%. Our patient 26 year-old Filipino gentleman presented to came to us during the 3rd year of presentation. us with a progressively enlarging mass over The late presentation coupled with the fact that the right forearm since 3 years ago. It started it is associated with NF1 greatly increased the as a swelling at the proximal forearm , mortality rate of the patient and unfortunately, progressively increasing in size especially in he passed away within a month of presentation. the last few months . He did not seek any The patient presented late mainly due to medical attention earlier due to poverty. Upon financial reason, and also initially it was examination, noted there were multiple skin almost asymptomatic apart from a lesions on the face and body suggestive of progressively enlarging forearm. The neurofibromatosis. The whole forearm was symptoms are usually secondary to local grossly swollen with a fungating mass pressure3 that manifest itself at the later stage measuring 4x4x4cm. Transhumeral of the disease when it became too big for amputation was subsequently performed and comfort. Management mainly is wide surgical the patient was discharged . Patient defaulted resection coupled with radiation therapy2. subsequent follow-ups and passed away at Chemotherapy has not shown to be beneficial home a month after presenting to us. according to Zehou et al4. The appropriate management of this patient especially if he presented earlier would have been wide surgical resection and radiation therapy. The amputation done at that time did however improve his quality of life of patient as the heavy, immobile, foul smelling lesion was removed. Sadly, it was a little too late.

CONCLUSION: Our patient’s neurosarcoma was associated with Neurofibromatosis. The 5-year survival rate was low at 30%. This coupled with poverty indirectly forced him to present late to Figure 1: Right forearm of patient on us, further increasing the mortality rate for presentation prior to amputation him.

DISCUSSIONS: REFERENCES: Malignant Peripheral Nerve Sheath Tumour 1. Rapini, Ronald P.; Bolognia, Jean L.; (MPNST) or neurosarcoma usually present as Jorizzo, Joseph L. (2007). Dermatology: 2- solitary neurofibromas among the 30 to 55 Volume Set. St. Louis: Mosby. ISBN 1-4160- age group and associated with 2999-0.

ABSTRACT TRUNCATED PO04D Management Of Seroma Using Stoma Bag

Ngim HLJ; Singh VA Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia.

INTRODUCTION: seroma resolved and the incision wound Seroma is a common post-operative healed well after 3 weeks. complication especially after tumor resection or lymphadenectomy. The incidence of seroma CASE 3: has been reported to up to 56.8% in cases of A 75 year old man with right plantar melanoma undergoing inguinal malignant melanoma with metastasis to the lymphadenectomy [1]. Management options ipsilateral inguinal lymph nodes for the past 3 for established seroma include simple months, underwent wide resection of right observation, aspiration, suction drainage and plantar and ipsilateral inguinal lymph nodes sclerotherapy using fibrin glue [2]. with split skin graft of the right plantar. Occasionally, a seroma may persists or recurs Vacuum assisted dressing was done over the despite successive drainages, causing increase plantar split skin graft wound for 5 days, prior morbidity and lengthy hospital stay thus to discharge home after the skin graft showed impairing the patient’s quality of life. We signs of taken. 1 month post-surgery, he suggest that stoma bag can be used to manage presented serous discharging wound over the patient with persistent draining seroma in the right inguinal region. A stoma bag was applied community. over his inguinal and he was discharged home.

CASE 1: DISCUSSIONS: A 65 year old lady with right thigh epidermal Current treatment for seroma include multiple inclusion cyst for the past 20 years underwent aspiration, inpatient drainage and surgical excision biopsy. The mass removed was 10 x resection of seroma [2]. These methods have 6 x 3cm, located at the subcutaneous level their risk which include infection and over the lateral aspect of the right thigh. She prolonged hospital stay. Usage of stoma bag was complicated with post-operative seroma 1 can be an option to treat seroma in the month post-excision. An incision and drainage community. Under aseptic technique, a 1cm was done but she continued to have persistent incision is made over the seroma under local draining of serous, which quickly soaked up anesthesia. The seroma is drained as much as her dressing, thus leading to multiple changing possible. A stoma bag is cut according to the of the dressing. A stoma bag was placed over incision and placed on the patient so that the the incision and drainage wound to enable serous discharged can be collected into the collection of the discharging serous, so that bag. Patients will be given advice on stoma she can be discharged home. The wound bag and wound care prior to discharge. This healed well after the seroma resolved. method enables patients to be treated without prolonged admissions and would not affect the CASE 2: patient’s ambulation mobility. A 54 year old gentleman presented with right thigh liposarcoma for the past 20 years, REFERENCES: underwent a wide resection. The swelling 1. Kretschmer, L., et al., Postoperative measured 16 x 11 x 9cm in size, located at the morbidity of lymph node excision for lateral aspect of the proximal part of right cutaneous melanoma-sentinel thigh. 3 weeks post-operatively, he presented lymphonodectomy versus complete regional with a seroma which was treated initially with lymph node dissection. Melanoma Res, 2008. aspiration. The seroma recurred at 5 weeks 18(1): p. 16-21. post-resection. A stoma bag was applied after 2. Kapila S, R.W., Behan FC, Management of a 1 cm incision was made over the seroma. He seroma drainage in the community: a further was also treated as an outpatient basis. The ABSTRACT TRUNCATED PO05A Recurrent Desmoid Fibromatosis Of The Neck

Selvanathan Nanchappan; Yazid Kassim; Nor Hazla Mohamed Haflah. Department of Orthopaedics and Traumatology, Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Wilayah Persekutuan Kuala Lumpur, Malaysia

Introduction Desmoid fibromatosis is a rare, non- The recurrence is due to tumor itself being malignant, locally aggressive connective tissue adhered tenaciously to vital structures and tumor with a high recurrence rate (20 to 70%). There are various modalities of treatment surgeons are unable to get wide marginal including surgical resection, radiotherapy, resection.1Nuyttens et al in their study of 780 chemotherapy and hormonal therapy, patients found that radiotherapy alone or however, literature lacks level I evidence in surgery and radiotherapy resulted in better the form of randomized controlled trials to local control compared to surgery only compare the relative efficacy various surgical intervention. Combinations of treatment modalities. hormonal and anti-inflammatory therapy such as high dose tamoxifen and sulindac or Keywords - desmoid tumors, radiotherapy. indomethacin are other alternatives. Patients whom are able to tolerate chemotherapy can Case report be managed by using low-dose methotrexate A 61-years old lady presented with an 18- and vinorelbine for up to a year. Optimal months history of a slowly progressive right regime remains unclear, however patients neck swelling. The lesion was multinodular, appears to have faster response especially with firm and associated with weakness and the regimes, containing doxorubicin.3 numbness over the right upper limb. Biopsy confirmed the diagnosis of desmoid Conclusion fibromatosis and wide marginal resection was Wide surgical resection with adjuvant performed (Figure 1). The lesion recurred 10 radiotherapy is required in desmoids months later. Surgery had a high risk for fibromatosis to prevent recurrence. developing stroke since the tumor encased the subclavian artery and the vertebral artery Reference based on computed tomography angiogram 1. Sylvain Briand, MD, Olivier Barbier, MD, (CTA). Thus, the patient underwent 34 cycles Wait-and-See Policy as a First-Line of radiotherapy after which the swelling Management for Extra-Abdominal Desmoid subsided with mild residual pain. Tumors, Journal of Bone Joint and Surgery. Volume 96- April 16, 2014, Page 631-8. 2. S. Bonvalot, A. Desai1. The treatment of desmoid tumors: a stepwise clinical approach, symposium article, Annals of Oncology, Oxford Journals, Volume 23, Supplement 10, September 2012 3. Barbier O,Anract P, Pluot. Primary or recurring extra-abdominal desmoid Figure 1- Circumscribed lobulated tumor fibromatosis: assessment of treatment by tissue over the right neck. observation only. OrthopTraumatolSurg Res. 2010 Dec;96(8):884-889. Discussion The characteristic of this tumor is infiltrative with an irregular or lobulated contour.

PO05B A Rare Case Of Giant Cell Tumour Involving The Medial Condyle Of Distal Humerus

1Shashank R; 2Izani M 1Department of Orthopedic and Traumatology, Universiti Sains Malaysia, 16150 Kubang Kerian, Kota Bharu, Kelantan, Malaysia 2Department of Orthopedic and Traumatology, Hospital Raja Permaisuri Bainun Ipoh, Jalan Hospital, 30450 Ipoh, Perak, Malaysia

INTRODUCTION: Giant Cell Tumour (GCT) is a common benign primary bone tumour, seen commonly in the distal femur, proximal tibia and distal radius. Very few cases of GCT have been reported involving the distal humerus

CASE DISCUSSION: Post Intralesional Extended Curettage We present a rare case of a 35 year old woman who complained of progressive pain and restriction of movement over her left elbow over a period of 3 months duration. A plain radiograph revealed an expansile epiphyseo-metaphyseal lytic lesion over the medial condyle of distal humerus. MRI of the Post Insertion Bone Cement elbow was suggestive of the diagnosis with no breach of cortex. A Frozen section of the lesion revealed multinucleated giant cells CONCLUSION: Though Occurrence of GCT is rare in distal along with mononuclear cells, but with no humerus, it should be considered in the malignant cells. An extended curettage was differential diagnosis of any radiolucent performed, the lesion was soaked with 70% lesion. GCT though benign is locally alcohol, followed by bone cement insertion. aggressive and the surgeon needs to strike a This procedure was performed through a balance during treatment between reducing the anterio-medial approach to the the elbow. Post incidence of local recurrence while preserving operatively her range of motion is 20-120 maximal function. With adequate resection, degrees with no signs of reccurence recurrence can be prevented and joint function

can be preserved.

REFERENCES: 1.)Ajay P Manish P. Treatment of Giant cell tumor of bone: Current Concepts Indian J Orthop. 2007 Apr-Jun; 41(2): 101–108. 2.)Jatin P Anil M. Giant cell tumor-a very rare differential for a lytic lesion of the medial condyle of humerus. BMJ Case Reports 2015 Radiograph of left elbow june 3.)Ghostine B Sebaaly A. Multifocal Metachronus Giant Cell. Case Reports In medicine 2014 Jan

PO05C The Lymphoma Which Mimics Bone Tumour/Infection - Primary Bone Lymphoma: A Case Report

Tan KT; Ajit Singh V; Mansor A Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia.

INTRODUCTION: images (Figure 2). Bone marrow and trephine Primary bone lymphoma (PBL) is defined as biopsy of pelvis showed marrow replacement lymphoma that is only confined to the bone or by malignant large centroblastic lymphoid bone marrow, without evidence of systemic cells which are immunoreactive to CD20, involvement. PBL is rare, accounting for CD10 and Bcl-6. The Ki-67 proliferative approximately 3–7% of all bone malignancies, index was 70-80%. It was concluded that the 4–5% of extra nodal lymphomas, and 5% of lesion was a high-grade non-Hodgkin’s all non-Hodgkin’s lymphoma (1-4). It is also lymphoma, most likely a diffuse large B cell rare in children. Diagnosis was often delayed phenotype. Positron emission tomography- due to clinical presentation which mimicked computed tomography (PET-CT) scan showed more relatively common musculoskeletal diffused bone marrow tracking in the entire conditions such as infection or tumour, skeletal system including knees, left humeral especially in young age. head, ribs, and sternum without spleen or lymphatic nodes involvement. The final CASE SUMMARY: diagnosis was polyostotic diffused large B-cell A 16 years old girl presented with progressive non-Hodgkin’s lymphoma. She was treated global right knee pain associated with mild with chemotherapy (B-NHL BFM 04 regime), swelling. It was a daily resting pain with night which include cyclophosphamide, pain. The mild pain was not further methotrexate, cytarabine, vincristine, investigated by the primary doctor. However, etoposide, and ifosfomide. the pain had progressively worsened with VAS of 5/10 within 2 months. By the 3rd DISCUSSIONS AND CONCLUSION: month after the onset, the pain was disabling PBL lacks of systemic presentation but usually with VAS of 8/10, and she was unable to mimics other local musculoskeletal conditions walk. She was admitted to the primary hospital such as infection or tumour clinically (3). In and infection was ruled out after an the series published by Glotzbecker and . Due to the unresolving pain, colleagues, it was identified that one of the she was referred to the musculoskeletal reasons of delay in diagnosis was attribution oncology unit in the present centre, after about of these non-specific symptoms to other more 4 months from the initial onset of the knee common causes of musculoskeletal pain such pain, where further assessment was carried as muscle strain and synovitis (5). In out. Blood investigations showed conclusion, diagnosis of PBL is usually leucoerythroblastic picture with anaemia and delayed and requires high index of suspicion. leucopenia, raised C-reactive protein and raised erythrocyte sedimentation rate. Plain REFERENCES: radiograph showed a vague radiolucent lesion 1. Beal K, Allen L, Yahalom J. Primary at the distal femur epiphysis mildly extending bone lymphoma: treatment results and to metaphysics through the closed physis prognostic factors with long-term follow-up of (Figure 1). The lesion was poorly demarcated 82 patients. Cancer. 2006;106(12):2652-6. with wide zone of transition. Magnetic 2. Ramadan KM, Shenkier T, Sehn LH, resonance imaging (MRI) of the right knee Gascoyne RD, Connors JM. A showed heterogenous intensity at the marrow clinicopathological retrospective study of 131 of both both femurs and in T2 weighted patients with primary bone lymphoma: a images, which was further enhanced with population-based study of successively treated contrast and fat suppression in T1 weighted

ABSTRACT TRUNCATED PO06A A Rare Case Young Gentleman With Bilateral Neck Of Femur Fibrous Dysplasia With Right Neck Of Femur Fracture, A Case Report

Manas, Ammar; Elaine SZF; Abdul Wahid, A Muttalib; Samsul B, Suhana; Johnathan, Richford Department of Orthopaedic Surgery, Hospital Segamat 85000, Johor, Malaysia.

INTRODUCTION: Neck of femur fracture is an orthopedic problem usually related to longevity and ageing population with osteoporosis. Nevertheless it can also happen in young adult Figure 2: HPE sample from bilateral femur due to other causes eg. metabolic bone disease, primary or secondary bone tumour. However having neck of femur fracture due to fibrous dysplasia in young gentleman is a rare scene therefore needs to be reported. Fibrous dysplasia account for 5% of benign bone Figure 2: Post right total hip replacement lesion, however true incidence is unknown as and prophylactic left sliding hip screw many patient are asymptomatic.i fixation

MATERIALS & METHODS: DISCUSSIONS: Case Report. Fibrous dysplasia is genetic but non-hereditary condition whereby failure of the production of normal lamellar bone and normal bone RESULTS: ii Mr. MA, a 17 year old boy with no known co- marrow is replaced by fibro-osseous tissue . morbid presented with right hip pain for one This weakened bone and prone for fracture. year associated with abnormal gait after Most of the time lesion is in single bone (monostotic) but twenty percent it involves sustain sports injury 1 year prior. He denies iii weight loss, family history of cancer or other multiple bones (polystotic) like this case . In history of fracture. His examination reveals this case, even though he had only right neck shortening of right lower limb by 2 cm with of femur fracture, his left hip was bilateral neck of femur cystic appearance and prophylactically fixed with sliding hip screw right neck of femur fracture. MRI pelvis done after intramedullary reaming and bone graft. and shows multiple small cystic lesion at This will prevent left neck of femur fracture bilateral neck of femur. while waiting for normal bone formation in Bilateral femur intramedullary reaming and left neck of femur. iliac bone grafting done together with prophylactic fixation of left neck of femur CONCLUSION: with dynamic hip screw. Intraoperatively A polystotic fibrous dysplasia is a rare fibrous tissue noted over bilateral neck and condition and in cases of unexplained intramedullary femur. HPE sample taken is pathological fracture MRI has a role in consistent with fibrous dysplasia. Four months diagnosis and treatment. We also conclude after that right total hip replacement done and that intramedullary reaming and prophylactic was uneventful. Postoperatively there is no fixation of bone does prevent fibrous dysplasia more limb length discrepancy. bones from being fractured in a young adult.

REFERENCES:

i Parekh SG et al. Fibrous dysplasia. J Am Acad Orthop Surg. 2004 Sep-Oct. 12(5):305-13 ii Eisenberg RL. Bubbly lesions of bone. AJR Am J Roentgenol. 2009 Aug. 193(2):W79-94 Figure 1: X-ray and MRI Pelvis iii Godse AS, Shrotriya SP, Vaid NS. Fibrous dysplasia of the maxilla. J Pediatr Surg. 2009 Apr. 44(4):849-51 PO06C A Case Of Pleomorphic Rhabdomyosarcoma In Pregnancy

Ooi BH; Singh VA Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia.

INTRODUCTION: her family. Caesarean section was performed Rhabdomyosarcoma (RMS) is the common at 30 weeks of gestation. She was then soft tissue tumour manifesting features of planned for wide resection and proximal femur skeletal muscle differentiation, usually endoprosthesis, however, repeated CT TAP occurring in childhood or adolescence. The shows enlarging primary tumour with multimodal treatment of rms includes an worsening lung metastases. In view of the intense intravenous multi-agent chemotherapy, worsening lung metastases, operation was radiotherapy and surgery. However, withhold and proceeded with chemotherapy. chemotherapy in pregnancy is known to increase the risk of spontaneous abortion, fetal DISCUSSIONS: death and major malformations. Adult rhabdomyosarcoma tends to be more We here report an extremely rare case of a aggressive and more resistant to chemotherapy pleomorphic rhabdomyosarcoma in a 43 year than its childhood counterpart. The current old lady during pregnancy. guidelines for treating adult rhabdomyosarcoma are nonetheless based on CASE REPORT: the multimodality approach. This approach A 43 year old woman, Gravida 5 Para 4 at 29 includes wide resection of the primary tumour, weeks of gestation, was referred to our centre radiation therapy for microscopic or gross for right thigh pain and swelling for 1 year. residual disease, and multi-agent Her right thigh pain started about a year ago chemotherapy. Several which she visited a hospital for consultation. A chemotherapeutic agents have shown activity plain radiograph at that time shows lytic lesion in treating rhabdomyosarcoma,including over right femur, she was counselled for cyclophosphamide, actinomycin D, further workup, however she defaulted doxorubicin, vincristine, and more recently treatment and follow up. Her pain and ifosfamide and etoposide. As a conclusion, swelling progressively worsen and by the time management in pregnancy is very challenging she presented to us, she was unable to as deliberate delay raises concerns for ambulate due to severe pain. She also has loss maternal morbidity, especially when the of appetite and loss of weight. Clinically, she diagnosis occurs in the first and second was cachexic, lethargic looking with a huge trimester. The principles guiding care include swelling about 15X15cm firm mass over her the evaluation of tumour size and stage, nodal right thigh. status, gestation, parental wishes regarding Magnetic Resonance Imaging (MRI) and pregnancy. Therefore, management in a multi- computed tomography (CT) of the pelvis were disciplinary team is required with done. The scans show a heterogenous comprehensive counselling regarding the full enhancing soft tissue mass in right thigh with spectrum of management options. bony destruction of head, neck and proximal right femur measuring about 11x11x15cm. REFERENCES: Computed tomography of the thorax shows 1) Spindle cell rhabdomyosarcoma of the multiple lung metastases . No other bony retroperitoneum: an unusual case metastases on bone scan. Biopsy of the right developed in a pregnant woman but thigh mass was consistent with pleomorphic obscured by pregnancy. Lu Yu, Shou rhabdomyosarcoma. Jing et al Published August 1, 2014 She is co-managed by Orthopaedic oncology, 2) Treatment of Adult obstetrics and gynaecology, medical oncology. Rhabdomyosarcoma The diagnosis was discussed with patient and

ABSTRACT TRUNCATED PO06D Survival Rate For Osteosarcoma Paediatric Patients

Ibrahim, Nurulizzah; Babar; Bilal; Paul; Aaron Department of Orthopaedic Surgery, Queen Elizabeth Hospital, Karung Berkunci No. 2029, 88586 Kota Kinabalu, Sabah, Malaysia

INTRODUCTION: Osteosarcoma is a malignant neoplasms of DISCUSSIONS: mesenchymal origin.1 It exhibits rapid growth We had an astonishing 60% drop out rate. The in a centripetal manner and invades adjacent mortality of the non-compliant group was a normal tissues. Patients will complain of 100% within 12 months, with an average painful mass in contrast to painless mass for survival period of 6 months. From the soft tissue tumors. Malignant bone tumors can compliant group, the mortality has been 20%, further be divided into high grade and low with an average survival of 24 months. A grade. The former tend to destroy the study in Netherlands showed a rise from overlying cortex and spread into the soft 26.9% of patients with surgical resection in tissues while the latter generally contained 1979-1983 to 69% in 2003-2008. The 5-year within the cortex or the surrounding periosteal disease free survival rates were 57.8% for limb rim. Osteosarcomas metastasise salvage surgery and 66.1% for amputation.4 haematogenously where lungs are the most This highlights the importance of surgical common site. The mainstay of treatment is excision of tumor in improving survival rate. neoadjuvant chemotherapy followed by wide resection and then adjuvant chemotherapy.2 CONCLUSION: Long term survival rate for treatment Survival rate drop from 80% to less than 0% compliant patients is expected to be 60%- following patients being non-compliant to 70%.3 However, this falls rapidly with non- treatment. The main issue we have faced with compliant patients down to 40%. This regards to non-compliance is that the families descriptive study looks into the survival rate of refuse surgery after the neo-adjuvant patients who were non-compliant to treatment chemotherapy as the affected limb becomes as compared to those who still remain painless and function improves. compliant and the time of publication REFERENCES: METHODS: 1. Miller et al, Review of Orthopaedics 6th This is a retrospective study of osteosarcoma edition, 2012, pg 633 cases, diagnosed between January 2013 to 2. Miller et al, Review of Orthopaedics 6th December 2015. The survival rates between edition, 2012, pg 636 the compliant and non-compliant groups are 3. Isakoff MS, Bielack SS et al; compared. Our patients are aged below 16 Osteosarcoma: Current Treatment and a years as they are co-treated with the Paediatric Collaborative Pathway to Success; J CLin. Oncologist Oncol. 2015 Sept 20:33(27):3029-35 doi: 10.1200/JCO.2014.59.4895. Epub 2015 RESULTS: Aug 24 12 patients (age below 16 years old at 4. Melanie M H, Eveline SJM de Bont, D. presentation) selected for this case study had Maroeska WM, Survival trends and long term been diagnosed with osteosarcoma based on toxicity in pediatric patients with the HPE result from the initial incisional osteosarcoma. Sarcoma Journal vol. 2012, art. biopsy. All of the patients received 636405. www.hindawi.com neoadjuvant chemotherapy as initial treatment. Out of all the patients, 40% were compliant to wide surgical resection followed with adjuvant chemotherapy.

PO07A Epidemiological Spectrum Of Bone Tumors Presented To Tertiary Care Oncology Hospital, Malaysia

1 Saadon I; 2Bhardwaj A; 1 Zolqarnain A;1 Firdaus Z; 3Swe KMM. 1 Department of Orthopaedic, Hospital Sultan Ismail, Jalan Persiaran Mutiara Emas Utama, Taman Mount Austin, 81100 Johor Bahru, Johor, Malaysia 2 Newcastle University Medicine Malaysia, No 1 Jalan Sarjana 1, Kota Ilmu, EduCity@Iskandar, 79200 Nusajaya, Johor, Malaysia 3 Perdana University, Royal School of Medicine Ireland, Block B and D1, MAEPS Building, MARDI Complex, Jalan MAEPS Perdana, 43400 Serdang, Selangor, Malaysia

INTRODUCTION: prevalent were cartilaginous lesions (44.2%) Bone tumors are a rare group of heterogeneous followed by cystic lesion (26.8%) fibrous malignancies. Osteochondroma, Osteosarcoma lesion (12.3%) and bone forming (8.7%). The and Ewing’s sarcoma are the commonest most common site of bone tumors were at tumour usually occurring in the absence of an femur/ thigh (33.6%), followed by tibia/calf underlying cause.1 Primary bone tumors are (18.6%), humerus/arm (15.5%) and foot/ankle rare, yet they account for a major source of (6.4%) accordingly. Regarding Left and right mortality and morbidity among patients with distribution, left side were more commonly cancer. The geographic distribution of bone presented (49.5%) compare with right side tumors throughout the world appears to be (42.3%). quite variable, with a very low incidence reported in some Asian countries such as Figure (1): Benign and malignant distribution India, Japan, and China as well as in most of of bone tumors Latin America. In the United States, there seems to be an increased incidence among patients of African American and Caribbean descent over whites2-3. The aim of the study is to analyze the epidemiologic characteristics of bone tumors presented to tertiary care orthopaedics oncology hospital, Malaysia Figure (2): classification of malignant bone tumors METHODS: Hospital based cross sectional study was conducted at tertiary care oncology hospital, Malaysia from September to December 2014. Hospital data from 2006 to 2013 were collected.

RESULTS: There were total 220 bone tumor cases Figure (3): classification of benign bone identified during the study period. Among the tumors cases the mean age of the patients were 28.11 years ranging from 1year to 93 years and males were more prevalent (61.4%) than female (38.6%). Most of the cases were benign in origin 138 (62.7%) and 82(37.3%) were malignant bone tumors. Among malignant bone tumors; osteosarcoma were most prevalent (46.3%) followed by multiple myeloma (18.3%) and Ewing’s sarcoma DISCUSSIONS: (12.2%).Among benign tumors, the most Primary bone tumors are relatively uncommon. The most common begin tumour ABSTRACT TRUNCATED PO07B Epidemiological Spectrum Of Soft Tissue Tumors Presented To Tertiary Care Oncology Hospital, Malaysia

1 Saadon I; 2Bhardwaj A; 1Zolqarnain A; 3Swe KMM; 1Firdaus Z 1 Department of Orthopaedic, Hospital Sultan Ismail, Jalan Persiaran Mutiara Emas Utama, Taman Mount Austin, 81100 Johor Bahru, Johor, Malaysia 2 Newcastle University Medicine Malaysia, No 1 Jalan Sarjana 1, Kota Ilmu, EduCity@Iskandar, 79200 Nusajaya, Johor, Malaysia 3 Perdana University, Royal School of Medicine Ireland, Block B and D1, MAEPS Building, MARDI Complex, Jalan MAEPS Perdana, 43400 Serdang, Selangor, Malaysia

INTRODUCTION: prevalent was Lipo-sarcoma (22.6%) followed Soft tissue tumors of the musculoskeletal by Squamous cell carcinoma (15.7%) and system are reported relatively frequently. 1 In Rhabdomyosarcoma (13.0%) as in figure 3. general, benign soft tissue tumors occur more The most common site of soft tissue tumors common than malignant ones but the exact were at thigh (24.5%), followed by foot/ankle annual incidence is unknown. 2 Overall, the (12.3%), arm (9.1%) and calf (8.7%) age-adjusted annual incidence of soft tissue accordingly. Regarding Left and right sarcomas ranges from 15 to 35 per 1 million distribution, left side were more commonly populations. They account for approximately presented (49.3%) compare with right side 1% of adult malignancies and (45.2%). 7% to 15% of pediatric malignancies5.The Figure (1): Benign and malignant distribution incidence increases steadily with age and is of soft tissue tumors slightly higher in men than in women. Malignant soft tissue tumors occur twice as often as primary bone sarcomas3. The aim of the study is to analyze the epidemiologic characteristics soft tissue tumors presented to tertiary care oncology hospital, Malaysia.

METHODS: Figure (2): classification of benign soft tissue Hospital based cross sectional study was tumors conducted at tertiary care oncology hospital, Malaysia from September to December 2014. Hospital data from 2006 to 2013 were collected.

RESULTS: There were total 462 soft tissue tumour cases identified during the study period. Among the cases the mean age of the patients were 39.6 Figure (3): classification of malignant soft years ranging from 1year to 87 years and tissue tumors males were more prevalent (50.9%) than female (49.1%). Most of the cases were benign in origin (75.1%) and (24.9%) were malignant soft tissue tumors. Among benign soft tissue tumors; fatty tumors such as lipoma were most prevalent (31.7%) followed by vascular lesion (haemangioma) (23.6%), fibrous lesions (17.0%), tumor like lesion (15.3%), and nerve sheath tumors (8.5%) etc. Among malignant soft tissue tumors, the most

ABSTRACT TRUNCATED PO07C A Handful Of Basal Cell Carcinoma

1Mohamed MishwaarAshfaq; 1NorHazla Mohamed Haflah; 2Farrah Hani Imran; 1Yazid Kassim 1Department of Orthopaedics and Traumatology, Universiti Kebangsaan Malaysia, 43600 UKM, Bangi, Selangor, Malaysia 2Department of Surgery, Universiti Kebangsaan Malaysia, 43600 UKM, Bangi, Selangor, Malaysia

Introduction of the hand. Mohs surgery offers a highly Basal Cell Carcinoma (BCC) is a locally accurate yet conservative removal of BCC. In invasive malignant skin tumor that infiltrates difficult cases of BCC, it can attain maximal tissues in a three-dimensional preservation of normal tissueswith a high cure pattern.1Morbidity is usually due to local rate.1 Review of all studies published since tissue invasion and destruction. Moh’s surgery 1947 suggestedan overall 5-year cure rate of is one option of surgical treatment, although 99% followingMohs surgery for primary seldom indicated in handtumour. It is the BCC.2Thorough curettage of the lesion prior ultimate in frozen-section margin control, to resection can accurately define the true sampling 100% of the margin. borders of the BCC, further increasing the Key Words: Hand tumor, Basal Cell chance of a tumour-free margin.3 Carcinoma, Mohs Surgery Conclusion Case Report With careful planning and intra-operative A 69-year old gentleman presented with a 4- frozen section to determine tumour-free year history of a fungating mass over the margin, amputation of the hand can be dorsum of his left hand with severe restriction avoided in BCC. ofhis hand function (Figure 1A). His expectation was for tumour resection without Reference sacrificing any digits. MRI,however, showed 1. Robins P, Reyes BA. Cure rates of skin indentation onto the extensor digitorum cancer treated by Mohs micrographic surgery. tendons and the dorsal aspect ofthe 2nd In Dermatologic Surgery: Principles and metacarpal bone (MCB). Biopsy of the lesion Practice (Roenigk RK, Roenigk HH Jr, eds). revealedBCC. Heunderwent wide local New York: Marcel Dekker, 1989; 853-8. excisionof the tumor with partial resection of 2. Rowe DE, Carroll RJ, Day CL Jr. Long- the 2ndMCB. Intra-operative frozen section at term recurrence rates in previously untreated various suspicious areas, including the 2nd (primary) basal cell carcinoma: MCB,confirmed tumour-free margin of implicationsfor patient follow-up. J resection. DermatolSurgOncol 1989; 15: 315-28. 3. Johnson TM, Tromovitch TA, Swanson A B NA. Combined curettage and excision: a treatment method for primary basal cell carcinoma. J Am AcadDermatol 1991; 24: 613-17.

Figure 1. A: Before resection B: After SSG Post-operatively, the wound bed was prepared with serial negative pressure dressings and later covered with split skin grafting (Figure IB)

Discussion The primary objective in our patient is complete tumour resection with preservation PO07D A Case Of Radiotherapy Induced Osteonecrosis Of The Femur Mimicking Local Recurrence Of Leiyomyosarcoma

Harkeerat Singh; Babar Bilal; Asrul YHN; Ibrahim N; Siti Zulaifah CS; Chan SK; Paul AG Department of Orthopaedics, Hospital Queen Elizabeth, Lorong Bersatu, Off Jalan Damai Luyang 88300, Kota Kinabalu

INTRODUCTION: osteonecrosis and was treated with Radiotherapy (RT) is an important modality in prophylactic intramedullary nailing and the treatment of a wide variety of neoplasms. discharged home well. In bony and soft tissue sarcomas it is either used to treat a primary lesion or used to clear DISCUSSIONS: up remnant malignant cells over the reactive In patients with lytic lesions post radiotherapy, zone post surgical excision/incisions. working diagnoses should include primary Complications associated with bones post tumor recurrence, radiation induced sarcoma, radiotherapy include alterations in bone osteonecrosis or osteomyelitis of the growth radiation osteitis, stress fractures, underlying bone. Latency periods for osteonecrosis, osteomyelitis and radiotherapy osteonecrosis post RT is reported around 3 induced sarcomas. years post therapy, RT induced sarcomas tend to present later around 5yrs post RT and CASE REPORT: osteomyelitis with variable latency periods. 55-year-old Rungus lady initially presented to Common sites for osteonecrosis include the us with a right medial thigh swelling mandible, pelvis, shoulder, sternum and the measuring 10cm for the past few months. MRI spine. Post radiation sarcomas generally showed a soft tissue tumor of the medial comprise of osteochondromas and other compartment with involvement of the adjacent benign neoplasms in patients below the age of femur cortex. The lesion was then excised in two. In adults however, most of them are 2011 and HPE revealed high grade reported as high grade sarcomas. Management leiyomyosarcoma. She was then subjected to for ostenecrosis in general is for prophylactic 30 cycles of radiotherapy which caused her to skeletal stabilization or close monitoring of the develop skin thickening and contractures over lesion w serial imaging. her right knee. She was then well until 2016, where she was admitted for mild cellulitis of CONCLUSION: her right leg. During her stay she complained Radiotherapy induced osteonecrosis for lytic of a mild dull right thigh pain on weight lesions of the bone should be a diagnosis of bearing. exclusion, urgent imaging and biopsies should be carried out to rule out other notorius INVESTIGATIONS: pathologies Plain radiographs then revealed a lytic lesion over the mid shaft of her right femur with REFERENCES: bony erosion over posterior n medial cortices. 1. Inoue YZ et. Al. Clinicopathologic features A CT Thoraco-Abdominal-Pelvis was then and treatment of postirradiation sarcoma of done to look for metastatsis but did not reveal bone and soft tissue. J Surg Oncol 2000. any significant lesions. She was then Sep;75(1):42-50 scheduled for an MRI of the right femur which 2. Mitchell MJ, Logan PM. Radiation induced revealed a hetrogenous lesion in the marrow of changes in bone. Journal Radiographics the femur with cortical erosion and soft tissue 1998;18(5):1125-1136 enhancement. The working diagnosis was recurrence and was scheduled for a core biopsy which yielded necrotic bone with no evidence of metastatic tumor cells. She was then diagnosed with radiotherapy induced PO08A Floppy Lateral Position For Type II Internal Hemipelvectomy

Ibrahim, Nurulizzah; Babar; Bilal; Paul; Aaron Department of Orthopaedic Surgery, Queen Elizabeth Hospital, Karung Berkunci No. 2029, 88586 Kota Kinabalu, Sabah, Malaysia

INTRODUCTION: RESULTS: Hemipelvectomy is a procedure most often With the patient flopped posteriorily i.e the performed in tumour cases where limb-sparing left hemipelvis 45degrees, the incision was techniques or hip disarticulation procedure extended from the iliac crest and inguinal remains inadequate. There are four types of ligament to the symphysis pubis. This was hemipelvectomy, namely standard described in Karakousis and Vezeridis hemipelvectomy, extended hemipelvectomy, technique. conservative hemipelvectomy and internal The patient was flopped anteriorly i.e with the hemipelvectomy.1 This case study will discuss left hemipelvis in 135 degrees, a second our patient's position for the procedure. This incision was made with extended posterior patient named H underwent at type II internal approach to access the posterior part of the hemipelvectomy and was put on floppy lateral pelvis. position. There are a number of surgical DISCUSSIONS: methods for the procedure - Karakousis and Floppy lateral position provides a few Vezeridis, Eilber et al, Steel, Enneking and important advantages for hemipelvectomies Dunham, Braund and Pigott, and others. These where both an anterior and posterior approach require the patient to be in either lateral are required. One advantage is time. Only a decubitus position or supine rotated position.1 single cleaning and draping is required. Due to MATERIALS & METHODS: its access, it is easier to saw the pubic rami H underwent Type 2 internal Hemipelvectomy from anterior and posterior approach by in a floppy lateral position. Once H was flopping the patient anteriorly and posteriorly. securely intubated, orthoban was wrapped Last but not least, this also ensures that the around his bilateral upper limbs and right leg patient will have secure airway throughout the to minimize hypothermia in view of expected surgery with lower chances of dislodging the long surgery time. Then, H was positioned in endotracheal tube during repositioning. lateral decubitus. An axillary roll was placed Having shorter surgery time leads to reduce beneath the axilla. Two roll towels were blood loss, risk of infection, risk of placed anteriorly and posteriorly to his trunk hypothermia, risk of prolonged anasthesia as stabilizers. Two padded bars were used to which eventually leads to better recovery support his body anteriorly and posteriorly at period for the patient with expected good the mid-level. These were not in contact with outcome. The procedure we performed was an his trunk and which main purpose was to extra-articular resection of the proximal femur. prevent him from falling off the bed on either This involved a type II internal anterior or posterior positioning. In effect His hemipelvectomy. Reconstruction was done body was left floppy between the bars. His using a proximal femur oncology prosthesis position was secured with body straps and a (Mutars, Implantcast GmbH, Germany) and warmer was applied to his upper body. Picture an ice-cream cone prosthesis (Lumic, 1 and 2 shows H in floppy lateral position. Implantcast GmbH, Germany) The entire procedure with its reconstruction took just under 7 hours. CONCLUSION: The Floppy lateral position is advantageous to the surgeon in applying different approach to the pelvis. Anterior and posterior access is feasible thus providing flexibility to the surgeons. This position may be beneficial to

ABSTRACT TRUNCATED PO08B Rare Presentation Of Pseudogout Mimicking Malignant Tumour

Shanjay; Azammuddin A; Manoharan K Department of Orthopedic, Hospital Raja Permaisuri Bainun, Jalan Hospital, 30900 Ipoh, Perak Darul Ridzuan.

INTRODUCTION: Calcium pyrophosphate deposition disease is a 1 Fig.1 Swelling of left thumb metabolic arthropathy caused by the deposition of calcium pyrophosphate dehydrate in and around joints, especially in articular cartilage and fibrocartilage. Its incidence less than 5% from population and affects female more compared to male (ratio 2 1.4:1) . Large joints are more commonly Fig. 2 Xray of Left Hand affected and knee is the most commonly involved joint, followed by the wrist, ankle, elbow, toe, shoulder and hip1. Common presentation includes sudden and severe pain in the joint along with redness, warmth and 1 DISCUSSIONS: swelling . Here we are presenting a case of Calcium pyrophosphate deposition disease swelling over right thumb which mimick treatment program usually depends on severity malignant tumor in a 70 years old lady. of symptoms presented. The goals of treatment are to relieve pain, maintain full joint CASE REPORT: movement and muscle strength and keep A 70 years old female presented with left inflammation under control3. Rarely surgery thumb swelling for 6 years, progressively indicated to reduce pain and improve increasing in size 7 x 4cm. She claims movement in a joint that is badly damaged or swelling associated with occasional bleed and unstable. As for this patient the presentation of pus discharge. She has constitutional swelling in small joints of the hand raised symptoms, loss of weight and appetite but no clinical suspicion of malignancy which is pain or fever. actually a rare presentation of metabolic On examination, swelling over left thumb at arthropathy which leads to Ray Amputation of metacarpophalangeal joint, diffuse with pus the thumb. discharge and foul smelling. No tenderness on palpation and no neurovascular deficit. REFERENCES: Xray of left hand done reported soft bone 1. Paul MacMullan, 2012; US National forming lesion seen involving the distal Library of Medicine; Treatment and phalanx of the left thumb with possible management of pseudogout: insights for the fibrosarcoma. clinician Ray's Amputation of left thumb done and 2. Ellman M.H., Levin B. intraoperatively the bone was nibbled until (1975) Chondrocalcinosis in elderly proximal 1/3 of metacarpal bone with no persons. Arthritis Rheum 18: 43–47 extended bony destruction. 3. Nicola Dalbeth. Best Practice Journal. Initial histopathological examination showed 2013 Iss, BPJ55:20-27 features are of benign mesenchymal lesion with differentials of Chondroimyxoid fibroma or Gouthy tophi with chondroid metaplasia. Final confirmed diagnosis reviewed by endocrine histopathologist, the result showed Calcium pyrophosphate deposition. Post-operative course was uneventful. PO08C Congenital Pseudarthrosis Of Tibia: Histopathology Revisited

1TJ Teoh; 2Noraini M.Dusa; 1PC Chye 1 Department of Orthopedic and Traumatology Oncology Unit, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia 2 Department of Pathology Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia

INTRODUCTION: fibrous tissue and adipose tissue. The fibrous Congenital pseudarthrosis of the tibia (CPT) is tissue is composed of fibromatosis-like spindle a rare congenital disorder of bone formation in cell proliferation with elongated, somewhat the tibia, with reported incidences ranging wavy nuclei. Collagen is deposited in between from 1 in 140,000 to 1 in 250,000 live births. the cells. While at the level of pseudarthrosis 50% of CPT cases are associated with transitional zone, there are cortical and neurofibromatosis type 1. In general, medullary bone with attached fibrous tissue. understanding of the underlying pathology is There is proliferation of fibrous tissue wirhin still inadequate for effective treatment of the the Haversian canal, associated with the disease. We present the histopathology reactive new bone formation rimmed by findings of a case of failed excision of osteoblast. Osteoclastic bone remodelling is pseudarthrosis and bone transport. evident. The attached fibrous tissue contains marked proliferation of spindle cells on the CASE REPORT: surface of the bone that grow in fascicles and CKH, a 9 year old boy with type 1 have spindle wavy nuclei. At focal area, there neurofibromatosis was diagnosed to have is proliferation of fibromatosis-like tissue congenital pesudarthrosis of right tibia since 3 within the marrow cavity. years of age. He was managed by various orthopaedic surgeons with splints and braces CONCLUSION: for increasing bowing and deformity of right Congenital pseudarthrosis of tibia is still a tibia in his earlier childhood and eventually disease where the histopathology is yet to be underwent resection of pseudarthrosis with fully understood. Many surgical interventions Ilizarov external fixation without bone grafting have been used over past decades to treat the at the age of six years old. Soon after removal disease but success remained rare and difficult of the Ilizarov external fixator one and a half to achieved. A good understanding of the years later, his right tibia fractured resulting in underlying pathology is vital for achieving persistent pain and angulation and he was only greater successes in the management of these able to ambulate with hand crutches. Both patients. patient and parents refused further surgical attempts for bone union and requested for REFERENCES: below knee amputation. 1. S. Pannier Congenital Pseuarthrosis of Tibia [cited 6July 2011] DISCUSSIONS: 2. Hermanns-Sachwen B et al. Vascular Histological studies in the periosteum of the changes in the periosteum of congential amputation site shows fibrous tissue consists pseudarthrosis of the tibia.2005; 201(4):305 of dense collagenous tissue. Besides, the anterior tibial cortex at the level of amputation shows proliferation of spindle cells in a collagenous stroma within the Haversian canal. From the amputation site until distal tibia epiphysis, the bone gap of tibia and fibula show presence of pseudarthrosis (villous synovial-like tissue lined by synoviocyte layer with congested subintima) surrounded by PO08D Large Distal Tibia Osteochondroma With Deformed Fibula: Excision And Anatomical Reconstruction Of Ankle Syndesmosis

Goh KL; Mohamed Azril MA; Mohd Ariff S; Mohammed Harris AK Department of Orthopaedics, Traumatology & Rehabilitation, Kulliyyah of Medicine, International Islamic University Malaysia, Jalan Hospital Campus, 25100 Kuantan, Pahang, Malaysia.

INTRODUCTION backslab for 2 weeks and allowed full-weight Osteochondroma is a benign cartilaginous bearing after 6 weeks. disease of the bone. Its exophytic growth can occasionally result in periarticular deformity RESULTS and pain. We describe a case of large At one year follow-up, the lateral malleolus osteochondroma of the lateral malleolus has remodelled and the syndesmotic joint has causing deformity and pain in a growing child. anatomically reduced with the tightrope (Figure 2). No recurrence was detected. The METHODS pain resolved and he had no residual A 12 year-old boy with multiple hereditary deformity. exostosis, presented with a large left ankle osteochondroma which became painful for the past 1 year with worsening deformity of the lateral malleolus. Examination revealed multiple small bony swelling over both wrists, knees and scapulae. Local examination revealed a bony swelling at the left lateral malleolus measuring 8X8 cm Figure 2: Anatomically reduced ankle with varus deformity of the ankle. However, syndesmosis at one year the range of ankle motion was full. Radiograph revealed a large sessile bony DISCUSSIONS outgrowth on the distal lateral tibia Multiple osteochondromas is an autosomal compressing the lateral malleolus with dominant disorder with a very high thinning of the bone and widening of the penetrance. The lesions usually develop within syndesmotic joint (Figure 1). the first two decades of life and cease to grow with the closure of the physeal plate 1. Most are asymptomatic throughout their lives but they may present with ankle pain, a palpable mass and unrestricted ankle motion 2. Untreated or partially excised lesions may potentially lead to plastic deformation of the Figure 1: Pre-operative radiograph showing distal tibia and fibula and pronation deformity 2 large osteochondroma of the distal tibia of the ankle in skeletally immature patients . compressing the lateral malleolus From our literature review, this is the first reported case of syndesmotic reconstruction in He underwent excision of the tumour and an ankle osteochondroma with syndesmotic anatomical reconstruction of the syndesmotic widening. Syndesmotic reconstruction should ligament via anterior approach. Multiple drill be considered if widening is significant. If left holes were made at the base of the lesion and untreated, syndesmotic instability may lead to the tumour was osteotomized. The ankle early ankle pain and osteoarthritis. Due to the syndesmosis had 2 cm widening and high growth potential in children, the lateral reconstruction was performed using malleolus and the distal tibia have high tightrope(Arthrax) with endobuttons. propensity to remodel to normal alignment. Postoperatively, he was immobilised with

ABSTRACT TRUNCATED PO09B Metachronous Osteosarcoma In A 10 Year-Old Boy – A Case Report

R Hassan; N Hanif; Azuhairy A; Zulkiflee O Department of Orthopaedics & Traumatology, Penang General Hospital, Jalan Residensi, 10990 George Town, Pulau Pinang, Malaysia

INTRODUCTION: This is a case of a ten year-old boy who was recently diagnosed with metachronous osteosarcoma of the distal end of femur bilaterally.

CASE PRESENTATION: The patient presented with a progressive swelling at the right thigh which was diagnosed as a conventional osteosarcoma of the distal diaphysis of right femur without distal metastases. He subsequently underwent neoadjuvant chemotherapy, followed by wide resection of the distal end of right femur and insertion of right femur megaprosthesis five months later. However, after completion of therapy, there was an incidental finding of a new lesion at his contralateral femur discovered during a bone scan by his oncologist, five months later. The patient was subsequently diagnosed with metachronous osteosarcoma of his bilateral femur, yet he is not keen for a second resection of tumour.

DISCUSSION: Although metachronous osteosarcoma carries the poorest of prognosis compared to other variants of osteosarcoma, the disease remained fairly static with the current treatment regime that our patient is on.  - .*  - PR01A Case Report Of Charcot Neuropathy-Rare Manifestation Of Syphilis

T.R Karthik; Hudzairy.A; B.S Tan Department of Orthopaedic Surgery, Hospital Sultananah Nora Ismail, Batu Pahat, Johor, 83000, Malaysia

INTRODUCTION: 15.5mg/L. The screening for Hepatitis, human Syphilis is a bacterial sexual transmitted immunodeficiency virus, and tuberculosis were disease caused by Treponema Pallidum. (1). negative. Venereal Disease Research Syphilis remains prevalent in developing Laboratory (VDRL) and Rapid Plasma Reagin countries and some areas of North America. (RPR) tests were positive for Treponema (2). In Malaysia, the incidence has been Pallidum.g gradually decreasing from 1999 to 2006. (3) DISCUSSIONS: We present a case of a 55 years old gentleman Syphilis is an infectious venereal disease who presented with multiple joint pain and caused by the spirocaete, Treponema Pallidum. swelling for few months. The diagnosis of The disease is transmissible mainly via tertiary syphilis was made from detailed history unprotected sexual contact, from mother to following high index of suspicion, series of X child in utero or during delivery, and through rays and blood investigations. (3) We treated blood product transfusion. (4) Three stages of this patient conservatively with lifestyle syphilis are primary, secondary, and latent or modification advices and symptomatic relief tertiary stages. Primary and secondary stages medications and antibiotics. However, this can be called reversible stages as the patient may require operative intervention in manifestations are mainly mucocutaneous, and the future for the arthropathies, which includes their progression can be halted with early arthroplasty surgeries or arthrodesis. treatment. (4) The latter stage, the latent or CASE REPORT tertiary stage results from untreated secondary 55 years old gentleman, with no premorbid syphilis, which can cause internal organ illnesses, presented with complaints of swelling systems damage and bony destruction.The and pain over right elbow, right knee and right treatment for syphilis is a course of penicillin ankle for the past 6 months. Patient has been or azithromycin. (5) dependent on crutches for ambulation due to CONCLUSION: this problem. The swellings and pain over the This case has emphasized the complexity and right elbow, knee and ankle has been getting variability of syphilis, also known as the great worse in the past 3 weeks, for which the patient imposter. It is very important for orthopaedic was given analgesics in a district clinic. There surgeons to diagnose and treat this disease in its was no history of congenital defect, trauma, early stage to prevent disastrous complications, fever, and constitutional symptoms. including neurosyphilis, which affected the Examination of right elbow, right knee and joints of the patient in this case report. right ankle showed deformity over the joints REFERENCES: and hard swelling over regions, which was non- 1.E. medicine Medscape/syphilis tender. The range of motion of all the affected http://emedicine.medscape.com/article/229461- joints was reduced due to pain. X rays of the overview affected joints showed diffuse, unilateral joint 2.Malaysian health statistics. destruction and lytic changes. There were no https://micpohling.wordpress.com/2008/04/02/mal aysia-health-statistic-hiv-gonorrhea-syphilis fractures. 3.http://www.cdc.gov/std/syphilis 4.World Health Organization. Treponemal infections. Geneva: WHO; 1982. Technical Reports Series 674. 5.Calonge N. Screening for syphilis infection: recommendation statement. Ann Fam Med. 2004;2:362–5. The routine blood investigations were normal. C-reactive protein was elevated to a value of

PR01B Are The Microorganisms Isolated From Diabetic Foot Ulcer Sensitive To Our Empirical Antibiotics?

1Hartharanjeet S. Phinder; 2N. Prashant; 1Sharil AR 1Department of Orthopedic Surgery, Hospital Sultan Abdul Halim, Jalan Lencongan Timur, Bandar Amanjaya, 08000 Sungai Petani, Kedah, Malaysia 2Department of Orthopedic Surgery, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia

INTRODUCTION: Pie Chart 1: Types of bacteria species isolated Diabetic foot ulceration is the leading cause of from infected diabetic foot ulcer non-traumatic lower limb amputation and fills up almost 30% of patients’ bed occupancy in Orthopedic Department in hospitals. Generally, our current choice of empirical antibiotic treatment is Ampicillin/Salbactum. This study is designed to identify bacterial causes of infected diabetic foot ulcer in patients treated at Orthopedic Department of Hospital Sultan Abdul Halim, Sungai Petani and assess their susceptibility to antibiotics.

METHODS: A retrospective study was carried out on 200 diabetic patients who were admitted to this DISCUSSIONS: hospital with infected diabetic foot ulcer from Antibiotic susceptibility testing remains one of November 2013 to May 2015. 113(56.5%) importance contributing factor in the were males and 87(43.5%) were females. management of diabetic foot ulceration. Tissue and swab cultures were collected in Current choice of antibiotic treatment in operation theatre under aseptic technique and infected diabetic foot ulcer is to target gram transported in sterile solution of normal saline positive organism but in this study, it shows and test tube respectively. Culture, isolation, that gram negative bacteria are the most antibiotic sensitivity and identification of the common isolated bacteria. Antibiotics such as microorganisms were done according to the Meropenem and Imipenem are expensive for standard microbiological procedures. the level of economical development even though these antibiotics showed sensitivity to RESULTS: all the microorganisms isolated. 209 pathogens were isolated and summarized in Pie chart 1. 80.86% of samples isolated had CONCLUSION: Gram-negative bacteria and remaining 19.14% We recommend broad spectrum antibiotic such had gram-positive bacteria. Pseudomonas as Aminoglycosides or 3rd generation aeruginosa was the most common bacteria cephalosporins as initial treatment for infected isolated (20.6%), followed by Klebsiella diabetic foot ulcer while waiting to obtain Pneumonia (18.7%), Escherichia coli (10.5%) accurate identifications of pathogens for and Staphylococcus species (9. 09%).All the targeted antibiotic therapy to ensure optimal microorganism were sensitive to Meropenem patient outcome. and Imipenem. 78% of microorganisms isolated were sensitive to Cefoperazone, 75% to Gentamicin and 68% were sensitive to Ampicillin/Salbactum .

PR01C Effect Of Prolotherapy (Dextrose 10%) To Treat Articular Cartilage Injury And Speed Up Recovery In Rabbit Model

1Embun, Denny; 2Razif Ali 1Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

PURPOSE: expression is both treated and control knees. The effects of Dextrose 10 % prolotherapy on Immunohistochemistry staining showed very the healing of damaged and repaired articular minimal Type II collagen expression in treated cartilage were investigated and control knees. The overall synovial biopsy results show no much difference between METHODS: treated and control groups. Most of the results This study was conducted using 10 New showed minimal to moderate fibrosis in both Zealand white rabbits as experimental models. group and minimal inflammatory cells noted. However 1 rabbit died possibly due to infection. Focal cartilage defects 5mm CONCLUSION: diameter x 2mm depth, surgically created in Treatment of articular cartilage injury with the medial femoral condyle of bilateral knees periodic intraarticular prolotherapy dextrose of the hind legs ( Hind Knee ), were either 10% treatment produced no significant treated by means of Dextrose 10% difference in results than “conservative prolotherapy and control knee were given treatment” in full thickness articular cartilage normal saline. The right knee as treatment damage. However, larger samples, longer group was given intra-articular injection of duration, different dosage and timing of 0.3ml Dextrose 10%. The left knee used as injections, detailed study using biochemical control was given intra-articular injection of analysis, inflammatory mediator as well as 0.3ml normal saline. All intraarticular tissue biomechanical analysis are needed to injections were given at 4 weeks, 8 weeks and look for the exact mechanism of action as well 12 weeks post surgery, which were blinded as the benefits of prolotherapy procedures. All rabbits were sacrificed at 16 weeks post-surgery. Knees dissected from rabbits were then evaluated for macroscopic evaluation using ICRS Cartilage Repair Assessment (Protocol A) and histological analysis using modified O’Driscoll (O’Driscoll et al 1988). The results were evaluated by 1 histopathologist (blinded in procedure) and the mean value of both scoring systems were calculated and interpreted.

RESULTS: It was observed that treated knee with prolotherapy dextrose 10% did not enhances regeneration in full thickness cartilage defect injury compared to control knees. The mean value microscopic O’Driscoll score of treated knee is lower than control knee (17.44 vs 17.78, p=0.778). The mean value of macroscopic score (ICRS Cartilage Repair Assessment Protocol A) of treated knee is higher than control knee (4.89 vs 3.33, p=0.156). There was minimal proteoglycan PR01D A Rare Case Of Septic Arthritis Masking Leptospirosis

Ramalingam K; Ganaisan P; Nicholas WE Department of Orthopedics, Hospital Tengku Ampuan Rahimah, 41200 Klang, Malaysia.

INTRODUCTION: good clinical suspicion as well as adequate Leptospirosis is making a comeback in our resuscitation and clinical vigilance is essential Malaysian setting. Its diagnosis alone is often to ensure a good outcome for the patient. difficult, and requires a high index of clinical suspicion. A patient with a completely REFERENCES: different presentation, may often lead the 1. Shirtliff ME, Mader JT. Acute septic management on a different path. We report arthritis. Clinical microbiology reviews. here a case of Staph Aureus Septic arthritis, 2002;15(4):527-44. Epub 2002/10/05. who also had a concurrent Leptospiral 2. Bal AM. Unusual clinical infection manifestations of leptospirosis. Journal of postgraduate medicine. 2005;51(3):179-83. METHODS: Epub 2005/12/08. Patient had undergone arthrotomy washout of 3. Panagopoulos P, Terzi I, Karanikas M, his knee under standard aseptic precaution and Galanopoulos N, Maltezos E. Myocarditis, cultures were obtained. Ig M serology was pancreatitis, polyarthritis, mononeuritis positive for Leptospirosis and he was treated multiplex and vasculitis with symmetrical with antibiotics. His knee was flactuant again, peripheral gangrene of the lower extremities and he underwent a second washout out. as a rare presentation of leptospirosis: a case Antibiotics was given for a total of 6 weeks. report and review of the literature. Journal of medical case reports. 2014;8:150. Epub RESULTS: 2014/06/03. He responded well to antibiotics and 4. GUIDELINES FOR THE DIAGNOSIS, supportive treatment and was discharged for MANAGEMENT, PREVENTION AND follow up. His knee range of movement was CONTROL OF LEPTOSPIROSIS IN reduced on discharged, but slightly improved MALAYSIA; DISEASE CONTROL on 1st follow up. His liver functions also are DIVISION DEPARTMENT OF PUBLIC improving on follow up. HEALTH MINISTRY OF HEALTH MALAYSIA 2011 1 ST edition DISCUSSION Leptospirosis is a protean infection, which often presents with fever and multisystem involvement. A biphasic illness, usually with temperature spikes, and this coincides with leptospiremia. Septic arthritis is a clinical condition, where bacteria has been recovered from the synovial fluid with the use of standard microbiological techniques. It is important to note that leptospirosis is a difficult diagnosis to achieve on its own. A presentation with a septic knee, will most likely divert the attention away from it, and it will require a high clinical suspicion index

CONCLUSION: Septic Arthritis on its own has a devastating sequalea. With the superadded Leptospirosis infection, septicemia is an immediate worry. A PR02A Predictors Of Amputation In Necrotizing Fasciitis Of The Lower Limbs

Low CA; Tam KH; Wong MA Department of Orthopaedic Surgery, Hospital Tuanku Ampuan Najihah, Km 3 Jalan Melang, Kuala Pilah, 72000, Malaysia.

INTRODUCTION: Characteristic Non- Amputation p- Necrotizing fasciitis is a major cause of amputation (n=15) value morbidity and mortality. There is insufficient (n=24) data on risk factors associated with Age 55 62 0.068 amputations in these patients. The aim of this Gender 0.332 study was to evaluate the risk factors Male 15 7 associated with major amputation. Female 9 8 WBC 20.1 25.9 0.022 DM 19 11 0.674 METHODS: >1 operation 6 10 0.01 Clinical data pertaining to patients Duration 0.104 hospitalized in 2013 to 2015 with NF were <7 days 20 9 retrospectively evaluated. Demographic and >7days 4 6 clinical risk factors for major amputation Timing op 0.485 <24 hours 9 4 (above ankle amputations) were analyzed. >24hours 15 11 Gas shadow 0.076 RESULTS: Yes 9 10 We identified 39 patients hospitalized with NF. No 15 5 The major amputation rate was 38.5% (n=15). Skin necrosis 0.0003 Yes 5 12 On bivariate analysis, the presence of raised No 19 3 white blood cell counts (p=0.22), hemorrhagic bullae (p=0.0003) and patients requiring more Table 1: Characteristics of NF patients according to whether amputation of lower limb was performed than one wound debridement (p=0.01) significantly predicted amputation during CONCLUSION: admission. Amputation was not predicted by Patients presenting with such clinical age, gender, underlying diabetes mellitus, predictors should alert healthcare providers duration of symptoms, timing to first operation regarding the risk of the disease progressing to and presence of gas shadow on plain amputation. radiographs. REFERENCES: DISCUSSIONS: 1. The epidemiology of necrotizing fasciitis The amputation rate of this study was 38.5%, including factors associated with death and which was higher than those reported. amputation. Dworkin MS, Westercamp MD, Dworkin et al similarly reported that skin Park L, McIntyre AEpidemiol Infect. 2009 necrosis was a significant determinant of of 1 Nov; 137(11):1609-14. limb loss. Infection causes tissue edema and 2. Necrotizing fasciitis. Puvanendran R, Huey muscle necrosis, and skin necrosis will occur JC, Pasupathy SCan Fam Physician. 2009 Oct; consequent to thrombosis of microvascular 55(10):981-7. vessels.2

PR02B A Case Report; In Utero Femur Fracture Atypical Presentation In Day 2 Of Life Baby

Saperi Z; Luqman A; Ruzaimi MY Department of Orthopedics, Hospital Kajang, Jalan Semenyih, Kajang, Selangor, 43000, Malaysia.

INTRODUCTION DISCUSSION Femoral fracture in-utero in otherwise a normal Femoral fracture in-utero is uncommon. growing foetus is rare. It contributes big Diagnosis must be made in order for proper influence of the implication and outcome in treatment, management and follow up. term of medical and medico legal aspect. Fractures of bone intra-utero may occur due Proper history, physical examination, difficult in labour especially in assisted vaginal investigation and follow up needed to guide for breech delivery. [1] proper treatment and management. Maternal abdominal trauma as a result of direct injury can lead to fracture which might be miss MATERIAL AND METHODS on serial ultrasound during ante partum follow Clinical evaluation, assessment and up.[2]. Pathological fracture of long bone also investigation were done during patient needs to be rule out as it can affect the child hospitalisation. Paediatric medical record of general health status such as osteogenesis patient also reviewed. imperfecta, ricket or malignancy.[3]

RESULTS CONCLUSION Patient referred to orthopaedic department, In-utero femur fracture is uncommon condition Hospital Kajang with chief complain of left which needs proper clinical assessment, thigh swelling post delivery day 2. evaluation and investigation to arrive on Ante partum and intrapartum history were diagnosis. It will raise an impact on medico unremarkable. There is no similar problem in legal issue and working diagnosis is important family. Antenatal follow up and serial for further treatment. This patient still under ultrasound was normal. investigation and follow up in Hospital Kuala Baby is not syndromic and delivered via Lumpur. spontaneous vaginal delivery at 39 week 5 days with birth weight of 2.98KG and APGAR score REFERENCE 9/10. Noted swelling over left thigh with no 1. Cunningham FG, Leveno KL, Bloom SL, skin changes. No any evidence of bruises over Hauth JC, Gilstrap LC III, Wenstrom KD (eds) other part of body. Ortolani and Barlow test (2005) Section IV. Labor and delivery, chapter normal. Pupil is dark brown and sclera is pink 25: CESAREAN delivery and peripartum in colour. Xray femur (AP/LAT) reported by hysterectomy. In: Williams Obstetrics, 22nd radiologist as undisplcaed mid shaft of left edn. McGraw-Hill, New York, 589–599 femur fracture with suspected congenital bone 2. Shah AJ, Kilcline BA. Trauma in pregnancy. cyst. Emerg Med Clin North Am. 2003; 21: 615- 29. 3. Unexplained fractures in infancy: looking for fragile bones. Nick Bishop, Alan Sprigg, and Ann Dalton Arch Dis Child. 2007 Mar; 92(3): 251–256. doi: 10.1136/adc.2006.10

PR02C Tuberculosis Of The Knee, A Case Report

Premdas V; Firdaus A; Ruzaimi, MY Department of Orthopaedics, Hospital Kajang, Jalan Semenyih, Kajang, Selangor, 43000, Malaysia.

INTRODUCTION stiffness, limp, swelling, and local heat. Tuberculosis (TB) is no longer confined to Although suggested that the organism undeveloped or developing nations. difficult to culture, a 1984 study by Mondal Extrapulmonary manifestations of tuberculosis showed an 89% sensitivity of aspirate cultures are reported in less than one in five cases with for identifying the organism in known the knee affected in 8% after the spine and hip. infections.2 TB infection in knee is very rare and it’s very difficult to establish a diagnosis. CONCLUSION Tuberculosis infection of the knee is an MATERIALS & METHODS uncommon condition which needs vigilance Clinical evaluation, assessment and for its diagnosis, utilizing a combination of investigation were done during hospitalization AFB smear, culture and histopathology plus and periodically after discharge. Medical combined medical and surgical approach. records of patient was also reviewed. REFERENCES RESULTS 1) Henderson MS, Fortin HJ. Tuberculosis of Patient presented to Orthopaedic Dept. the knee joint in the adult. J Bone Joint Hospital Kajang, with complaint of painful Surgery (Am) 1927;9:700–13. right knee for over a period of nine months. 2) Mondal A. Cytological diagnosis of She had developed an antalgic gait, difficulty vertebral tuberculosis with fine needle. J Bone to climb stairs, and limited range of movement Joint Surgery (Am) 1994;76:181–4. of the right knee. It was a difficult task for us to investigate and to conclude a diagnosis even with treatment of antibiotics and analgesia. Final diagnosis was established with HPE results of biopsy taken during diagnostic arthroscopy.

Xray (AP/LAT): shows soft tissue swelling, narrowing of joint space can be due to cartilaginous erosion, no obvious foci lesion or bony destruction seen.

DISCUSSION Joint TB may be suspected in a chronic case of joint pain, usually monoarticular and weight-bearing as noted in this case study. To establish a diagnosis of TB knee is very difficult and require high index of suspicion. Hederson and Frinton1 reported on patients treated for knee TB described common presenting symptoms as gradual onset, pain, PR02D

Cardiac Complication Post Prosthetic Limb In Transfemoral Amputee, A Case Report

Nurhanani MN; W. Nursakinah WM; Aina ZB; Hairenazli A; Anuar A; Ruzaimi MY Department of Orthopaedics, Hospital Kajang, Jalan Semenyih, 43000 Kajang, Selangor, 43000, Malaysia

INTRODUCTION CONCLUSION Traumatic leg amputation commonly affects Higher energy expenditure is required for young, active people and could leads to poor amputee with prosthesis compared to able long term outcomes. bodied. Therefore proper physical Amputees with prosthesis could regain daily rehabilitation is vital prior to prosthesis fitting normal activity with successful and suitable and returning patient to daily activity. Higher rehabilitation programme. Cardiovascular is energy expenditure is translated as one of the risks that could develop among development of cardiac symptoms in this amputees with prosthesis if no proper cardiac patient. rehabilitation prior to preparing patient for prosthesis limb. REFERENCES 1) Perkins ZB; De’Ath HD et al. Factors MATERIALS AND METHODS affecting outcome after traumatic limb Clinical evaluation, assessment and amputation. British Journal of Surgery. 1:75- investigation were done during hospitalization 86, January 2012. and clinic follows up. Medical records of 2) Mozumdar A; Roy SK. Validity of an patient were also reviewed. alternative anthropometric trait as cardiovascular diseases risk factor. European RESULT Journal of Clinical Nutrition. 60(10):1180- Patient had alleged motor vehicle accident and 1188, October 2006. sustained severe crush injury with traumatic 3) Marcelle PR; Marilia MN et al. Increased left above knee amputation. She underwent peripheral vascular resistance in male patients physiotherapy at Rehabilitation Centre under with traumatic lower limb amputation. ‘Return To Work Programme’ in . 20(6):341-345, December 2015. However, she developed heart failures symptoms on exertion within 1 month after fully return to work as catering manager with left above knee prosthetic limb.

DISCUSSION In amputees with prosthetic limb, more energy is demanded from the cardiovascular and pulmonary system. Mozumdar et al reported on higher prevalence of cardiovascular risk factor among individuals with above knee amputation than below-knee amputation. Supported by Marcelle et al case report, which showed increased peripheral vascular resistance in patient with traumatic amputation. Studies done by Perkins et al demonstrated those patients who undergo leg amputation after trauma are at risk of poor long-term physical and mental health.

PR03A Acute Haematogenous Osteomyelitis In Paediatrics Following Upper Respiratory Tract Infection And Immunocompromised Patient; A Case Report

Sallehudin A; Hairenazli A; Syarul AS; Kahir M; Anuar A; Ruzaimi MY Department of Orthopaedics, Hospital Kajang, Jalan Semenyih, Kajang, Selangor, 43000 Malaysia

INTRODUCTION symptoms is within 2 weeks from time of Osteomyelitis, defined as an inflammation of presentation. Major source of infection are bone generally caused by pyogenic organism, haematogenous spread arising from others foci is a common disorder of childhood. Infection of infection eg. Respiratory tract infection. It most commonly is caused by blood-borne may happen in patient with bacteria that localize in the metaphysis. Trauma immunocompromised status, malnourished. or surgery also may result in direct inoculation Ron et al managing acute haematogenous or implantation of bacteria into the bone, or an osteomyelitis is crucial to achieve cure in adjacent focus of infection might extend osteomyelitis and septic arthritis. An ideal directly to the bone, resulting in osteomyelitis. antibiotic for such treatment has the following Immunocompromised patient has higher characteristic; Appropriate microbiologic susceptibility to osteomyelitis. coverage, excellent penetration through bones and joints, proven safety and efficacy, suitable MATERIAL AND METHODS for use in ambulatory treatment after the initial Clinical evaluation, assessment and phase of intravenous therapy. investigation were done during patient hospitalisation. Patient's paediatric medical CONCLUSION record reviewed. Acute osteomyelitis in paediatrics has a good prognosis with adequate treatment ranging RESULTS from early detection and antibiotic A 4 years old boy referred to Orthopaedic administration. department with history of pain over the left ankle for 2 days. Patient has underlying REFERENCES nephrotic syndrome since March 2014. He 1. Nada S et al., Management of acute presented with left ankle pain for 2 days with haematogenous osteomyelitis in children.2010 limping gait and refused to walk. Prior to that, Feb 8(2): pg 175-181 he has history of fever and upper respiratory 2. Ron D et al., Management of acute tract infection symptoms for 2 days. The fever haematogenous osteomyelitis and septic was associated with chills and rigor. On arthrits in paediatric patient physical examination, the left ankle has minimal swelling and mild redness. It was warm to touch but the range of motion was full. X ray of the left ankle, tibia and fibula showed no obvious fracture. Ultrasound findings showed subcutaneous tissue oedema at the left shin and medial part of the left ankle with no evidence of deep seated collection. Bone scan which was done on 30/11/2015 showed features of left tibia osteomyelitis. He was given IV Cefuroxime for two weeks followed by 4 weeks of oral.

DISCUSSION Nada S et al reported acute osteomyelitis is an inflammation of bone caused by pyogenic organisms. In the acute setting, duration of PR03B Effects Of Bone Marrow Enhancement On The Integration Of Gamma Irradiated Allograft- A Preliminary Study

1FY Thong; 1Azura Mansor; 2Norimah MY; 1Faizatul Izza Rozalli; 1Farhana Fadzli 1Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia 2Malaysian Institute for Nuclear Technology Research (MINT), Bangi, 43000 Kajang, Selangor, Malaysia

INTRODUCTION: autologous bone marrow enhancement use. The gold standard of bone-grafting is (p>0.05). autologous bone from the iliac crest but its Figure 1: Mean of radiological Grades by Groups harvesting has its disadvantages. Allografts Weeks Group A Group B offer а viаble аlternаtive; however vаrious 0 0 0 contаminаnts аnd pаthologies mаy be 3 6.5 6 trаnsferred. The need to ensure the sаfety of 5 7.5 7.3 recipients’ hаs resulted in the use of vаrious A1 A2 A3 A4 B1 B2 B3 B4 methods of sterilizаtion, which causes changes Union 3 - 3 4 2 - 2 2 in biological properties. Thus, there is a need Spongiosa 4 - 4 4 1 - 2 2 for technologies to enhance healing by Cortex 2 - 3 4 0 - 3 3 improving the incorporation of allografts. Bone 4 - 3 4 1 - 4 4 Marrow MATERIALS & METHODS: Sum 13 - 13 16 4 - 11 11 2 groups of 4 animals each were used. Each Figure 2: Summary of Histological Scores rabbit had a bone defect created in the meta- DISCUSSIONS: diaphyseal region of the tibia and were studied As concerns regarding safety of bone grafts for 5 weeks. In the study group, the defect is have increased, so have the use of new filled with Gamma irradiated allograft with sterilization methods which affects both the bone marrow enhancement. While the control biological and biomechanical integrity of the group only Gamma irradiated allograft. graft material. It was suggested that the best Analysis was done: way of ensuring the incorporation of foreign 1. Radiologically, CT scans are taken at grafts is to impregnate the graft with marrow weeks 1, 3 and 5 post surgery and are obtained from the host. However to date, a scored by 2 radiologists blinded to definitive clinical study demonstrating the treatment. efficacy of autologous bone marrow aspirate 2. Pathological, all tibias analysed as a graft enhancer does not exist. The present macroscopically, before being sent for study aims to study the effects of autologous histopathological analysis; and by a bone marrow enhancement on allografts pathologist blinded to treatment. sterilized via Gamma irradiation with regards RESULTS: to healing of a unicortical bony defect in Radiological: Almost all subjects showed 50 rabbits. percent of the defect being covered by new CONCLUSION: bone by the 3rd week; with the average Based on the results of this preliminary study, residual defect size being smaller in the study bone graft incorporation is not enhanced by group at 5 weeks. Comparison of HU units at the used of bone marrow enhancement in the defect site shows the study group having allografts. an apparent advantage over the control group. REFERENCES: However analysis showed all differences were 1. Nade, S., & Burwell, R. G. (1977). statistically insignificant (P>0.05). Decalcified bone as a substrate for Pathological: Abundant callous formation was osteogenesis. J Bone Joint Surg [Br], observed macroscopically in the study group. 59(2), 189-196. Final histopathological scores show no 2. Nather A, David V, Teng JWH et al difference in outcome with or without (2010) Effect of autologous

ABSTRACT TRUNCATED PR03C

Effects Of Different Intensity Treadmill Training On Bone Mineral Density In Young And Old Rats

Randhawa SS; Chong PP; H Balaji; TK Zaman Department of Orthopaedic Surgery, University of Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia

Introduction mean difference in BMD after 8 weeks was It is known that exercise increases bone 1.76. density. Bone mineral density (BMD) is a measure of bone density which reflects the Discussion strength of bone as represented mostly by its The main objectives of this study was to calcium content. There have been scant reports investigate the effects of aerobic exercise on on the effects of exercise and bone mineral bone mineral density and its effect on two density in different age groups. It was different age groups of rats at two time points. therefore the goal of this study to identify the Previous studies undertaken have shown that effects of exercise on bone mineral density in exercise does increase bone mineral density a young and old rat population. and they include interventions such as swimming, jumping, climbing and resistance Methods exercise with only a limited few reporting on Thirty young (8-12 weeks old) and 30 old effects of treadmill running. Here in this study Sprague Dawley rats (12 months old) were we have shown that daily 60 minutes of each divided into 5 groups with 6 rats in each treadmill running does not necessarily result in group. They consisted of a control group; an increase in BMD in all age groups but in sacrificed before study intervention, sedentary fact only in the elderly group (12 months old group for 2 weeks, sedentary for 8 weeks, rats) trained for 2 weeks and trained for 8 weeks. Sedentary regime involved 10 minutes of Conclusion treadmill exercise once a week at a speed of Overall from this study, exercise does 0.3 km/hr. Exercise training regime involved contribute to a positive increase in BMD. treadmill exercise of 1 hour for 5 days a week Increase in BMD is only present in the old rat at an intensity of 50- 60% of maximal exercise group that trains for 8 weeks as compared to capacity. The rats were then sacrificed and the young rat group where there is a decline in their femurs were harvested at the completion BMD after 8 weeks of training. Training for 2 of the training protocol. BMD of all femurs weeks does result in an increase in BMD in were undertaken using the Scanco X treme CT the young rat group and a decline in the old rat scan. group. We conclude from this that exercise training for 8 weeks in the elderly will result Result in an increase in BMD. BMD of all 60 young and old rat femurs were obtained and the mean bone density value of References the young rat group after 8 weeks of training 1. Dempster DW. 2003. Bone was 993.04 [mg/ HA ccm] as compared to microarchitecture and strength. Osteoporos Int 1004.97 obtained from the sedentary rat at 8 14:S54–S56 weeks. For the old rat group, 8 weeks of 2. Goseki M, Omi N, Oida S, Ezawa I, Sasaki training yielded a mean bone density value of S. Voluntary exercise increases osteogenetic 1058.65 and 1056.86 for the sedentary rat. The activity in rat bones. Bull Tokyo Med Dent mean difference in BMD in the young rat Univ. 1995;42(1):1-8. group after 8 weeks was -28.32, demonstrating an overall decline in BMD in young rats after 8 weeks of training. In the old rat group, the PR03D Prevalence Of Neuropathic Pain Post Lower Limb Amputation In Hospital Selayang

Abdullah N.; Zakaria AF Department of Orthopaedic, Hospital Selayang, Lebuhraya Selayang-Kepong, 68100 Batu Caves, Selangor Darul Ehsan, Malaysia

INTRODUCTION: Post amputation neuropathic pain is a devastating complication leading to inability to return to work, delay in using prosthesis and even depression. The study helps in evaluating the prevalence of this condition, as lower limb amputation is a common surgery performed in Hospital Selayang.

MATERIALS & METHODS: This is a retrospective and descriptive study of 196 patients in the year of 2014 to 2015. Data of patients who have undergone above (AKA) DISCUSSIONS: or below knee amputation (BKA) were There are limited studies on prevalence of obtained using the Electronic Medical Record neuropathic pain post lower limb amputation (EMR). Subjects were categorized based on and this may well be the first study in Malaysia. their demographic, side of limb and aetiology The result showed correlating factors of amputation. They were identified of having associated with this disorder. Managing this neuropathic pain either as phantom sensation condition is challenging, as there are (PSs), phantom pain (PP), residual limb/ stump multidimensional aspects of pain and affective pain (RLP) or absent pain (AP) as described by disorders that may contribute to the total pain experience. Eugene Hsu et al. Types of anaesthesia given either general (GA) or regional (RA) were also evaluated. Data was statistically formulated CONCLUSION: Neuropathic pain post lower limb amputation is using SPSS 17 software. Incomplete EMR and a debilitating complication and the percentage other types of lower limb amputations were of patients suffering from it is noteworthy. A excluded. more detailed study on planned perioperative

intervention would be beneficial in reducing RESULTS: the occurrence. A total of 15.3% of patients suffered from neuropathic pain post lower limb amputation with a prevalence of female Indians. Infection REFERENCES: 1. Eugene Hsu et al., Postamputation pain: (15.2%) was the leading cause of limb loss epidemiology, mechanism and treatment; followed by trauma (3.57%) and peripheral Journal of Pain Research 2013; Vol 6: 121-136. vascular disease (2.04%). More patients 2. S Rasmussen et al., Management of nerves develop neuropathic pain after above knee during leg amputation – a neglected area in our amputation with right side more common than understanding of the pathogenesis of phantom the left. Regional anaesthesia was seen to be limb pain, Acta Anaesthesiol Scand 2007; Vol associated with post operatively neuropathic 51: 1115–1116 pain compared to general anaesthesia. Phantom sensation (66.67%) is the most experienced by patients as opposed to PP (43.33%) and RLP (40%).

PR04A Similar Annexin-8 Expression Of Active Osteoclasts Found In Osteoblasts And Osteocytes In Vitro

1,2,3Zawawi MSF; 3Dharmapatni AASSK; 3Cantley MD; 4McHugh KP; 5Atkins GJ; 3Haynes DR; 6Pavlos N; 3Crotti TN 1Department of Orthopaedics, School of Medical Sciences, Universiti Sains Malaysia (USM), Kelantan, Malaysia. 2Department of Pathology, School of Medical Sciences, Universiti Sains Malaysia (USM), Kelantan, Malaysia. 3School of Medicine, The University of Adelaide, SA, Australia. 4 Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, U.S.A. 5Bone Cell Biology Group, Discipline of Orthopaedics & Trauma, The University of Adelaide, SA, Australia. 6Faculty of Medicine, Dentistry and Health Sciences School of Surgery, Centre for Orthopaedic Research, University of Western Australia, WA, Australia.

INTRODUCTION: RESULTS: Annexin-8 (AnnVIII) has been shown to be Figure 1: NFATc1, AnnVIII expression in expressed by human osteoclasts in vivo, in rheumatoid arthritis and peri-implant tissues. Murine AnnVIII is induced over the time course of osteoclast differentiation in vitro, with higher levels expressed when cultured on murine calvarial bone compared to plastic. AnnVIII siRNA knockdown suggests a role in cytoskeletal reorganization during osteoclast differentiation (1). In silico analysis and co- transfection of AnnVIII promoter with NFATc1 expression vectors support AnnVIII as an NFATc1-regulated osteoclast gene. Additionally, AnnVIII gene expression is suppressed by NFATc1 inhibitor, 11R-VIVIT peptide (2). MATERIALS & METHODS: DISCUSSIONS: We investigated expression of AnnVIII by Quantitative RT-PCR analysis demonstrated human osteoblasts and osteocytes compared expression of osteoclast genes such as β3 with human peripheral blood mononuclear integrin (β3) and NFATc1 as well as AnnVIII cells (PBMCs)-derived osteoclasts by human derived osteoclasts grown on differentiated on whale tooth dentine. dentine in vitro. In addition, we found Formation of active osteoclasts was verified osteoblast and osteocyte expressed AnnVIII, by dentine pit resorption. Primary osteoblast NFATc1 and β3. The expression of AnnVIII cultures were generated from human was similar to that seen in osteoclasts. intertrochanteric trabecular bone samples. Cells were grown under conditions permissive CONCLUSION: for human osteoblast differentiation over 35 This study shows that all three key cells days, giving rise to a mineralised, osteocyte- regulating bone metabolism expressed like culture (3). Osteoblast-like cells (pre- AnnVIII, a gene important for osteoclast mineralisation, proliferative stage, expressing activity. E11, TNAP, COLA1, MEPE, but negative for REFERENCES:

DMP1 and SOST mRNA) were isolated at Day 1. Crotti et al., J Cell Phys 2011.

3 and osteocyte-like cells (post-proliferative, 2. Zawawi et al., Biochem Biophys Res post-mineralisation stage, expressing Comm 2012. increased PHEX, DMP1 and SOST) at Day 35. 3. Atkins et al., J Bone Min Res 2011.

PR04B Incidence Of Hospital Acquired Pressure Ulcers In Patients With Lower Limb Long Bone And Pelvic Fractures In A District Hospital

MR.MHelmi; MdShariff.MS; LAzura Department of Orthopaedics, Hospital Ampang, Jalan Mewah Utara, Pandan Mewah, 68000 Ampang, Selangor, Malaysia

INTRODUCTION: developed PU were above the age of 65 years Long bone lower limb and pelvic fractures (10 patients/ 62.5%) and five (31.3%) were impairs a person’s ability to ambulate. This between the ages of 55 to 65. The single temporary ‘immobile’ state may lead to the young patient (aged 17 years) had both tibia formation of pressure ulcers (PU). This may and femur fractures and also upper limb long be worsened by a long waiting surgical time bone fractures. This same patient is the only due to various factors, and/ or prolonged person that developed PU in those with traction. The aim of this study were to combined tibia and femoral fractures (1 out of determine the incidence of PU in patients with 16/ 6.25%) and combined upper limb and femur, tibia and/or pelvic fractures and the lower limb fractures ( 1out of 10 /10%). factors that may have contributed to its Three patients who had developed PU had a formation. history of previously treated malignancy of METHODS: various causes. The incidence of PU was A cross sectional study was conducted in 100% as no other had previous history of Hospital Ampang within 6 months period malignancies. starting from May 2015 until October 2015. DISCUSSIONS: Patients who were hospitalised with femur, Incidence of hospital acquired PU in health tibia and/or pelvic bone fractures were facilities across the world varies from 6.5% to included in this study. Their demographic, as high as 9%. Our incidence rate may be history and co-morbidities were documented. slightly higher at 10.6% but this may be due to The skin overlying the sacrum and heels were our focus on only lower limb fractures. In the examined on admission and daily by the elderly, our incidence was at 17% (10 out of primary team members. All the findings were 57 patients) and this is slightly lower as in documented. Patients who were at high risk of some studies the incidence in the elderly was getting PU as determined by Braden scale as high as 73%. were nursed according to preexisting nursing Female gender also seemed to be a significant protocols. However, those patients with pre- risk factor. This may be also due to the age as existing PU were excluded from this study. many of the female patients were the elderly RESULTS: with fragility fractures whereas majority of the A total of 151 patients were included in this male patients were young men admitted due to study: 102 patients had a single femoral high impact trauma causing the fractures. The fracture, 30 patients had a single tibia fracture, history of previously treated malignancies three patients had pelvic fracture and 16 were noted to very significant as all three patients had a combination of femoral and patients with this ‘risk factor’ did develop PU. tibia bone fractures. Majority of patients were CONCLUSION: male (91 patients/60.3%) and were below 65 The elderly age, female gender, previous years of age (94 patients/62.7%). 16 patients history of malignancies and multiple long (10.6%) developed PU while hospitalized. bone fractures seems to be significant risk Eight (5.3%) developed isolated sacral PU, factors in developing PU in patients with long one (0.67%) heel PU, five (3.31%) had bone lower limb and pelvic fractures. isolated gluteal PU and two patients had a REF both of sacral and gluteal PU (1.32%). Twelve Hospital-Acquired Pressure Ulcers: Results patients were female (20% incidence overall from the National Medicare Patient Safety amongst the female patients) and four male Monitoring System Study (4.4 % overall incidence of PU amongst the Courtney H. Lyder ND et al male patients). Majority of patients who PR04C Orthopaedic Surgery Schedule Online System (OSSOS) Improves Surgery Schedule Management In The Department Of Ortopaedics, Hospital Universiti Sains Malaysia

1,2Mohamed, Faudzly Adi Rizal; 1Zawawi, Muhamad Syahrul Fitri; 1Yusof, Mohd Imran; 2Nik Ismail, Nik Isrozaidi 1Department of Orthopaedics, School of Medical Sciences, Universiti Sains Malaysia (USM), 16150 Kubang Kerian, Kelantan, Malaysia 2Department of Software Engineering, Faculty of Computing, Universiti Teknologi Malaysia (UTM), 81310 Skudai, Johor, Malaysia.

INTRODUCTION: Figure 2: The output enables automatic Department of Ortopaedics, Universiti Sains schedule and data analyses. Malaysia (USM) has been practising the traditional way of managing surgery schedule. Every operation threatre (OT) list is manually written and computerised. By developing a systemic database using an internet-based technology, Orthopaedic Surgery Schedule Online System (OSSOS) may improve and enhance the efficiency of the current scheduling practice.

MATERIALS & METHODS: The development of OSSOS was designed based on the knowledge of Object-Oriented (OO) and Object-Oriented Analysis and Design (OOAD). Software technology tools such as Hyper Text Markup Language (HTML), Hypertext Preprossesor (PHP) and JavaScript as programming language were used in conjunction with the MySQL as the database management system.

RESULTS: DISCUSSIONS: We have developed an interactive, responsive Consistent with the knowledge about the and dynamic webpage and mobile-web. specifications of the latest software and hardware, OSSOS operates well and user Figure 1: Main page of OSSOS via website. friendly. This system is being used by users as trials and we have been receiving positive feedbacks.

CONCLUSION: We hope this project may overcome surgery schedule-related issues and improve treatment service in the Department of Orthopaedics, Hospital Universiti Sains Malaysia.

REFERENCES: 1. Fei et al., Computers & Industrial Engineering 58 (2010) 221–230. 2. Cardoen et al., European Journal of

Operational Research 201 (2010) 921–932.

3. Saremi et al., Int. J. Production Economics 141(2013) 646–658. PR04D Necrotising Fasciitis: A 3-Year Retrospective Study Of Cases At Hospital Duchess Of Kent, Sabah

Lee KW, Yasser AK, N Shakirah AH , Loo WH Department of Orthopaedics, Hospital Duchess of Kent, KM3.2 Jalan Utara, 90000 Sandakan, Sabah

INTRODUCTION: Table 2:microorganisms isolated Necrotising fasciitis (NF) is a rapidly Microorganism Number Percentage progressive inflammatory infection of the Pseudomonas 2 7.4% Enterobacter 4 14.8% fascia,with secondary necrosis of the Staphylococcus 3 12.5% subcutaneous tissues 1. Upon admission and Streptococcus 6 22.2% subsequent debridements,various data can be Others 4 14.8% collected. No Growth 3 11.1% METHODS: Retrospective review of all NF cases at HDOK Table 3:laboratory results from 1st of January 2011 to 31st December Laboratory data Total Number Percentage 2015 was done.Diagnosis of NF was identified Hb (g/dL) <11 17 11 64.7% WBC(cells/mm3) >15 17 11 64.7% based on intra-op findings.Microbiological Creatinine>141mmol/L 17 3 17.6% findings taken during intra-op were Na(mmol/l)< 135 17 12 70.6% traced.Patients were excluded if intra-op Glucose (mmol/l) >10 17 7 41.2% findings were not NF. CRP (mg/l) >150 11 6 54.5% RESULTS: DISCUSSIONS: A total of 27 cases of NF were identified.26 Diabetes mellitus was the leading predisposing patients were confirmed to be alive 6 months factor in our patients as found in previous post discharge(96%).There were 11 studies2,3.It was usually due to a combination males(40.7%) and 16 females (59.3%).Overall of increased susceptibility to minor trauma median age was 56 (mean 53.84); 50.2 for resulting from peripheral sensory males (median 49.5) and 57 for females polyneuropathy,tissue hypoxia caused by (median 57).Table 1 shows the co-morbidities diabetic vascular disease and underlying of patients.The most common was diabetes immunodeficiency3.The mortality rate is mellitus(48%). The most common site for NF relatively low in our studies as it is a was lower extremities with 12 patients (44.4%) retrospective study on patients managed each for right and left lower limbs.Lower limbs optimally in hospital settings.The mainstay of NF was 24 patients(88.8%) in total. Isolated management are early and complete surgical microorganisms are summarized in Table debridement combined with antimicrobial 2.The organisms isolated are mostly therapy and close monitoring4,5.These monomicrobial,as opposed to most studies that contributed to the relatively low mortality rate show polymicrobial dominance 6.Table 3 of our studies.Among the criteria of LRINEC shows blood results in accordance with score,the one with the highest predictive value LRINEC score. is hyponatraemia. Out of the 11patients with The mean duration of hospital stay was 25.6 full blood results, only 6(54.5%) has LRINEC days. ≥6, reinforcing that clinical judgment trumps LRINEC score. Further studies needed to Table 1:co-morbidities Co-morbidities Number Percentage determine the reasons behind monomicrobial No medical illness 7 26% dominance in our study. Diabetes Mellitus 13 48% REFERENCES: Hypertension 8 30% 1.RichardF,MichaelSB;.(July09,2015).Necroti Renal disease 1 3.7% singFascitis.emedicine. Dyslipidaemia 5 18.5% 2.HungCC,ChangSC,LinSF.Clinical CVS diseases 1 3.7% manifestations, microbiology and prognosis of Others 3 11.1%

ABSTRACT TRUNCATED PR05A Efficacy Evaluation of HydrocynTM Aqua In Comparison To Commercially Available Super Oxidized Solution In Diabetic Foot Ulcers

Abdul Aziz MS; Amran AS Department of Orthopaedic, Hospital Universiti Sains Malaysia, Kubang Kerian, 16150 Kelantan

INTRODUCTION: Table 1: Percentage of wound size reduction after 2 Diabetic patients will have 15 percent of risk to weeks of treatment. develop diabetic foot ulcers during the disease Group Mean Mean t- p-value 1 (n) (SD) difference statistic course. The treatment aim is to get wound (95% CI) healing combining surgical and non-surgical Hydrocyn 30.21 treatment.Disinfectants have been used (20.05) traditionally but it has the argument of cyto- 7.87 (- 1.68 (58) >0.05 toxicity against host2. HydrocynTM Aqua is an 1.53,17.23) CASOS 22.34 antiseptic solution in the form of stable super (16.11) oxidized solution with neutral pH and longer *Independent t-test was applied; shelf life.The objective of this study is to 3 TM Table 2: Wound bed scoring after 2 weeks of treatment compare the efficacy of Hydrocyn Aqua with Group Mean Mean t-statistic p-value the commercially available super oxidized (n) (SD) difference solution (CASOS) in term of wound size (95% CI) reduction and optimal wound bed preparation. Hydrocyn 14.50 (1.53) 0.03 (- 0.08 (58) >0.05 METHODS: 0.77,0.84) This is a prospective, single-blinded CASOS 14.47 randomized controlled trial involving patients (1.59) with both type diabetes mellitus, who attended *Independent t-test was applied Orthopaedic Department, Hospital Universiti DISCUSSIONS Sains Malaysia, Kubang Kerian between June Super oxidized solution is produced when 2015 to December 2015 with infected foot purified water containing chloride is oxidized ulcers and surgically debrided. Patients who creating oxidized water and chlorine further fulfilled the criteria were randomized to receive producing Hypochlorous Acid and Sodium treatment with HydrocynTM Aqua (n = 30) or Hypochlorite. Study for in vitro antimicrobial CASOS (n = 30) with daily dressing for 2 and antiviral showed it exerts a wide weeks. Outcome measures include antimicrobial spectrum compared to acidic demographic data, size of wounds, wound bed disinfectants. Multiple studies showed scoring3 and complications at baseline and at 2 nontoxic neutral pH super oxidized solution is weeks. more effective and safer than conventional 2 disinfectant. RESULTS: CONCLUSION: Wound reduction percentage after 2 weeks of There is no significant difference for the TM treatment with HydrocynTM Aqua and CASOS efficacy of Hydrocyn Aqua compared to the showed no difference between both (p- commercially available super oxidized solution value >0.05, Mean Difference 7.87 [-1.53, in the treatment of diabetic foot ulcers. 17.23] t (58) = 1.68). The wound bed scoring at REFERENCES: 2 weeks of treatment showed no difference for 1.Academy of Medicine Malaysia. CPG. Management of both treatments. (p-value > 0.05, Mean Diabetic Foot Ulcers 2004 2. Luca PD (2006), Super-oxidised Solutions Therapy Difference 0.03 [-0.77, 0.84], t (58) = 0.08). No For Treatment Of Infected Diabetic Foot Ulcers, Wounds adverse reactions recorded for both groups. 2006;18(9)262-270 3.V. Falanga, Wound bed scores and its correlation with healing of chronic wound, Dermatologic Therapy, Vol. 19, 2006, 383–390 PR05B Atypical Femur Fracture With Use Of Bisphosphonates

1 Avthar Singh; 2Ang Charles 1Hospital Tengku Ampuan Rahimah Klang, Selangor, 41200, Malaysia 2Department of Orthopaedic Surgery, Hospital Tengku Ampuan Rahimah Klang, Selangor, 41200, Malaysia

ABSTRACT: CASE REPORT: Bisphosphonates has been widely used to treat A 74year old Indian lady was diagnosed with osteoporosis with significant data and studies osteoporosis in 2008 based on DXA and proving its efficacy in reducing osteoperotic started on alendronate 70mg weekly. She was fracture risk. Although bisphosphonates are otherwise assymptomatic. The medication was generally safe and well tolerated, recent cases continued during each follow up with no has been reported on the adverse effects CTX/DXA done. On 13/03/2014 she related to its long-term use, mainly jaw experienced lower back pain and left thigh osteonecrosis and atypical femur fracture. pain to which an lumbosacral x-ray and left Alendronate’s ability to accumulate in bone femur x-ray was done. The treating surgeon with some persistent protective effect after detected abnormal cortical thickening and therapy is stopped, making it reasonable to beaking of outer cortex on the left femur x-ray consider a "drug holiday." The duration of and advised her to discontinue the alendronate. therapy and the length of the holiday is based She was also advised for careful ambulation as on clinical judgment. However due to lack of the slightest trauma my result in a fracture. On understanding on the pathogenesis of these 15/9/2014 during her evening walk, she complications and its decision for drug accidentally stepped on a pebble (no fall) to holiday which is based on clinical judgment, which she felt a sudden intense pain over her these complications continue to occur. left thigh and unable to continue walking. On examination, she was unable to weight INTRODUCTION: bear, left thigh was slightly swollen and tender Osteoporosis is a skeletal disorder defined as over lateral aspect of proximal left femur. reduced bone strength predisposing the Knee and hip movements were free and individual to increased risk of vertebral and painless. Neurological examination were non non-vertebral fractures. Bisphosphonates have significant. No abnormal findings over the been widely used in the management of right leg and no signs of active arthritis. osteoporosis. They decrease bone resorption Laboratory investigations shows no and turnover, increase BMD, maintain abnormalities with C-reactive protein (CRP) at structural and material properties of bone, and 1.79 mg/L, Erythrocyte sedimentation rate thereby reduce the risk of fractures. It has been (ESR) 10 mm/hr, serum calcium 2.21 mmol/L suggested that the long-term residence time of (corrected), serum phosphate 1.08 mmol/L, bisphosphonates in bone and their ability to Alkaline phosphatase (ALP) 70 IU/L and decrease bone turnover for prolonged periods creatinine 55 umol/L (all results within may eventually impair the ability of bone to reference range) remodel, leading to accumulation of Plain radiograph of left femur showed a microdamage and increased bone fragility. subtrochanteric fracture with cortical Unusual subtrochanteric/diaphyseal femur thickening of the femur diaphysis. On fractures in patients treated with alendronate comparing with the plain radiograph taken on have been reported and suggested that 13/3/2014, the fracture line was seen running excessive suppression of bone turnover and thru the site where the beaking was previously length of treatment may be involved in their seen pathogenesis, although no causal relationship was shown.

ABSTRACT TRUNCATED PR05C Role Of Baking Soda In Gouty Tophi Wound

Kee Ai Wong; Sia Ung; Noreen FMN; Azira Y; Faris K Orthopaedic Department, Sarawak General Hospital, Jalan Hospital, Kuching, 93586, Malaysia

INTRODUCTION: Upon discharge, the wound was clean, Gouty tophi wound poses a great challenge to granulating with minimal tophi material. wound care professionals because the sequelae Review of wound during follow-up showed a of chonic ulcerative tophaceous wound may re-epithelializing wound, which significantly eventually result in sepsis or amputation1. reduced in size. Patients with gout are at high risk of comorbidities such as renal failure, which may RESULTS: further contribute negative impact in wound healing2. Baking soda had been use in cleansing and treating wounds since ancient Egyptian. Figure 1: Day 0 Figure 2: Day 36 Figure 3: Day 57 Nowadays in dentistry, baking soda is proved to enhance removal of plaque biofilm by DISCUSSIONS: There is yet a guideline for wound care of decreasing viscosity of the polysaccharide tophaceous ulcers. Recurrence and chronicity matrix of plaque fluid and its detergent effect of the disease are the major challenge besides due to its alkalinity3. Bicarbonate ion as negative charge also causes displacement of the under-treatment and even ignorance of management for patients with tophaceous bacteria on wound bed3. However, its usage in wounds. Further study regarding the tophi wounds is yet to explore. mechanism of action and ideal dilution of the

baking soda should be carried out in order to CASE REPORT: have maximum benefit on tophaceous wound. A 76 year-old Chinese man with underlying gout presented with right foot abscess and infected gouty tophi of right lateral ankle. On CONCLUSION: Application of baking soda in tophaceous admission, he was tachycardic with wound left a footprint in wound care temperature of 38.4 C. Wound debridement of profession. Future laboratory and clinical right lateral ankle and incision and drainage research are required to provide more were performed soon after his presentation to promising evidence. our center. Post-operatively, the wound care of the tophi wound became a challenge despite trial of various modern dressing i.e. Salcoceryl REFERENCES: gel and Aquacel Ag. 1. Filanovsky MG, Sukhdeo K, McNamara After all the dressing techniques have been MC. Ulcerated tophaceous gout. BMJ exhausted, an idea of baking soda was case reports. 2015 employed for the wound management. 1g of 2. Patel GK, Davies WL, Price PP, Harding baking soda was mixed with 50cc normal KG. Ulcerated tophaceous gout. saline. Gauze treated with the mixture as International wound journal. 2010 Oct; mentioned was left on the wound for 15 7(5): 423-7 minutes, followed by desloughing and 3. Ghassemi, A. et al. 2008. A four-week application of a thin layer of Salcoceryl Gel. clinical study to evaluate and compare the The procedure was done twice a day. The effectiveness of baking soda dentifrice tophaceous wound improved significantly 3 and an antimicrobial dentifrice in days after the dressing. Tophi material could reducing plaque. J Clin Dent 19(4), be removed easily from wound bed and thus pp.120-126. wound healing progressed into granulation state. Patient was discharged nine days after the commencement of dressing using soda. PR05D The Effect Of Age And Exercise On Tendon Characteristics – An Animal Study

Kasim, Noor Sa’adah; T Kamarul Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

INTRODUCTION: It has been well established that various factors affect tendon homeostasis, including exercise and aging. While long-term exercise has been proven to improve tendon structural and biochemical properties, physiologically age related changes would have an adverse effect on the these properties which result in weaker performance. This study aims to DISCUSSIONS: investigate the effect of exercise on This experimental study demonstrates that the morphological and homeostasis changes in overall effect of exercise is beneficial in the different age groups. tendon based on histological and gene MATERIALS & METHODS: expression analysis. The increases in tenocyte 60 Sprague Dawley rats were used in this number and collagen expression were noted in experimental study which were equally response to exercise; which also proven to be divided into 2 groups; young (8 weeks old) adequate in maintaining collagen expression in and old (12 months old). They were further the elderly. The elevated expression of subdivided into 2 subgroups; sedentary and Tenascin–C, which is associated with trained groups which underwent different inflammation and repair in the sedentary exercise protocol and euthanized at 0 week, 2 tendon implies that occasional, infrequent low weeks and 8 weeks. intensity activity may be associated with more

RESULTS: harm to the musculoskeletal system. Histological evaluation found that the tenocyte CONCLUSION: number in the young trained group was This experimental study concludes that significantly higher than in the sedentary frequent, moderate intensity is beneficial for group. The tendinopathy features were marked the tendon; as demonstrated by histological in the old tendon and exercise did not reverse and gene expression analysis. Howver, the these changes. The collagen expression was effect of low intensity and irregular exercise elevated in the trained tendon of both young need to be re-evaluated especially in and old group; however the expression of biomechanical analysis. collagen seem to be exhausted in the old REFERENCES: tendon after prolonged period of exercise. 1. Ari Pajala et al. Tenascin-C and type I and Tenascin–C was found to be significantly III collagen expression in total Achilles tendon higher in the sedentary group of both young rupture. An immunohistochemical study. and old tendon. Histol Histopathol 2009; 24, 1207-1211. 2. Birch H.L et al. Physical activity: does Figureg 1: Collagengp I Expression long-term, high-intensity exercise in horses result in tendon degeneration? Journal of Applied Physiology 2008;105(6), 1927-1933.

Figure 2: Tenascin-C Expression PR06A Study Of Post-Operative Fever In Patients Undergoing Orthopedic Surgeries

Rao Muhindra; Chung Sing Han; Yusoff Muhammad Department of Orthopedics, Hospital Sultan Haji Ahmad Shah, 28000 Temerloh, Pahang, Malaysia.

INTRODUCTION: Onset of fever following surgery Fever is rise in the core body temperature above the normal diurnal variations.1 10 According to studies of healthy individuals 18 8 – 40 years of age, an a.m. temperature of 6 greater than 37.2 °C or a p.m. temperature of 4 1 greater than 37.7 °C would define a fever. patientsno of 2 However, there is no exact definition or 0 uniform clinical definition of a significant less than 48 48 to 72 hours more than 72 fever. The incidence for postoperative fever hours hours ranges very widely from 14% to 91% as per duration published data, depending on the definition of DISCUSSIONS: fever in those studies as well as the patient A total number of 280 patients undergoing population of those studies.1,2 This study aims orthopedic surgery were prospectively to identify the incidence of post-operative reviewed for development of fever as defined. fever in orthopedic surgeries and the causative The 6% of patients (17) who developed fever factors. is much lower than numbers seen in similar studies abroad.2 In this study it was observed METHODS: that majority of the cases developed fever A prospective study was conducted in early on (13 of the 17 had fever in less than 48 orthopedic wards Hospital Sultan Haji Ahmad hours), similar to data for similar studies.2 As Shah, Temerloh between October until there were no obvious causative factor for the November 2015. During this period a total of fever, we postulate that the cause of fever in 280 patients who underwent various the early post-operative period to be due to orthopedic surgeries including elective clean physiological reaction of the patients to the implant surgeries and emergency fracture surgery itself. 2 patients developed clear fixation were evaluated for fever during the infection during the post-operative period post-operative period. Exclusion criteria were requiring cultures and antibiotics. The onset of patients who had fever prior to op and those fever for those who developed infection was who passed away in the operation theater. delayed (both occurring after 3 days). Data in the form of type of surgery done, type of anesthesia given, the duration post CONCLUSION: operatively fever started as well as whether Non infective cause is the predominant cause cultures and antibiotics were required were of fever in the early postoperative period.2 collected and tabulated. Fever after 48 hours post op would benefit from further workup to identify an infective RESULTS: cause. In our study, 280 patients underwent orthopedic surgeries. Of these 17(6%) patients REFERENCES: developed post-operative fever. 9 patients had 1. A Rudra et al; Postoperative fever; Indian J temperature spikes within 48 hours of surgery. Critical Medicine oct-dec 2006 vol 10 4 patients developed fever during 48 to 72 2. Anand R Baid; Study of post-operative hours. 4 patients developed fever after 3 days fever in patients undergoing clean surgeries of surgery. Of the 9 patients who developed fever early on only 2 had an underlying cause of fat embolism syndrome and cerebral edema respectively. PR06B Instructional Videos In Orthopaedic Surgery: Determining The Effectiveness Of Instructional Teaching Videos On Learning Outcome And Learner Satisfaction In Application Of Above Elbow Plaster Of Paris

Aridz, M.Reza; Abbas, AA; CK Chan; Suhaeb A.M. Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

INTRODUCTION: significant association was found between Casts and splints application is one of the students’ age, gender, previous Orthopaedic fundamentals in Orthopaedic Surgery. Short experience, previous teaching in cast clinical attachment in Orthopaedic Surgery application or previous cast application with during medical school is not adequate for the final OSCE scores. students to master this technique. The challenge is to improve the methods of Table: Comparison of OSCE delivering teaching strategies. We compare (1) performance scores between groups the effectiveness of instructional video and (n=108) traditional lecture in achieving learning Comparison Mean Difference (95% p- outcome and learner satisfaction and (2) the group confidence interval) value more effective format of video presentation, sequential versus segmental. Group 1 & -0.729 (-1.253,-0.206) 0.004 Group 2 METHODS: Group 1 & One hundred and eight medical students were -0.866 (-1.401,-0.331) 0.001 Group 3 given a lecture on above elbow Plaster of Paris (POP) application. After the lecture, they were Group 2 & -0.136 (-0.671,0.398) 0.816 randomly allocated into three groups. Group 1 Group 3 (n=37) proceeded with above elbow POP application. Group 2 (n=37) completed the DISCUSSIONS: task while watching an instructional video on Instructional videos, regardless of the mode in above elbow POP application technique which it is presented, proved beneficial and played in segments. Group 3 (n=34) were was more effective in clinical skills teaching shown the same video and were required to with better learning outcome compared to a complete the task after the screening. Each normal traditional lecture. participant was assessed using a 14-item modified Objective Structured Clinical CONCLUSION: Examination (OSCE) and given a score out of Implementing instructional video teaching 10. A modified Likert score reflecting enhances clinical skills outcome in medical participants' subjective perceptions of the students in POP cast application whole experience was completed after the test. REFERENCES: RESULTS: 1. Mehrpour et. al. Clin Orthop Relat Res, Group 3 students had the highest mean score 2013; 471(2):649–654 (8.35 ± 0.86), followed by Group 2 students (8.21 ± 0.92) and lastly, Group 1 students (7.49 ± 1.03). Comparison of OSCE scores between Group 1 & Group 2, and Group 1 & Group 3 students were statistically significant (p <0.005 and p <0.001 respectively). The only statistically significant association found to affect OSCE scores was teaching methods being used (p<0.001). No statistically PR06C An Experience In Human Donor Bone Harvest

Ramalingam, Sasidaran; Sudhagar K; Sanjeevan R; Denesh Menon; Sharveen G Department of Orthopaedic Surgery, Hospital Sultanah Bahiyah, Km 6, Jln Langgar, 05460 Alor Setar, Kedah Darul Aman, Malaysia

INTRODUCTION: contour of the lower limbs preserved using Awareness of organ donation is on rise among saw bone material. Throughout procedure, the the population. Added effort from health care donor was treated with utmost respect and workers in increasing the awareness helps in care. Family members were updated timely in educating the public in regards to organ regards to progress. donation. The firewall of social taboo in regards to organ donation is slowly fading thus DISCUSSIONS: helping number of organ donors. Pioneering Disease transmission, either viral or bacterial, allogeneic bone marrow transplant in Malaysia is extremely rare with bone allografts. The last back in 1987, more research into tissue and incidence of a fatality due to disease organ donor has been done keeping in par with transmission from bone allograft occurred in international medical standards. 2001 and was due to a major deviance from standard industry practice. The incidence of METHODS: viral transmission, such as hepatitis or HIV, is 40 years old female with underlying calculated to be less than 1 in 1.6 million, with hypertension brought in unconscious to no cases reported in several years. This safety emergency department with GCS 5/15.. Upon profile compares very favorably to other arrival patient was intubated and resuscitated. biologic materials. Bones grafts has structural Emergency CT brain revealed intra and non structural purposes. parenchymal bleeding. The patient was referred to neurosurgical team and intensivist. CONCLUSION: The patient was declared brain dead in the The usage of bone products from bone presence of 2 non benevolent consultants. The allograft is on rise in arthroplasty, trauma and family confessed, that patient pledged as an oncology related surgeries. Bone bank plays a organ donor and expressed the desire to donate central role. Increasing pledge of organ donors the tissues and organs. Transplant and Organ can further reinforce the supply and benefits Procurement team in Hospital Sultanah the human mankind. Bahiyah was alerted. REFERENCES: RESULTS: 1. Jurgensmeier D, Hart R:Variability in Target bones to be harvested are bilateral tissue bank practices regarding donor femur and tibia. Anterior longitudinal incision and tissue screening of structural done over the right thigh extending the whole allograft bone. Spine (Phila Pa 1976) length of femur. Attachments to the femur was 2010;35(15):E702–707. dissected carefully without much periosteal 2. Suzina Sheikh Abd Hamid Tissue stripping. Anterior midline incision continued Bank, Universiti Sains Malaysia distally over the tibia. Both tibia and femur Health Campus, Kubang Kerian, were dissected and harvested en bloc. Kelantan, Malaysia. Cell and Tissue Ligamentous attachment retained as source of Banking (Impact Factor: 1.03). tissue. Post harvesting, set of bilateral femur 11/2010; 11(4):401-5. and tibia saw bones aw were prepared. The DOI: 10.1007/s10561-010-9188-2 articulating distal end femur and proximal end tibia were joined using POP. The head of saw bone femur was snuggly fit into the acetabulum and harvested area replaced with saw bone. The skin was sutured. Normal PR06D

Core Decompression With Reverse Bone Graft Technique And Hydroxyapatite Granules In Avascular Necrosis Of The Femoral Head

B. Devadasan1; A. Hafiz2 1 Mawar Medical Centre, 71, Jalan Rasah, Seremban,70300 NSDK, Malaysia 2 University Islam Antarabangsa Malaysia(UIAM), Department of Orthopaedics, 25300 Kuantan, Malaysia

Introduction: (AMREC) and manufactured by GranuLab – Core decompression is used in precollapse Patent P1 20040748 fulfilling the criteria for lesions to forestall disease progression in American Society for Testing and Materials avascular necrosis (AVN) of femoral head (ASTM) F1185-88(1993) Standards which is (FH). The author reports a new technique ‘Standard Specification for Composition of using reverse bone graft technique to Ceramic Hydroxyapatite for Surgical effectuate core decompression. Implants’. Derived from Malaysian limestone, ranging from 200-5000 μm gamma sterilized. Aim: To prevent precollapse in Ficat Type 1&2 and Results: revascularization using synthetic bone graft After 6 months, there was no collapse of material. subchondral bone and the FH showed revascularization along bone grafted site with Methods: viable graft and increased radiotracer activity A 18 year female police trainee with Magnetic using 99-Tc MDP WB Bone Planar Resonance Imaging (MRI) confirming AVN Scintigraphy. Clinical success was defined as Stage 2 Ficat, clinically painful hip not evident Harris hip Scores of 80 points with a x-ray in x-rays consented to undergo this new evident incorporated graft. technique. Reverse bone graft technique with a Coring reamer – Patent 5423823. A Discussion: minimally invasive technique with lateral 2cm Reduction in intraosseous pressure is achieved incision introducing 8.5 mm core reamer to by using large bore 8.5mm coupled with HA remove a core of bone up to the subchondral granules promoting revascularization. bone. The subchondral cyst decompressed and curetted under video recorded Image Conclusion: Intensifier. Demarcated avascular bone This technique is minimally invasive and segment excised and bone graft reversed and effective in young patients with early stage of inserted with cortical bone acting as a support FH AVN and has shown revascularization to prevent collapse and the distal segment along the bone grafted site. augmented using 5 grams of osteoconductive granular synthetic bone graft material based on calcium phosphate hydroxyapatite (HA 2500-5000 μm). Avascular segment histopathologically confirmed AVN. Core tract started at subtrochanteric area, prevented from stress riser by protected weight bearing for 2 months.

Biomaterials: HA granules named as GranuMasTM developed under Intensified Research in Priority Areas (IRPA) Research Project (No. 03-01-03-0000-PR0026/05) and invented by the Advance Materials Research Centre *    PP01A

Infantile Cortical Hyperostosis Secondary To Prostaglandin Therapy: Case Report

Kishan Rao; Wong; Ashwini Sood; Chuah SK Department of Orthopaedics, Hospital Kulim, 09000 Kulim, Kedah, Malaysia

INTRODUCTION: DISCUSSION: Infantile cortical hyperostosis (ICH) is a ICH is a benign self limiting condition. It is benign self limiting disease appearing in early characterized by a triad of clinical symptoms infancy. The role of this report is to address which are soft tissue swelling, bony changes the important complication that arised after and irritability. The exact aetiology of this given Prostaglandin E1 therapy to a newborn condition is still unknown. There are few cases with ductus arteriosus dependent congenital of ICH been reported in infants following heart disease. prolonged treatment with Prostaglandin E1.[4,5] The classic form of ICH usually MATERIALS & METHODS: occurs within the first 5-7 months of life. In This is a case report of a74 days of life full ICH, there is an exacerbated subperiosteal term baby diagnosed with complex cyanotic intramembranous bone formation heart disease (TGA/PDA/ASD/VSD). Child (hyperostosis), triggered by local was started on PGE1 infusion since 11hour of inflammation (periostitis). Radiography is the life. On day 61 of life, the child was referred most valuable diagnostic study in ICH. Xrays to orthopedic team as noted to have developed show layers of periosteal new bone formation, swelling over bilateral lower limbs with with cortical thickening. ICH is mostly self- spiking of temperatures. limiting and resolves within 12-24 months and usually does not require any RESULTS: treatment.[3]NSAIDS such as Indomethacin or On examination, bilateral lower limbs noted Naproxen can be used in really symptomatic swollen and indurated, more on the right cases. side,extending from hip to foot. It was tender on touch. CONCLUSION: AP radiograph of The aim of this report is to address the pelvic and bilateral important complication that arise from prolong lower limbs: use of prostaglandin in peadiatric patients. The Periosteal diagnosis can be made with high index of thickening(cloak) suspicion with a good history, clinical overlong bones of examination, basic laboratory studies, and bilateral lower limbs. plain radiographs in most cases.

REFERENCES: 1. Caffey J, Silverman W. Infantile cortical hyperostosis, preliminary report of a new syndrome. Am J Roentgenol Rad Therapy 1945;54:1-16 2. Bernstein RM, Zaleska DJ. Familial Aspects of Caffey Disease. Am J Orthop 1996;24:777-778 3. Mohammed ALF. Caffey Silverman Disease: Case Report and Literature Review AP radiograph of bilateral upper limbs: Kuwait Medical journal 2006; 38(1):49-52. Cortical hyperostosis over long bone. 4. Jao Fernando Lourenco de Almeida. Helio K, Luiz H, Hercowitz, Hello K, Eduardo JT. ABSTRACT TRUNCATED PP01B Locked Knee In Child : A Rare Presentation Of Trevor's Disease

Hanif K.; T.R. Kartik; HudzairyA.; B.S.Tan. Department of Orthopedic, Hospital Sultanah Nora Ismail, Jalan Korma, 83000 Batu Pahat, Johor, Malaysia

INTRODUCTION: surrounding chondral thickening arising form Locked knee in children is rare and right medial femoral condyle epiphysis, challenging case to manage. It is a diagnostic predominantly of its posterior aspect. It is dilemma and its differential diagnosis varies, fragmented (largest 1.1cm x 1.6 cm) with one of which is Trevor’s disease. Trevors’ surrounding cartilaginous cap with maximum disease or Dysplasia Epiphysealis Hemimelica thickness of 6mm. Noted bony loose body (DEH) is a rare developmental lesion that is measuring 1.4cm x 1.2cm. The appearance are histologically identical to an osteochondroma in keeping with multiple intra-articular affecting one or more epiphyses of long osteochondroma, with no significant bones[1] enhancement of the cartilaginous (post contrast). While other structures appears MATERIALS & METHODS: normal. Base on the Xray and MRI imaging We are presenting a case report of a 7-years differential is most likely dysplasia old child presented to us after an alleged fall in epiphysialis hemimelica or Trevor’s disease. sitting position while playing, post trauma complaint of pain and limited range of The locked knee was reduced with closed movement over the right knee joint. manipulation and reduction and the joint was Upon examination noted swelling, more over immobilize with above knee backslab, patient the postero-medial aspect of the right knee, not was then discharge with follow up. During increasing in size, with hard consistency, not follow up patient had shown full range of warm and not erythomatous. There is minimal movement, and no difficulty during tenderness upon palpation however crepitus ambulation with normal gait. Patient is still were absent. Patient was more comfortable under our close follow up. Surgical removal of with his right knee being kept in a 90 degrees the lesion remain an option and was flexed attitude and an attempt to passively considered, however in view of patient is extend the knee results in tenderness currently asymptomatic, skeletally immature and due to the benign nature of the lesion, he RESULTS: was treated conservatively. Surgical Patient undergone series of investigation intervention may be reconsidered as the including X-ray and MRI in which the patient become more mature, and if the lesion diagnosis of Trevor’s disease was taken into causes any symptoms . account. X- rays of the right knee show multiple bony DISCUSSIONS: loose bodies over the anterior aspect of the Trevor’s disease or DEH is a benign disorder, knee joint. No loose bodies over the popliteal and no cases of malignant transformation have region. The epiphyseal plate over the distal been reported. The reported incidence is one in right femur and right tibia were intact. No 1 000 000. Mouchet and Belot originally fracture seen. described it as a ‘tarsomegalie’in 1926[2]. Trevor described 10 patients with this condition in 1950, using the name ‘tarso- epiphyseal aclasis’; this abnormality is also commonly referred to as ‘Trevor’s disease’[3]. Fairbank reported 14 patients with the condition in 1956 and renamed it ‘dysplasia Subsequently MRI was done, noted that there epiphysealis hemimelica’[4], which is still in are irregular outgrowth associated with use today. Despite DEH’s rarity, 73 authors

ABSTRACT TRUNCATED PP01C Traumatic Lisfranc Variant Injury Complicated With Brachymetatarsia In A Toddler

1ND Agung, 1MJJ Lim, 2 MY Sharizan, 2 MA Kamalruzaman Department Of Orthopaedic, Hospital Enche’ Besar Hajjah Khalsom, Kluang KM 5, Jln Kota Tinggi 86000 Kluang Johor, Malaysia

INTRODUCTION: Paediatric foot injury is often overlooked due to the subtle deformity and immature skeleton1. Foot swelling and inability to bear weight may be the only initial presenting features. The complexities of radiographic evaluation, in particular the immature foot, make diagnosis even more difficult. This can Fig 1: Initial radiograph Fig 2: Radiograph at 3 have devastating consequences on the child. showed no bony months showed avascular We report a case of traumatic pure abnormalities necrosis of first MTB ligamentous lisfranc variant injury of the first metatarsal bone of the right foot in a toddler, complicated with abscess and subsequent brachymetatarsia of the first ray secondary to Fig 3: On follow up avascular necrosis. noted shortening of the first ray CASE REPORT:

A 3 years old boy jumped out of a moving van and presented to casualty with right foot pain, DISCUSSIONS: swelling and inability to bear weight. He was The pediatric equivalent of the adult discharged with backslab and given outpatient tarsometatarsal fracture dislocation of lisfranc appointment. Orthopedic team saw him two ligament is the “bunk bed” injury. The weeks later, with sepsis and right foot abscess mechanism of injury is similar for both but secondary to infected hematoma. lesser severity happen in pediatric due to more An incision and drainage of the right foot were pliable supports. In this child, he had sustained performed. Intraoperatively, noted to have only ligamentous injury without any fracture. pure ligamentous injury with total dislocation Children with lisfranc injury may only present of the first ray with no remaining soft tissue with midfoot pain, swelling, plantar bruising, attachment and necrotic looking first ray. and inability to bear weight without There was also frank pus involving the medial radiographic evidence. and central compartment of the foot. Thorough st Posttraumatic brachymetatarsia can have a debridement performed and 1 ray was held significant impact on a child as he grows. In with kirshner wire to medial cuneiform. cases where the first metatarsal is short, the Subsequently, he went in for multiple hallux will progressively adducts and extends debridements. Tissue culture grew and the second digit will adduct in an effort to Staphylococcus aureus, which is sensitive to fill in the space of the hallux. Often these Cloxacillin. He received a good dose of patients will lack medial column stability antibiotics until infective markers normalize. therefore creating more stress on the lesser Wound subsequently healed well 6 weeks later metatarsals. As the patient tries to supinate for and the child is able to walk and run around. rd the deformity, lateral weight bearing stresses Unfortunately, during 3 month follow up, are increased creating pain along the lateral noted the patient has shortening and gradual column. Subsequently in later life, this child adduction of the first toe (brachymetatarsia) will have gait and shoe wearing problems. and radiograph revealed avascular necrosis of st Surgical treatments that can be offered later the 1 metatarsal bone. are lengthening surgery or bone grafting.3 ABSTRACT TRUNCATED PP01D

A Rare Bilateral Post-Axial (Wide Metatarsal Head) Polydactyly Of Great Toe: A Case Report.

Muhammad Faiz K; Kamil MK Department Of Orthopaedic, Hospital Tengku Ampuan Rahimah, Taman Chi Lung, Jalan Langat, 41200 Klang, Selangor, Malaysia

INTRODUCTION: Polydactylyyyy of foot is one of the commonest congenitalg anomalies. The complexitypy of the deformityy rangeg from a simplep soft-tissue problemp to a completelyp y developedp accessoryy ray.y Generally,y, it is classified as preaxial,p, central or pppostaxial dependinggp on duplication Figure:g X-rayy bilateral foot: Widened of location. Postaxial polydactylypy yy accounts for metatarsal head with complete duplication of about 80% of foot polydactylypy yy whilst preaxialp greatg toe polydactylypy yy representsp 17% of foot polydactylypy yy cases [][1]. This case is beingg DISCUSSIONN: vindicated due to its rarityy and had not been This case vindicated several ppertinent facts reportedp earlier and simultaneouslyy to create that needs further elaboration. Firstly,y, awareness and in depthpg understanding to subdivision of postp axial is accordingg to achieve good functional and cosmetic results. metatarsal ppatterns which were described as soft-tissue duplication,p, wide metatarsal head,, CASE REPORTED: Y-shapedpp metatarsal and complete duplicationp A 15-yearyyy old Malay boy was diagnosedg with [1].[] Secondly,y, our orthopaedicp team exercise congenitalgyg anomaly of bilateral great toe since extreme care and gpgarnered valuable experience birth and recentlyy encountered difficultyy in that was crucial towards the patient’sp wearingg footwear and experiencep severe pain.p wellbeing.g At a g,glance, it may yppp appear simple Other abnormalities were not ppresent. Uponp but multi-formityyg of its configuration deserves examination,,p polydactyly y yy of the bilateral greatg careful consideration before and duringg toe completepp complex and nail duplication p was surgicalg correction. [][2] Both ggreat toe seen. Movement of the lateral and medial toe reconstruction is crucial in order to obtain is restricted. Others systemy was normal. goodg functional outcome. The functional Operationp revealed disarticulation of the jjoint outcome seems to be related to the stabilityy of after fillingg of the extra bonyy architecture and the interphalangealp and metacarpo-phalangeal reconstruction of tendon and dominant bone. jointsj [2]. As the metatarsal head is p,prominent, it was trimmed and flush to the metatarsal shaft and REFERENCESNC S similarlyyj the joint capsule p was repaired. p 1.Castilla E.E.,,g Lugarihno da Fonseca R., , da (Untreated( metatarsal head pprominent may Graca Dutra M. and Paz J.E.: Hand and foot cause a painful postoperative.) postaxialppyyy polydactyly: Two different traits. Am. J. Med. Genet.,, 73: 48-54,, 1997. 2. Rayeny,y,yyy GM, Fray B, Ulnar Polydactyly. Plast Reconstr Surg. 2001 May; 107 (6): 1449- 54. PP02A An Early Experience Of Treating Paediatric Neck Of Femur Fracture

Kesavan R; Hafiz D; Norzatulsyima N; Isymth AR Hospital Miri, Jalan Cahaya, 98000 Miri, Sarawak, Malaysia

Introduction that of a high impact. Other mechanisms of Femoral neck fractures are rare in children and injury that have been described are such as usually originate from high energy trauma. It indirect abduction and external rotation force represents less than 1% of all paediatric hinging the femoral neck against the fracture and this is due to the thick, strong acetabular rim causing the fracture [3]. periosteum cover and the tough bone of children[1] .Fractures of the femoral neck are Avascular necrosis (AVN) remains as the most always a challenge for orthopaedic surgeons, dreaded complication following these not only because the treatment needs fractures, reported to be 18% to 30% by expertise, but also because of its subsequent various authors [4]. The incidence of AVN has complications. been reported to be 41% when hip decompression was not done compared with Case Report 8% in cases treated with early hip We report a 5-year-old girl who presented to decompression [5]. us with a closed left femoral neck fracture. The mechanism of injury in our case was that In our case, avascular necrosis has not been of a high-impact trauma from motor vehicle observed up until 6 months post injury. The accident. Upon arrival, the left lower limb was main factors influencing AVN rate are the externally rotated and no obvious deformity initial fracture displacement, the degree of seen. Attempted movement around the hips initial insult, and the timing of surgical was painful. Radiographs of the pelvis (Figure fixation together with hip decompression. 1) showed left cervico–trochanteric (Type III) Operative fixation should be carried out femoral neck fracture as per the Delbert preferably within 48 hours of fracture [6]. classification. A study done by Bali et. Al., which analysed She was operated on within 24 hours. Closed 36 children with femoral neck fracture, reduction was attempted on the left side under concluded that the femoral neck fractures in an image intensifier and the fracture was fixed children need aggressive operative treatment with two partial treaded cannulated screw aiming at anatomical reposition of femoral 7.0mm. Post-operatively, the patient was neck rather than conservative treatment [7]. treated with spica immobilization for 6 weeks. A follow up review showed that the fracture Other complications which can occur are non– healed well. After 6 months, the radiograph union, coxa vara, coxa valga, leg length did not show any sign of avascular necrosis of discrepancy, arthritic changes and premature the femoral head (Figure 2). Range of closure of proximal femoral epiphysis [4]. Our movements of both hip joints was full and patient, however, did not experience any of painless. There was no limb length these complications. discrepancy. Conclusion Discussion Early diagnosis and surgical intervention can Femoral neck fractures in children are always lead to a good outcome. Proper assessment of a result of high energy trauma because the pelvic radiographs especially in patients femoral neck of children is dense and hard involved in high impact trauma is mandatory compared to adult femoral neck2. As a result, and a high index of suspicion will lessen the these fractures are usually associated with chances of missing such injuries in children. other injuries. Occasionally, they occur secondary to underlying metabolic disorders [1]. The mechanism of injury in our case was ABSTRACT TRUNCATED PP02B Outcome Of Surgically Treated Subtrochanteric Femur Fractures In The Adolescent Age Group

1Ki Rui Lin, 2Ferdhany M Effendi, 1Choo Tze Yong, 1Norhaslinda Bahaudin, 1ZZM Zuki 1Hospital Sungai Buloh, Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia 2University of Technology MARA, Sungai Buloh Campus, Jalan Hospital, 47000 Sungai Buloh Selangor, Malaysia

INTRODUCTION: Adolescents represents unique patient Figure 1 (left) and 2 (right): Plain population with regards to subtrochanteric radiograph of left femur, anteroposterior view femur fractures. As compared to other femoral showing united subtrochanteric fracture, after fractures, subtrochanteric fractures have dynamic compression plating and rigid higher degree of communition, shortening and intramedullary nailing respectively. angulations if treated conservatively. 5 DISCUSSIONS: METHODS: Subtrochanteric Fractures in the paediatric and Retrospective review of surgically treated adolescent age group is rare.1 subtrochanteric femur fracture in the There is tendency for the fracture pattern to be adolescent age group seen in a Malaysian displaced due to muscle forces acting on the public hospital over a period of 18months. proximal femur. These results in the proximal fragment to be flexed, abducted and externally RESULTS: rotated thus causes management difficulties. Nine patients were included in the study with Conservative management have shown to be an average age of 14 years. Only one (11%) associated with complications such as out of the nine patients was female. Average malalignment and limb length inequality.5 follow up period was 16 months. All initial From our research, results of operative radiographs showed coronal angulations and treatment are satisfactory in terms of shortening averaging 20 degrees and 2.2 cm alignment and function. Patient have adapted respectively. Seven (78%) out of 9 patients with normal gait and full function of lower had undergone extramedullary fixations. extermities within 12 weeks. Implants used includes 2 dynamic compression plates, 3 locking compression CONCLUSION: plates, 1 angle blade plate and 1 distal femur Based on this small series, retrospective locking plate. Two patient underwent review, surgical treatment of subtrochanteric intramedullary fixation using rigid femur fractures in the adolescent produced intramedullary nail. All fractures have united good outcome irrespective of the fixation at the time of last follow up with average method. Further randomized prospective union time of 7.9 weeks. Radiological studies are needed to determine the optimum outcome based on Beatsy et al showed 7 (78%) type of fixation of subtrochanteric femur out of 9 patients had good outcome. fractures in the adolescent.

REFERENCES: 1. Daum, R, Jungbluth, K, Metzger, E & Hecker, W 1969, '[Results of treatment of subtrochanteric and supracondylous femoral fractures in children]', Chirurg., vol. 40, no. 5, pp. 217-220.͒ 2. Theologis, T & Cole, W 1998, 'Management of subtrochanteric fractures of the femur in children', J Pediatr Orthop., vol. 18, no. 1, pp. 22-25.͒

ABSTRACT TRUNCATED PP02C Corrective Osteotomy Of ‘V-Shape’ Malunion Of Right Radius With ‘Double Dislocation’ Of Radio-Ulnar Joint : A Case Report

AMM Norzakiah; RIM Anuar; NJ Ashikin; Azli AHM Department of Orthopaedic, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Malaysia.

INTRODUCTION: radius affect the adjacent joints as both were Forearm fractures are common in children and held in dislocated position. As the forearm commonly treated conservatively. There are bones function as one unit, the movement of cases however, operative intervention such as forearm in relation to joint function is grossly intramedullary fixation are performed in order affected. After corrective osteotomy of the to achieve acceptable alignment. In radius and ulnar shortening performed, the uncomplicated cases, such fractures heal proximal and distal radio-ulnar joints were uneventfully. However, it is not without located (Figure2 and 3). Thus, the functional complication such as malunion. outcome especially pronation and supination We report a case of forearm fracture that improved. complicated with severe malunion and dislocation of proximal and distal radio-ulnar joints.

CASE REPORT: A 12 years old boy had involved in motor- vehicle accident 6 years ago and sustained closed diaphyseal fracture of radius and ulna. He was then underwent intramedullary fixation with K wire of radius and ulna. However, after removal of implant, noted slow Figure 2 Figure 3 progressive painless deformity over his right forearm. Examination noted deformity of right CONCLUSION: forearm with ulnarly angulated forearm. Corrective osteotomy of the malunion of Functionally, he had limited pronation and forearm fractures is a wise option to consider supination. The wrist and elbow joint range of in order to improve function as well as movement were full. The radiograph showed cosmetic appearance. severe malunion of right radius with proximal and distal radio-ulnar joints dislocation REFERENCES:

(Figure 1). The corrective osteotomy of radius 1. Nazari AT, Shalimar A. Zulkiflee O, and shortening of the ulna was performed. He Srijit D. Paediatric Forearm Fractures: achieved good function and improved Functional Outcome of Conservative pronation and supination. Treatment. Bratisl Lek Listy 2009; 110(9): 563-568. 2. Geenen RCI, Besselaar PP. Outcome after Corrective Osteotomy for Malunited Fractures of the Forearm Sustained in Childhood. The Journal of Bone and Joint Surgery 2007; 89-B(2): 236-239. 3. Fuller DJ, McCullough CJ. Malunited Figure 1 Fractures of the Forearm in Children. The Journal of Bone and Joint Surgery DISCUSSION: 1982;64-B(3): 364-367. Malunion of forearm fractures are bound to happen even though the fractures are treated surgically. In this case, severe malunion of the PP02D Neglected Hilton’s Law Causing Missed Diagnosis of Slipped Upper Femoral Epiphysis: A Case Report

1Ramesh M, 2Surekha K, 1Suresh A, 1Suriya K, 1Shoba A, 1Asliza Y, 1Asyraf W 1Department of Orthopaedic Surgery, Hospital Tuanku Ampuan Najihah, Jalan Melang, 72000 Kuala Pilah, Negeri Sembilan, Malaysia 2Department of Emergency Medicine, University of Malaya, Jalan Universiti, 50603 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia

BACKGROUND:

Slipped upper femoral epiphysis (SUFE) is a relatively common hip disorder that occurs in Figure 1: A missed late childhood and early adolescence. It diagnosis. The usually occurs between the ages of 10 - 17 epiphysis is flush with years with a prevalence of 10 cases per Klein’s line and 100,000 children. Patients usually suffer from Steel’s sign positive limping and localised pain in the hip, groin or (marked with an knee. arrow) during first visit

CASE REPORT :

A 14-years-old boy seeked treatment twice in Figure 2: Progression the emergency department with history of of slip with head falling thus complaining pain in the left knee located posterior and and thigh. The radiographs showed negative inferior in relation to for fracture even though there was a metaphysis during significant slip of the upper femoral epiphysis. second visit The patient was discharged with analgesics for soft tissue injury of the knee, however the pain did not resolve with analgesics.

Three weeks later, on further examination and Figure 3: After repeated x-ray, he was diagnosed with SUFE fixation with 6.5mm of the left femur. The patient was cannulated cancellous subsequently treated successfully with surgical screw reduction by in situ pinning of the left femur.

CONCLUSION:

Chief complaint of the knee and thigh pain REFERENCES: does not exclude hip pathology if the clinician fully understood Hilton’s law in Sanjay M Khaladkar, Preeti Sherawat. musculoskeletal pain. This case shows how Early diagnosis of slipped capital femoral SUFE may masquerade as soft tissue injury of epiphysis on magnetic resonance imaging. the knee because of referred pain. Med J DY Patil Univ 2015;8:72-76

PP03A Transphyseal Separation Of Distal Humerus: A Rare Injury In Young Children

Md Yusoff, Z; Abdul Rahim, N R; Felix LYS Department of Orthopaedic Surgery, Hospital Ampang, Jalan Mewah Utara, Pandan Mewah, 68000 Selangor, Malaysia,

INTRODUCTION: to rule out foul play. Transphyseal distal Transphyseal fractures of the distal humerus humerus injuries require surgical intervention are rare injuries and typically occur in children to reduce the risk of long term complications. under the age of 3. Possible causes include These may include cubitus varus, birth injuries, non-accidental injuries and fall osteonecrosis of medial condyle, and possible from height1. growth arrest of the distal humerus. Because of its rarity, it is often missed or misdiagnosed. We would like to report a CONCLUSION: recent case which came to our centre. Distal humerus epiphyseal injuries can be difficult to diagnose in younger children and MATERIALS & METHODS: babies. This is due to the absence of A 2 year old girl presented with left elbow ossification nuclei at the distal humerus, pain and swelling after a fall from height. The especially in newborns and babies. girl fell off a chair, witnessed by her mother. Ultrasonography has been shown to be useful The child fell in a prone position, with the left adjunct to plain radiographs in assisting with elbow under her. diagnosis of these distal humerus injuries2. It Initial radiographs were suspicious for distal is important that the clinician be aware of the humerus epiphyseal injury, with a slight possibility of non-accidental cause of this medial displacement of the radius and ulna fracture. A high index of suspicion, as well as bones. The child was admitted and put on a prompt diagnosis and treatment may be able to backslab. Surgery was planned for reduce long term complications of such percutaneous k-wiring KIV open reduction injuries. under emergency. REFERENCES: RESULTS: 1. Abzug JM et al, Transphyseal Fracture of The child underwent surgery successfully. the Distal Humerus, Journal American Intraoperatively noted that there was Academy Orthopedic Surgery. 2016 Feb; transphyseal separation of the distal humerus. 24(2): e39-44 Open reduction and cross k-wiring of distal humerus was done in the manner of fixation 2. Supakul N et al, Distal humeral epiphyseal for supracondylar humerus fractures in separation in young children: an often-missed children. Reduction was protected with an fracture-radiographic signs and ultrasound above elbow backslab. She was discharged confirmatory diagnosis, American Journal well, but remains under our follow up. Roentgenology 2015 Feb; 204(2): W192-8

DISCUSSIONS: These fractures are often subtle and often radiological diagnosis is missed. A radiological finding of forearm not in alignment with the humerus on plain radiograph, especially with a posteromedial displacement of radius and ulna2, would support such a diagnosis. These fractures are often associated with non-accidental injuries, therefore any diagnosis transphyseal distal humerus injuries should be carefully screened PP03C Painful Pseudoparalysis Of The Upper Limb In An Infant: Pulled Elbow

1Nur Ayuni KA, 2Mohd Fairuz S 1Department of Orthopaedic, Hospital Shah Alam, Persiaran Kayangan, Seksyen 7, 40000 Shah Alam, Selangor, Malaysia 2Department of Orthopaedic Surgery, Faculty of Medicine, MARA University of Technology, Sungai Buloh Campus, Jalan Hosptial, 47000 Sungai Buloh, Selangor, Malaysia

INTRODUCTION: DISCUSSIONS: Nursemaid’s elbow also known as pulled Pulled elbow is a common benign condition elbow is a condition where there is radial head that usually can affect any children under 5 subluxation caused by annular ligament years of age with highest incidence at 2-4 displacement(1) causing pseudoparalysis of years. Before 7 years of age the radius has a upperlimb. shape similar to a pole without a head or neck, thus being prone to easy dislocations. For the SUMMARY: 1 year old or older group, walking and running We described a case of pulled elbow in an begin from about that age with frequent falls. extreme age; a 4 month-old boy. Thus, resulting in pulled elbow because of a pulling force applied to the arm during rescue CASE PRESENTATION: from falling by the caretaker. While in infants, This is a case of a fretful 4-month old boy who the peak frequency of injury is at 6 months. presented with sudden refusal to move the Even though it has been reported that incident right upper limb after the boy’s elder brother of pulled elbow occurring in infant is usually had pull his right arm. On examination, the through the arm being trapped underneath the child was not moving his right upper limb. rolling body(3), the likeliness of it occurring There was tenderness over the radial head and due to the usual mechanism is still possible as child was crying especially on supination of in this case. The traction force need not the forearm. However, no deformity was noted necessarily be from a vertical manner, as in over the right elbow. tugging on a falling child, as it can occur as long as tractional force is applied over a FigureFigure 1: PicturePicture shownshown the pronated forearm which possesses relatively child is hanging the arm loosloosely lax tissue, pulling the radius through the toto hihiss ssideide wwithith ththee eelbowlbow in slightly flexed and pronated. annular ligament. In most of the cases, no swelling or bruising are seen while the elbow can usually be flexed and extended, but Figure 2: The child’s right elbow X-ray (AP and supination of the forearm meets resistance and lateral view) which is unremarkable as the causes pain. Radiography exposes the child to ossification centers are yet to appear. Neither a dose of ionizing radiation and is considered fracture line nor posterior fat pad sign are to be of little help but in some cases where the demonstrated. history is atypical, it might be necessary in less clear cases to exclude more severe injuries.

CONCLUSION: Although this child is only 4 months old, pulled elbow is one of the differential Close manual reduction by using pronation diagnosis that has to be taken into maneuver of the forearm was chosen as the consideration. With an understanding of the successful rate is higher (2). Upon pressing anatomy, etiology and pathomechanics, the over the radial head during the maneuver, characteristic history and examination findings clicking sound was heard and child was of a pulled elbow will usually lead the actively moving the right upper limb thereafter. clinician to the correct diagnosis.

ABSTRACT TRUNCATED PP03D Case Report: Atraumatic Bilateral Knee Dislocation In Newborn

Azwan A.; Phang Z. H.; Kamarul A.; Riaz F.; Razip S.; Mujait K. Department of Orthopaedic, Hospital Pakar Sultanah Fatimah, Jln Salleh, 84000 Muar, Johor, Malaysia.

INTRODUCTION: CONCLUSION: Congenital dislocation of knee is a rare entity Packaging disorders may present with multiple in clinical practice. Estimated incidence is dislocations and deformities. Early nearly 0.017 in 1000 live births (1). This intervention with serial casting and deformity generally accompanies with other manipulation minimises disability and congenital musculoskeletal abnormalities like prevents ambulatory problems. In our case developmental hip dysplasia, club foot, there was a good response to manipulation and spina bifida, arthrogryposis multiplex serial casting. This differs from cases with congenita, hindfoot and forefoot deformities inherent pathology like arthrogryposis where (2). response to treatment is not so good. Family should be informed about further problems MATERIALS & METHODS: like early arthrosis or potential knee problems A term baby boy born via spontaneous vaginal in the future. The incidence is very rare (17 in delivery to mother with uneventful prepartum million live births only) but early diagnosis of and intrapartum presented with bilateral this deformity is very important for effective congenital knee dislocation. The knee treatment and avoids further medico-legal dislocation was treated first with gradual problems (1). stretching and weekly above knee cast. Leveuf and Pais classification is the most popular REFERENCES: classification and categorizes the deformity 1. Jacobson K, Vopalecky F. Congenital into three subgroups (7). Casting should be dislocation of the knee. Acta Orthop Scand done in full flexion position as knee allows. 1985;56:1–7 Forced flexion is not advised because of potential problems like fracture, epiphyseal 2. Curtis BH, Fisher RL. Congenital damage and impaired circulation (1). At 7th hyperextension with anterior subluxation of week good flexion was achieved at both knees. the knee surgical treatment and long term observations. J Bone Joint Surg Am RESULTS: 1969;51-A:255–9 The congenital knee dislocation was treated with weekly above knee cast. A follow up at 3. Mukesh et al. Congenital dislocation of the age of 5 month showed normal position of the knee. Acta Orthop Scand 1985;56:1–7 both knees. 4. Tachdjian MO: Pediatric Orthopaedics. DISCUSSIONS: Volume 1. Philadelphia. Saunders 1990: 609- Congenital knee dislocation is first described 18 by Chanssier in 1812 (4). Reported incidence is nearly 0.017 in 1000 live births without any 5. Warner WC, Canale ST, Beaty JH: difference between right and left knees (5). Congenital deformities of the knee. Volume Main etiologic factor is not known yet. The 2, In Insall JN, Scott WN (eds): Surgery of different theories have been described about the Knee. Philadelphia. Churchill this rare entity. According to mechanical Livingstone 2001:1337-56 theory, the deformity is originating from abnormal fetal posture in intrauterine period of 6. Fernandez-Palazzi F, Silva JR. life (4). Another and most reliable theory is Congenital dislocation of the knee. Int the primary embryologic theory that easily Orthop 1990;14(1):17-9 explains the other additional deformities accompanying with the knee problem (6). ABSTRACT TRUNCATED PP04A

Case Series: Slipped Capital Femoral Epiphysis – A Commonly Missed Diagnosis In Adolescent With Knee Pain

Gooi SG; Cheong KH; Ong TJ; Zulkiflee O Department of Orthopaedic Surgery, Hospital Pulau Pinang, Jalan Residensi, 10450 Georgetown, Pulau Pinang.

INTRODUCTION: Four out of five patients who admitted to our Slipped capital femoral epiphysis (SCFE) is a hospital has delay between their first seeking hip pathology seen among adolescents. The medical advice and referral. diagnosis can be challenging as not all patients DISCUSSIONS: presented with typical symptoms of hip paretin The incidence of SCFE is only 1 to 7 per 100 and early radiographic findings may be subtle. thousand, therefore it may be rare condition to The purpose of these case series is to raise general practitioners in their professional awareness among the doctors regarding the lifetime. In our series, all of them presented importance of early diagnosis of SCFE and with emphasis more to the ipsilateral knee recognising knee pain as an important pain, with or without hip pain. They seek presentation of underlying hip pathology. treatment at local clinic, however knee x-ray instead of pelvis or hip x-ray was done. 4 out METHODS: of 5 patients were only treated as soft tissue A retrospective study of patient with SCFE in injury and given analgesics. The diagnosis of our centre from December 2014 to January SCFE was only picked up at least 3 weeks 2016. Detailed history, demographic data and later after repeated visit. Upon referral to our xray were obtained from record office. The center, these patients had developed degree of slippage was classified into grade 1 radiographically grade 2 slippage of upper (0° to 30°), grade 2 (30° to 60°) and grade 3 femoral epiphysis. Only 1 patient with early (60° to 90+°)1 base on the shaft-epiphysis referral had grade 1 slip. angle on lateral projection. 15% of the SCFE patients presented with knee or distal thigh pain while 85% will described RESULTS: as hip, groin or proximal thigh discomfort. Table 1 below shows the symptoms at initial Those with initial complaint of knee pain is presentation, duration of the onset of more likely to receive misdiagnosis2,3 and symptoms until diagnosis and grading of found to have slips of greater radiographic slippage when refer to our center. severity.2

Pa Age(year Knee Hip Duration Grading CONCLUSION: tie s)/Gende pain pain (onset of of We conclude that unilateral knee pain is a nt r symptoms slippage common presentation in SCFE. It often leads until to delay diagnosis which eventually leads to diagnosis) severe slippage and potentially long-term morbidity. 1 13/Femal √√ √ 1 month Grade 2 e REFERENCES: 2 13/Male √√ √ 2 days Grade 1 1. M.G.Uglow, N.M.P.Clarke Aspect of Current Management – The management 3 12/Male √√ X 1 month Grade 2 of slipped capital femoral epiphysis J 4 11/Male √√ √ 2 months Grade 2 Bone Joint Surg [Br] 2004;86-B:631-5 2. Matava MJ, Patton CM, Luhmann S, 5 14/Male √√ √ 3 weeks Grade 2 Gordon JE, Shoenecker PL. Knee pain as the initial symptom of slipped capital femoral epiphysis: an analysis of initial

ABSTRACT TRUNCATED PP04B A Successful Reconstructive Case Of Tibia Hemimelia In Syndromic Child: Experience In National Tertiary Centre

AMM Norzakiah; RIM Anuar; NJ Ashikin; Azli AHM Department of Orthopaedic (Paediatric Institute), Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Malaysia.

INTRODUCTION: The management of congenital long bone Tibia hemimelia is a very rare congenital deficiency is rather challenging as to few disorder. It is characterised by either absent or factors need to be considered. In tibia deficient of the tibia in relatively normal hemimelia, presence of extensor mechanism is fibula. Therefore clinically the affected leg an important factor to attempt limb salvage will appear short and the foot will be in procedures. The stability of the foot is also equino-varus position. It is infrequently another factor to look into as the management associated with other malformations. of unstable ankle may varies from primary We report a case of a syndromic child with amputation, arthrodesis and reconstruction. unilateral tibia hemimelia, whose underwent In this case, the patient has extensor series of reconstructive procedures and mechanism of the involved tibia, of Jones succeed obtaining functional good outcome. classification type II. Reconstruction was the wise option via centralization of the fibula by CASE REPORT: synostosis of the proximal tibia and fibula. A 12 years old boy was born with VACTERL Marked shortening of the leg tackled with syndrome, also noted to have short unilateral distraction osteogenesis to get an equal limb leg with equino-varus position of the length and the foot deformity also corrected ipsilateral foot. Radiograph of the leg revealed along with the tibial procedures. presence of proximal tibia with absence of He achieved fairly good functional outcome distal tibia, Type 2 according to Jones with painless unaided gait, almost plantigrade classification (Fig. 1). He underwent surgery, foot and reasonable knee range of motion (Fig. namely centralization of the fibula (Fig. 2). 3). Subsequently he had series of lengthening procedures to correct the limb length inequality. He was also simultaneously had his ankle corrected surgically. His knee range of movement is 10 degrees to 120 degrees. Functionally, he is able to walk in plantigrade foot with residual 2 centimetres shortening.

Fig. 3: Photograph of both legs shows almost

equal length and plantigrade foot.

CONCLUSION: Fig. 1 Fig. 2 The management of tibia hemimelia is mainly surgical correction or reconstruction. Fig. 1: Tibia hemimelia with presence of proximal tibia, and distal tibia is not seen Whenever possible, limb salvage procedure is wisely to take into consideration.

Fig. 2: Radiograph after centralization of the

fibula DISCUSSION:

ABSTRACT TRUNCATED PP04D Is It Just Neuropraxia? A Report On A Neglected Supracondylar Fracture Of The Humerus With Wrist Drop

Rizal Z; Ardilla Hanim AR; Shukrimi A Department of Orthopaedic, Traumatology, and Rehabilitation, International Islamic University Malaysia, Pesiaran Sultan Ahmad Shah, Bandar Indera Mahkota 25200 Kuantan, Pahang, Malaysia.

INTRODUCTION: During his clinic visit, he started to show signs Supracondylar fracture of the humerus in of recovery, evidenced by improved distal children is a common occurrence following a sensation and advancing Tinel sign. fall on outstretched hand in boys with the average of 7 years old. 95% of these cases are DISCUSSION: the extension type. The commonest traumatic In about 75% of all children with nerve injury during extension type fracture is supracondylar fracture of the humerus, medial the anterior interosseous nerve (AIN) at 4.6%, displacement of the distal fragment is more followed by radial nerve at 4.1%, ulnar nerve common than lateral displacement. According at 2.6%, and posterior interosseous nerve at to a local study by Khademolhosseini et al 1.1% (Babal, 2010). Ulna nerve injury is more (2013), 86-100% of nerve injury are common in flexion type with the incidence at neuropraxia that recovers within 6 months, 16.6% (Babal, 2010). with average between 2 to 3 months. Thus the study recommended that for a closed fracture CASE REPORT: with traumatic nerve injury, surgical We report a case of a 10 year-old boy exploration and neurolysis or nerve grafting is presented to the hospital 4 weeks after a fall indicated if the injured child showed no on outstretched hand. He complained of pain clinical or electrical evidence of neurological and deformity of left elbow. He did not seek recovery at 3 months. According to Christina any medical treatment earlier due to his unwell et al (2004), the indications for open reduction mother. Clinical examination revealed that he include the cases of irreducible fracture, had a tender varus deformity of his left elbow, vascular injury, open fracture, and post wrist drop, and reduced sensation over the reduction nerve injury. Here, we subjected the snuffbox area. Initial radiographs of his left child for open reduction due to his neglected elbow revealed an extension type of painful elbow with radial nerve injury. supracondylar fracture with abundant callus, and 40o varus deformity of the distal humerus. CONCLUSION: In view of his neglected injury, deformity, and Incidence of peripheral nerve injury following clinical radial nerve injury, he was subjected a closed supracondylar fracture in children is for open reduction, exploration with radial commonly due to neuropraxia. However in a nerve neurolysis, osteoclasis and crossed rare occurrence like in this case, exception pinning of the left humerus. Intra-operatively, must be made with good clinical judgement to we found that the medial column of the distal serve patient with the best possible outcome. fragment was communited and displaced posteromedially, causing unstable reduction. REFERENCES: The sharp edge of the lateral column of his 1. Khademolhosseini et. al. British Journal of proximal segment was impinging the radial Pediatric Orthopedics 2013, 14–17. nerve, thinning it out with evidence of 2. Babal et. al. Journal of Paediatric laceration about 50% of its nerve calibre. Orthopaedic 2010, 30(3), 253–63. Neurolysis was performed due to the abundant 3. Cristina et. al. Techniques in Shoulder and fibrous tissue adhering around the impinged Elbow Surgery 2004, 5(2), 90–102. nerve. Osteoclasis and crossed pinning was performed. There was no intraoperative complication and he was later discharged well. PP05A 2-Pin Unilateral Gradual Distraction With Ulna Osteotomy For Treatment Of Chronic Monteggia

Gooi SG; Wang CS; Zulkiflee O Department of Orthopaedic Surgery, Penang General Hospital, Jalan Residensi, 10450 Georgetown, Penang, Malaysia.

INTRODUCTION: elbow showed reduced radial head, 3 cm of Missed Monteggia fracture is a well-known ulna lengthening without DRUJ subluxation. complication. Treatment for chronic radial At one year follow up ulna was united, radial head dislocation remains controversial. head remained reduced and stable in all range Generally the duration from which it is missed of motion. determine the difficulty of surgery and functional outcome. DISCUSSIONS: In chronic Monteggia fracture, radio head The aim is to correct deformity of the ulna, dislocation lead to deficient joint restraint reduction of the radial head, maintaining laterally, causing gradual cubital valgus. Our stability and improve ROM of elbow. Several aim was to restore the radial head reduction surgical techniques have been proposed and at the same time maintain its stability namely annular ligament reconstruction, while allowing correction of the ulna. corrective osteotomy of the ulna with internal fixation, and corrective osteotomy with In our surgery, there was only one shanz pin Ilizarov. inserted proximally and distally to the osteotomy site. This less rigid construct allow METHODS: natural ulna angulation during the process of We report a 13 years old boy, who had a fall at lengthening while expecting the radial head to five years old. He was treated conservatively reduce spontaneously. At the end of the with above elbow POP for fracture left lengthening, there was displacement of ulna forearm. Post injury deformity was noted. In between the gap. This resembled the view of painless mild angulation of the elbow angulation of ulna needed in acute correction. initially, they did not seek medical attention. In this technique, no open reduction of radial He was only brought to our clinic 8 years later head and no acute correction for ulnar when the pain and deformity were worsen. angulation are needed. This minimal invasive, and gradual lengthening process prevent joint There was left cubital valgus of 45o, limited stiffness and neuromuscular injury. supination of 60o, and pronation of 15o. Radiographic revealed left cubital valgus with Gicquetl and Exner reported gradual ulna anterior dislocation of radial head. distraction with external fixator without opening the joint. They too highlighted the We performed left proximal ulna osteotomy lengthening of the ulna with angulation as key using uniplanar Monotube external fixator to reduce radial head. Alexendre found that with only one shanz pin proximally and reconstruction of the annular ligament was distally. Gradual distraction with 1mm/day unnecessary as may lead to elbow stiffness lasted for three months for spontaneous radial and AVN of radial head. head reduction. There was no documented neurological deficit. CONCLUSION: Simple construct monotube gradual distraction RESULTS: with ulna osteotomy for treatment of chonic At six months post-surgery the bone gap well Monteggia fracture with radial head consolidated and the external fixator was dislocation is promising. removed. Clinically cubital valgus was reduced to 10o, ROM was full. X-ray of left REFERENCES:

ABSTRACT TRUNCATED PP05B Subacute Osteomyelitis Of The Ulna: A Case Report

Manharpreet Singh Sandhu; George Ezekiel; Achdiat Mapha Fansuri Department of Orthopaedic Surgery, Hospital Putrajaya, Jalan P9, Pusat Pentadbiran Kerajaan Persekutuan Presint 7, 62000 Putrajaya, Wilayah Persekutuan Putrajaya, Malaysia

INTRODUCTION: Paediatric subacute osteomyelitis (SAO) presents a diagnostic and therapeutic challenge to clinicians.1 The radius and ulna are rare sites for haematogenous osteomyelitis in children (<3%).2 Although cure rates have improved due to early detection and improved antibiotics, the diagnosis is not always obvious 1.X-ray showing initial ulna styloid fracture and may be delayed.3 Treatment usually 2.Cortical erosions seen over ulna 1 month involves surgical drainage, debridement and later antibiotic therapy. 3.MRI imaging showing increased signal intensity over whole ulna. CASE REPORT: 4.Intraoperative image of pus, bone sinus tract We report a case of a 13 year old boy who and thickened periosteum. presented to us with the swelling of the forearm for 1 month duration after a fall, DISCUSSION: treated conservatively for a left closed ulna Osteomyelitis in a growing bone poses a major styloid fracture. Subsequent radiographs challenge despite advancements in treatment. showed cortical erosions of the distal half of The infection is commonly caused by the ulna including the epiphyseal, metaphyseal staphylococcus aureus and starts primarily in and diaphyseal regions. MRI revealed high the metaphysis.3 Delay in diagnosis and intensity signal throughout the whole ulna treatment may lead to chronicity and bone with surrounding soft tissue swelling. associated with pathological fracture, Surgical drainage and debridement was sequestrum formation, cavities and sinuses.3 performed, tissue and bone samples taken Bone deficiency may occur resulting in long were sent for appropriate investigations. term effects such as growth arrest, cosmetic Antibiotic therapy was subsequently initiated. and mechanical deformities. Defects in the ulna mainly occur distal to the olecranon.3 The RESULTS: proximal interosseous membrane and annular Tissue and Bone cultures grew staphylococcus ligament may become deficient following aureus. bone infection.4 Due to stagnation of the ulna growth, discrepancy between the radius and Bone and tissue HPE were consistent with an ulna results in a cubitus varus deformity, abscess wall. lateral curvature of the radius and a shortened forearm. Ulna deviation occurs at the wrist. A 6 week course of IV Ceftriaxone was Unimpaired radial growth results in initiated in view the patient was allergic to dislocation of the radial head and thus may penicillin. give rise to posterior interroseous nerve palsy.4

Infective markers, ESR CRP and WBC CONCLUSION: showed improvement throughout the course of Osteomyelitis in the peadiatric age group treatment should not be taken lightly, early diagnosis and prompt initiation of treatment may prevent The circumferential swelling of the forearm subsequent complications of chronic reduced and patient remained afebrile osteomyelitis. Children with multifocal throughout hospital stay.

ABSTRACT TRUNCATED PP05C Developmental Dysplastic Hip With Ligamentous Laxity: A Case Report

P Devarani; Gooi SG; Dato Zulkiflee O Orthopedic Department, Penang General Hospital, Jalan Residensi, 10990 George Town, Pulau Pinang, Malaysia

INTRODUCTION: significant enough, the femoral head may DDH is a generic term describing a spectrum spontaneously dislocate and relocate. Because of anatomic abnormalities of the hip that may the femoral head is not reduced, the be congenital or infancy. DDH is more acetabulum does not grow and remodel and, common in breech deliveries, positive family therefore, becomes shallow. Ligamentous history, in children with joint laxity and in laxity is related to DDH in several ways. The girls1. The early diagnosis of DDH is condition is associated with the development important for a successful outcome. Delays in of DDH when laxity is a familial trait1. This management results in residual abnormalities effect is much stronger in female and eventual degenerative arthritis. Figure 1: Right Hip DDH Figure 2: Right MATERIAL & METHODS: Hip reduced A 4 years old girl was referred to be having a limping gait. Patient was asymptomatic. Patient had a normal birth history and no family history of DDH and joint laxity. On examination, there was asymmetrical inguinal fold on the right side. The right lower limb is externally rotated and shorter by 2 cm. There are limitations of abduction movement. Ellis than in male children1. Wynne-Davies et al in test showed right femur shortened while the 1970, proposed that heritable ligamentous tibia appears to be equal length. Galezzi sign laxity was one of two major mechanisms for was positive. Patient had generalised joint the inheritance of DDH2. The treatment of laxity with Beighton score of 8. Pelvic Xray DDH is age-related and the goal is to achieve showed right hip DDH with shallow and maintain concentric reduction of the acetabulum. Acetabulum index was 32 femoral head into the acetabulum. Close degrees. Patient was planned for open reduction is appropiate management for most reduction, femoral shortening and infants under 18 months of age. For those 18 acetabuloplasty of the right hip. After the months above, treatment is more challenging induction of anaesthesia, we noticed the right and operative management is usually required. hip is easily reducible and has a wide safe The femoral head is usually in a more angle.Intraoperative shows proximal location in the older child, and the acetabulum index less than 25 degrees with muscles that cross the hip are more severely lateral pooling over the superolateral contracted1. Femoral shortening is an essential acetabulum due to redundant capsule. A part of the management of the older child. decision of close manual reduction and hip Muscles surrounding the hip, especially the spica was made in view of the right hip easily adductors, become contracted, limiting reducible and stable. Patient’s right hip was abduction of the hip. The hip capsule reduced and stable during clinic follow up and constricts; once this capsular constriction during the change of hip spica. Post op 4 narrows to less than the diameter of the months, patient is ambulating well and able to femoral head, the hip can no longer be reduced ride a bicycle. Pt’s pelvic xray shows the right by manual manipulative maneuvers, and hip is reduced and stable and has an AI< 25 operative reduction usually is necessary1. In deg. this patient, this was never an issue in view of DISCUSSIONS: her ligamentous laxity. Her hip joint was During the immediate newborn period, laxity reducible easily without tension. of the hip capsule predominates, and, if clinically ABSTRACT TRUNCATED .  PS01A Normal Plain Radiograph In A Case Of Tuberculosis Spondylodiscitis Presenting With Cauda Equina Syndrome: A Case Report

Tan HP; Faris K; Ng MG; Avthar S; Kamil K Orthopaedic Department, Hospital Tengku Ampuan Rahimah, Klang, Selangor, Malaysia.

INTRODUCTION CONCLUSION Spinal tuberculosis is a destructive form of We are presenting this case to illustrate the tuberculosis that is common in young adults importance of high index of suspicion in and mainly involves the thoracic region of the foreign workers from endemic nations that may . Clinical manifestations have underlying tuberculous infection in the includes back pain, associated constitutional spine despite of a perfectly normal plain symptoms, paraplegia and deformities. radiograph. They can be a final diagnostic Characteristically there may be destruction of dilemma as the initial plain radiograph may not the intervertebral disc space, collapsed of spinal portray the actual pathology. segments, anterior wedging and also extension of the lesion into surrounding areas. Magnetic REFERENCES resonance imaging is a sensitive tool i aiding in 1. V Agrawal et. al. J Craniovertebr Junction the diagnosis of spinal tuberculosis. A Spine 2010 ; 1 (2) : 74-85 reduction in vertebral height is often seen with Kanabur P et. al. Ind J Orthop 2005; 39 (2) : irregularity of the antero-superior end plate 81-89 being relatively early and a subtle sign.

CASE PRESENTATION Here we present a case of a 33 year old Sri Lankan manual worker who presented with one week history of lower back pain that was associated with radicular symptoms. He did not have any neurological deficit. He was treated for possible back sprain with underlying herniated disc at level L4/5 or L5/S1. A plain radiograph done did not reveal any abnormality which further strengthened the diagnosis of herniated disc. He was treated conservatively with analgesia, muscle relaxants and started on a physiotherapy regime. He showed improvement in symptoms gradually but at the 4th day, he had symptoms of acute urinary retention, bowel incontinence, weakness of lower limbs and sensory deficit of both foot and ankles. Urgent MRI revealed features suggestive of tuberculous destruction of L5 vertebrae with destruction and evidence of subligamentous extension and cauda equina compression. Apart from an elevated erythrocyte sedimentation rate (ESR) and white blood count (WBC), all hematological investigation were normal. The Mantoux test gave a strongly positive result.

PS01B Stepped In The Neck During A Brawl In Prison: A Rare Cause Of C3/C4 Bifacaetal Dislocation

Lim SW; Sharon TXF; Thurai Kumar K Department of Orthopaedic, Hospital Sungai Buloh, Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia

INTRODUCTION: REFERENCES:

Bilateral facet dislocations represent 1. Uhrenholt L, Charles AV, Hauge E, significant high energy trauma to the cervical Gregersen M. Pathoanatomy of the lower spine. Being stepped on the neck during cervical spine facet joints in motor vehicle violence or brawl is a rare cause. crash fatalities. J Forensic Leg Med. 2009 Jul. 16(5):253-60. Case report 2. Hubbard ME, Jewell RP, Dumont TM, A 34 year old gentleman sustained a C3/C4 Rughani AI. Spinal injury patterns among bifacetal dislocation after being involved in a skiers and snowboarders. Neurosurg Focus. prison brawl whereby he was pushed to the 2011 Nov. 31(5):E8. floor and subsequently stepped on the neck by another assailant. He heard a crack sound and had loss of consciousness. After regaining consciousness, he was unable to move both upper and lower limb with ASIA C neurological status.

Magnetic Resonance Imaging demonstrated anterolisthesis of C3 over C4 with C4 vertebral body oedema with a C3/C4 discal tear with extruded nucleus pulposus and elevation of the posterior longitudinal ligament causing spinal canal stenosis and cord oedema. C3/C4 ACDF was done. Patient neurological status improved to ASIA D 1 month post surgery and currently still under our follow up.

DISCUSSIONS:

Motor vehicle accidents, falls, and accidents resulting from recreational activities are the leading cause(1). Violence is a relatively rare cause. A high index of suspicion due to significant history and physical examination findings should guide the clinician in determining the need for reviewing the initial radiographs (if taken and available) or request repeat studies, regardless of the initial imaging status.

PS01C A Rare Case Of Traumatic L1-L2 Spondyloptosis

1Amir FZ; 1YH Loke; 2Dzulkarnain A; 1Farid FF; 1Satpal SC 1Department of Orthopaedic, Hospital Selayang, Lebuhraya Selayang-Kepong, 68100 Batu Caves, Selangor, Malaysia 2 Department of Orthopaedic, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia

INTRODUCTION DISCUSSION Traumatic spondyloptosis is a very rare Spondyloptosis is a form of spinal dislocation occurrence associated with catastrophic or grade V spondylolisthesis. Hundreds of neurological injury. It is characterized by cases have been reported occurring at the complete dislocation in coronal or sagittal lumbosacral junction however only two cases plane of one spine on another. Most cases of L1 spondyloptosis were reported in 1999 were reported at the lumbosacral junction. We and 2011. To our knowledge, this may be the report a rare case of traumatic spondyloptosis third case of this injury and may well be the 1st occurring at L1-L2 vertebral body. case of L1-L2 spondyloptosis reported in Malaysia. CASE REPORT The high energy trauma causes severe We present a case of a 35 years old Indonesian displacement of the lumbar spine together with labourer in which he had a large concrete wall disruptions of facets, posterior ligamentous that fell onto his back. Upon presentation to structures and injury to the spinal cord. This orthopaedic centre, he was alert and conscious unstable spinal injury was best stabilized via with stable vital signs. There was a large posterior instrumentation for future ambulation abrasion wound at the back with ecchymosis. and rehabilitation. Neurological assessment of lower limbs shows power grade 0 of Medical Research Council grading and sensation diminished from T12 below consistent with ASIA A. Reflexes were hyporeflexic with lax anal tone. He also sustained multiple ribs fracture, bilateral kidney injuries and liver injury. a b c Lateral radiographs demonstrates 100% anterior dislocation of L1 vertebral body over Figure a shows radiograph of complete L2 vertebral body. MRI corroborated the dislocation L1-L2 and stabilization with radiographic findings and also compression posterior instrumentation (b,c) fracture L2, bilateral facet fracture L1 with transection of thecal sac at this level. CONCLUSION Traumatic spondyloptosis L1-L2 is a rare Patient successfully underwent single stage injury and highly associated with neurological instrumentation and interbody fusion via deficit. Posterior instrumentation and posterior approach seven days later. Reduction decompression is an effective option for this was done by placing pedicle screws and rods injury. separately superiorly and inferiorly to the dislocation. Dislocation was realigned using REFERENCE distraction instruments. Longitudinal rods 1. Vedpal Yadav, Diwakar Mishra, lalit were then fixed and locked. The fractured Maini, VK Gautam 2011, ‘Cowherd’s Injury: superior articular facet of L2 was resected for Traumatic retrospondyloptosis of L1 over L2 ease of reduction Posterior interbody fusion in a 7 year old child, Indian Journal of was performed using autografts mixed with Orthopaedics, vol.45,pp365-367 autologous bone grafts. 2. Yazici M, Alanay A, Aksoy MC, Acaroglu E, Surat A. 1999, ‘Traumatic L1-

ABSTRACT TRUNCATED PS01D Hodgkin’s Lymphoma Mimicking Spinal Tuberculosis

TeoYM; Abdul Rauf KZ; Norlizam Mohd; M.Fauzlie Yusof Department Of Orthopaedic Surgery, , Jalan Mufti Haji Khalil, 75400 Melaka, Malaysia

INTRODUCTION: staging of mixed-cellularity ( WHO). Anti-TB Tuberculosis is endemic in our nation, number was stop and started chemotheraphy (ABVD, of cases continues to rise and leading to high Adriamycin, bleomycin, vinblastine, rate of mortality and morbidity. Spinal dacarbazine). Radiotherapy was given for the tuberculosis is a frequently encountered multiple lymph nodes enlargement. Repeated extrapulmonary form of the disease. MRI is thoracic MRI after completed chemotherapy the preferred imaging modality in the show resolved spinal cord compression and assessment of spinal tuberculosis because of normal cord intensity( figure 3) . He is now its superior ability to demonstrate soft tissue currently able to walk independently with abnormalities (1). Spinal Hodgkin’s walking frame. lymphoma with B symptom can be a mimicker for spinal tuberculosis

METHODS: A 32 years-old institutionalized gentlemen presented with back pain for 3 months and bilateral lower limb paraplegia for 1 week , associated with fever, night sweat and weight loss. MRI of thoracic spine shows destruction (figure 1) (figure 3) (figure 2) vertebral body and spinal process T4& T5 with epidural abcess and spinal cord DISCUSSIONS: compression . ( figure 1) He was schedule for Spinal tuberculosis is a frequently encountered urgent laminectomy and decompression due to extrapulmonary form of the disease. present of acute neurological deficit. No frank Institutionalization is a known risk factor of pus noted Intra-operatively, T5 lamina and tuberculosis .It can present with chronic low epidural tissue was sent for Histopathological back pain with or without spinal cord Examination (HPE) other than conventional compression. MRI of spine is the modality of bacteriological studies and tuberculosis work- choice in cases which suspicious of TB spine up. He was started Antituberculosis (AntiTB) with neurological deficit . However, there is Drug based on risk factor, clinical presentation no pathognomonic finding on MRI that and MRI findings. reliably distinguishes tuberculosis from other spinal infections or from a possible neoplasm RESULTS: (2). Only 5% of cases of Hodgkin’s lymphoma Tuberculosis work up and bacteriological may develop spinal cord compression. In only studies was negative. However, HPE of 0.2% cases, cord compression is the initial epidural tissue shows findings of Classical presentation (3). Hodgkin’s lymphoma within Hodgkin’s lymphoma ( mixed cellularity) the spinal cord most often occurs as a with present of classical bilobed Reed- complication of widespread dissemination (4). Sternberg cell ( figure 2) . HPE of lamina also It is thought that the lymphomas usually enter shown marrow infiltration by Hodgkin’s cell . the epidural space by contiguous spread from a CT scan of thorax , abdomen and pelvic shown paravertebral mass through the vertebral multiple infrac-clavicular , mediastinal , para- foramen and expanding into the epidural space. aortic and inguinal lymph nodes enlargement. Surgical decompression is the first therapeutic Clincal staging of Stage IV with B approach for a condition with spinal cord symptoms( Ann Arbor Hodgkin Disease decompression. Tissues for HPE must Staging Classification) with pathological

ABSTRACT TRUNCATED PS02A Pott’s Disease In A 3 Years Old Toddler

K Fairuz1; N Khadijah1; MY Sharizan2; MA Kamalruzaman2 Department of Orthopaedic, Hospital Enche’ Besar Hajjah Khalsom, Kluang KM 5, Jln Kota Tinggi 86000 Kluang Johor, Malaysia

INTRODUCTION: Tuberculous spondylitis (TB) or Pott’s disease is one of most common form of extra pulmonary TB. It was first describe by Sir Percival Pott in 1779. Recent migration or foreign worker in these past few years has made statistic of TB cases increasing not only affecting the adult, but also children. Fig 1: Radiograph of thoracolumbar spine showing vertebral body destruction and severe CASE REPORT: kyphotic deformity T9-T10 and end disc We report a case of a 3 years old orang asli erosion. girl, who presented with fever for 1 week associated with chesty cough, rapid breathing DISCUSSION: and failure to thrive. She also has a Children are not miniature adults. Their progressive painless back deformity for almost anatomy is unique, and in this case it is 1 year but is still able to walk. There was advantagous. She has no neurological deficit history of direct contact with a relative despite severe kyphotic deformity. The suffering from TB. She had completed possible explanation could be because in vaccination accordingly. children, spinal canal is wider and the spinal cord is more elastic and strechable compared On examination, noted that this patient was to adults2. The cerebrospinal fluid is high in lethargic looking, and tachypnoic. BCG scar volume compared to adult, which provides was present. She had a gibbus deformity of the cushioning effect to the cord. In children, the spine and her growth was under 5th disease is characterized by an extensive and percentile. There was no neurological deficit. diffused involvement, the formation of abscess Her developmental milestone was up to her and the low incidence of Pott's paraplegias or age. tetraplegias1. However neurological involvement can occur at any stage of Pott’s Blood investigations results showed Hb of spine and even years later, when there has 10.2g/dl, WBC 16750/uL, serum electrolytes been apparent healing, because of stretching of were normal, ESR 120 and CRP 54.4.. the cord in the deformed spinal canal4. In Mantoux test was significant at 8mm children, the intervertebral disc is highly induration, but sputum gastric lavage for AFB vascular. Thus, usually infections are from times 3 were negative. Plain radiograph of the hematogenous spread from pulmonary TB. chest showed hydropneumothorax and right This differs from adults due to relative lung collapse, which requires chest tube avascular of the disc, the disc disease are drainage. Thoracolumbar spine radiograph usually due to an advance spread of infection showed a kyphotic deformity with Cobb’s from the adjacent vertebral body2. angle of 70º with the apex at T9 – T10 and presence of end plate erosion. High Resolution There is still no concensus regarding CT thorax was suggestive pulmonary and TB corrective surgery in children but external spine. braces application shows promising results to prevent further progression of kyphosis3. Anti-TB chemotherapy was commenced for 12 months and a thoracolumbar cast was applied.

ABSTRACT TRUNCATED PS03A Posterior Decompression And Laminoplasty For Cervical Spondylotic Myelopathy: A Case Report

Tan HP; Shafiq W; Andrew L; Avthar S; Kamil K Department of Orthopaedic, Hospital Tengku Ampuan Rahimah, Taman Chi Lung, Jalan Langat, 41200 Klang, Selangor, Malaysia.

INTRODUCTION was offered to undergo surgical intervention after he has failed all the conservative therapy. Posterior decompression by laminoplasty have Operation was successful and subsequent been widely accepted, and they provide follow-up noted marked improvement of sufficient results for cervical spondylotic symptoms over his bilateral upper limbs. myelopathy. Among posterior cervical instrumentations, pedicle screw fixation is a CONCLUSION strong tool of stabilization of unstable segment and correction of deformities in sagittal and The goal of surgical treatment is to achieve a coronal planes for the patient with cervical maximum of decompression without spondylotic myelopathy. On the other hand, compromising the spinal stability and neurovascular complications including injury respecting the sagittal profile of the spine. to the vertebral artery and nerve root cannot be Depending on the affected area, the completely eliminated. decompression may be executed through a simple discectomy, with or without fusion, or Even after surgeons became familiar with through extensive laminoplasty with grafting placement of cervical pedicle screws, screw and internal fixation. Post operative malposition rate by freehand technique is high physiotherapy plays an important role where it for patients with severe spondylotic condition. provides neurological recovery and better Combined procedure of posterior outcome. reconstructive surgery using pedicle screw fixation provides better clinical outcomes than laminoplasty alone for cervical spondylotic myelopathy accompanying local kyphosis or segmental instability.

CASE PRESENTATION

Here, we would like to report the result of this 64-year-old gentleman, who presented to our clinic with neck pain and worsening bilateral upper limbs numbness. He denied any history of trauma. He was given oral medication and advised to start physiotherapy during the initial consultation.

However, subsequent follow-up never show any improvement in his symptoms despite multiple visit to physiotherapy and increased frequency of analgesia consumption. Plain radiograph showed degenerative changes over the cervical vertebral. MRI reported multilevel degenerative cervical disc disease with disc- osteophyte complex causing significant cervical cord compression from C3-C6. Patient PS03B Surgical Site Infection (SSI) In Transforamina Lumbar Interbody Fusion (TLIF) Surgery In Hukm From 2011-2013

CYL Choong; SA Rhani; MH Ariffin; A Baharudin Department of Orthopaedics & Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 43600 UKM, Bangi Selangor, Malaysia

INTRODUCTION Table 1: Association between surgical The transforamina lumbar interbody fusion procedure and group of surgery (TLIF) technique allows for the treatment of Characteristics Group of p- degenerative lumbar spine pathologies. It can surgery value be performed using minimally invasive Open, MIS, surgery (MIS) or conventional open methods. n(%) n(%) The goal of this study was to compare incidence of surgical site infections (SSI) in bVancomycin both techniques, assess the possible risk powder usage factors for SSI in TLIF procedures, and Yes 14 32 0.311 evaluate their complications. (60.9) (76.2) No 9 10 METHODS: (39.1) (23.8) A retrospective study of patients who had bInfection undergone open TLIF and MIS methods Yes 3 2 (4.8) 0.477 performed at the Universiti Kebangsaan (13.0) Malaysia Medical Centre from January 2011 No 20 40 to December 2013 was made. All surgeries (87.0) (95.2) were performed under standard sterile bComorbidity conditions by experienced orthopaedic spine of Diabetes surgeons. The data collected were evaluated Mellitus and analysed for incidence and possible Yes 8 12 0.604 contributing factors for the occurrence of SSI (34.8) (28.6) in both TLIF groups. No 15 30 (65.2) (71.4) RESULTS: aDuration of 195.91 159.17 0.035* A total of 65 patients underwent a TLIF surgery + + 53.94 procedure with 23 patients (mean age 60) in (minutes), 83.08 the Open TLIF group and 42 patients (mean mean +s.d. age 61) in the MIS group. SSI developed in 7.7% of patients undergoing a TLIF aAmount of 582.61 321.43 0.025* procedure. Coagulative-negative blood loss (ml), + + Staphylococcus (CONS) was identified as the mean +s.d. 499.46 402.45 predominant pathogen (60%). Infection rates were lower in MIS groups (4.8%) as oppose to aPost-operation 12.26 4.24 + 0.029* those in open TLIF (13%). The MIS group day of + 3.12 also had significantly shorter surgical duration, admission 16.37 less amount of intra-operative blood and (days), mean shorter hospital stay by 8 days than the open +s.d. TLIF group. Patients with diabetes mellitus aIndependent t-test had 9 times higher risk for SSI. We did not bChi-square test find any statistical improvement in SSI rates *Significant if p-value < 0.05 with the use of intrasite vancomycin.

ABSTRACT TRUNCATED PS03C Cervical Chordoma : A Case Report

Zakhiri MR; Dzulkarnain A; Manmohan S; JH Goh; ZA Norazlin; Fazir M Department of Orthopedic and Traumatology, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia

ABSTRACT and fusion (ACCF) C4 was Chordoma is a rare primary tumour arising initially done followed by posterior spinal from notochord remnants. It is slow growing instrumentation and fusion C2-C6. The patient but can be locally invasive, and are found tolerated both procedure and experienced predominantly in the clivus and sacral spine. resolution of his neurological deficit. This tumour is rarely seen in the cervical spine, representing only 6% of all DISCUSSION AND CONCLUSION chordomas2.. We report a case of a 33 year old En bloc resection of the tumour is the standard male with chordoma of C4 vertebra, with both treatment for chordoma. The central location the anterior and posterior elements involved. A of these tumours will often causes difficulty in combined anterior and posterior approach was achieving total resection However, cervical used for tumour resection and spinal chordoma pose a challenge to surgeons reconstruction. The aim of this study is to because of highly risky anatomical region. discuss clinical and radiographic presentation Because of the need for spinal cord of cervical chordoma as well as surgical preservation, it is very difficult to achieve treatment. wide surgical margin in the cervical spine, resulting in intralesional tumour resection in almost all cases. This is due to the involvement of multiple compartments at the time of diagnosis of chordoma, making en bloc resection rarely practicable in cervical spine, unlike chordomas in other regions2. To eradicate this tumour completely is a Figure 1: Lateral view radiograph and sagittal challenge, as even if radical tumour removal is MRI showing C4 chordoma compressing on achieved, it is very difficult to determine the spinal cord clearance at microscopic level. Piecemeal removal of the tumour is a viable technique2. Combination of radical intralesional tumour debulking surgery with postoperative radiotherapy remains an effective way to treat cervical chordoma1.

REFERENCES Figure 2: Lateral view radiograph showing 1.Primary chordomas of the cervical spine: a combined anterior and posterior approach for consecutive series of 14 surgically managed tumour resection and spinal reconstrauction. cases; Yu Wang et al; J Neurosurg Spine 17:292–299, 2012 CASE REPORT This 36 year old man, with underlying 2.Surgical management of chordomas of the hypertension, presented with neck pain for 1 cervical spine; Ignacio J. Barrenechea et al; J year, associated with bilateral upper limb Neurosurg Spine 6:398-406, 2007 weakness and numbness. X-rays showed osteolytic lesion of C4 vertebra. MRI revealed a large mass, involving most of anterior elements of C4 vertebra with extension into the canal. Staged surgical intervention was done. Anterior cervical PS03D Morquio Syndrome : To Intervene Or Not?

Zakhiri MR; Dzulkarnain A; Manmohan S; JH Goh; ZA Norazlin; Fazir M Department of Orthopedic and Traumatology, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia

ABSTRACT Morquio syndrome is one of the mucopolysaccharide storage(MPS) disorder. It is multisystemic but usually manifests as progressive skeletal dysplasia. Morquio syndrome tends to have greater skeletal Figure 2: clinical presentation of the younger manifestations and spine involvement 2 patient, with lateral cervical radiograph and compared with other forms of MPS . Early sagittal spine MRI diagnosis and appropriate treatment of DISCUSSION AND CONCLUSION problems involving the spine are critical to Atlantoaxial instability is a common finding in prevent neurological deterioration and Morquio syndrome. Cervical spine problems subsequent loss of function. One of the most are usually contributed by odontoid hypoplasia important issue in managing these patients is and ligamentous laxity1. Odontoid hypoplasia cervical spine problem. Cervical spine and atlantoaxial instability are among the most problem, particularly instability and critical features of this syndrome2. With compression at the C1 and C2 level is present atlantoaxial instability, sudden extreme in almost all patients. This report outlines the movement of the neck due to fall or whiplash clinical and radiographic findings found in two injury can cause injury to the cord resulting in siblings with Morquio syndrome. sudden death or severe neurological deficit. CASE REPORT Early signs of myelopathy should be observed Two siblings of the same family, aged 10 and to look for evidence of compression and 8 years, were referred to orthopaedic clinic for cervical spine x-rays should be done during bone deformity. Clinically, both girls had follow-ups to look for instability. retarded growth with short stature for their Asymptomatic patients with evidence of cord chronological age. They presented with compression by MRI or cervical instability bilateral genu valgus, hip instability and spinal may be considered for surgery to prevent deformity. MRI spine of the older sibling permanent spinal cord injury1. Surgical showed hypoplastic odontoid process with techniques vary considerably. C1-C2 posterior subluxation C1-C2. Posterior instrumentation fusion is one of the most common procedure1, and fusion of C1-C2 was done. MRI spine of and this is the procedure of choice in our the younger sibling showed indistinct odontoid patient. process with narrowing of craniocervical REFERENCES junction. However, the parents opted not to 1.Spinal involvement in proceed with surgical intervention. mucopolysaccharidosis IVA (Morquio- Brailsford or Morquio A syndrome): presentation, diagnosis and management; Guirish A. Solanki et al; J Inherit Metab Dis (2013) 36:339–355 2.Roentgenographic diagnosis of

Figure 1: clinical presentation of the older mucopolysaccharidosis with particular sibling with her sagittal MRI spine and post- reference to Morquio syndrome; operative radiograph UmeshParashari et al; SA Journalof Radiology (2012)

PS04A

How Common Is Epidural Haematoma Causing Neurological Deficit Post Epidural Pain Management In Children? What Is The Treatment Option?

Zakhiri MR; Dzulkarnain A; Manmohan S; JH Goh; Nor Azlin ZA; Fazir M Department of Orthopedic and Traumatology, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia

Keywords: epidural analgesic, paediatric, postoperative, epidural haematoma, decompression

Introduction: the latest follow up, she was able to walk with The pediatric epidural is an accepted method improvement of right foot drop. of advanced analgesia in children. Pediatric epidural analgesia (PEA) is effective and Discussion: safer, especially with the advances in The UK Pediatric Epidural audit (1) showed a ultrasonography. PEA is still an important risk of serious complications to be 1 : 2000 technique to master and employ, and the and persistent complications to be 1 : 10 000 indication to proceed must be done thorughly. epidurals. Examination of the recent medical The complications of PEA are well reported in literature has revealed two complications of the literature. epidural analgesia, one that was recovered (2) and one that resulted in persistent damage. Case: Paraplegia or death secondary to central The patient is a 6 year old Malay girl, who techniques in all age patients was described as had underwent operation for choledochal cyst 1 : 10 0000 (3). Patients with epidural and hepatic duodenectomy done on 13/5/2015. hematomas who meet surgical criteria and Epidural analgesic was inserted at L1/L2 level. receive prompt surgical intervention can have Post operatively, on Day 2, extravasation was an excellent prognosis. The decision to noted at epidural insertion site, and perform a surgery in a patient with a traumatic subsequently the catheter was removed. Post extraaxial hematoma is dependent on several removal, patient developed back pain, factors (neurological status, size of hematoma, radiating more to the right as compared to the age of patients, CT findings) but also may left lower limb. Subsequently progressive depend on the judgment of the treating weakness was noted over bilateral lower limbs surgeon. In this case, early surgical with no bowel or urinary incontinence. decompression has promising result. Neurological examination revealed power over bilateral lower limbs was about 3, and the References: child had difficulty in standing and walking. 1. Llewellyn N, Moriarty A. The national MRI of the whole spine was done, which pediatric epidural audit. Pediatr Anesth 2007; revealed L1/L2 post epidural hematoma 17: 520–533. causing spinal stenosis and cauda equina 2. Kipnis E, Desoutter E, Dalmas S et al. Total compression (Fig 1). Laminectomy L1 was spinal anesthesia during combined general- done with deroofing of L2 on the 17/5/2015. epidural anesthesia in a 7-yearold child. Intraoperatively, blood clot about 2cc noted at Pediatr Anesth 2005; 15:54–57. level L1-L2, which was completely evacuated 3. 3rd National Audit Project (NAP3) National (Fig2). Post operatively, power of lower limbs Audit of Major Complications of Central was about 4 and she was able to stand with Neuraxial Block in the United Kingdom support but still could not walk. On post op day 8, shet was put on fiber glass body cast and discharged well. 2 months post surgery, there was persistent right foot drop. However she was ambulating well and with no other complains. Body cast was removed and the right foot supported with foot splint. During PS04B Surgical Reduction Of High Grade Adult Degenerative Spondylolisthesis

Ayob, KA; Chiu CK; Chan CYW; Kwan MK Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

INTRODUCTION: grade slip, sagittally oriented facet joints. The Degenerative spondylolisthesis is an acquired preparation of the intervertebral space is an condition where facet incompetence and disc essential step. There is a high complication degeneration allows the slippage of one rate where there are overzealous attempts in vertebra on another. reduction. There is often a bony lip arising Surgical treatment is considered if from the superior endplate of the inferior conservative approaches fail. This should be vertebral body. Attempts at disc removal and tailored according to the severity of the cage insertion without addressing this bony slippage, patient’s symptoms and expectations. block can be quite difficult and cause significant complications. METHODS: A 62 year old female with diabetes mellitus presented with gluteal pain which radiates to the posterolateral aspect of her right leg. There is reduced sensation over the right L5 dermatome and a weakened extensor hallucis longus. Radiographic examinations shows a grade III spondylolisthesis of L4-L5 and a magnetic resonance imaging demonstrated compression of the descending right L5 nerve root at the lateral recess. Attempts at Figure 1. Osteotomy of L5 bony lip conservative management failed and she had worsening of symptoms and also progression CONCLUSION: of the L4 over L5 listhesis. High grade degenerative spondylolisthesis is a rare occurrence, which requires surgical RESULTS: intervention if patient has neurological deficit A posterior decompression, partial reduction or has failed conservative management. This with instrumented posterolateral and interbody case demonstrates the vital steps in gaining fusion surgery was performed. access to the intervertebral space. Reduction methods include: 1. Maximum height of the Wilson frame to REFERENCES: reduce lordosis 1. Eismont FJ, Norton RP, Hirsch BP. 2. Removal of bony lip arising from the Surgical Management of Lumbar superior end-plate of the L5 vertebra to Degenerative Spondylolisthesis, J Am Acad facilitate access and instrumentation Orthop Surg. 2014 Apr 22(4): 203-13 3. Placement of cage over the anterior two 2. Rihn JA, Gandhi SD, and Albert TJ thirds of the intervertebral space. (2014). Posterior Lumbar lnterbody Fusion. In: Zdeblick TA, Albert TJ (eds.), Master DISCUSSIONS: Techniques in Orthopaedic Surgery - The The aim of surgery is to decompress the Spine, Lippiocott Williams & Wilkins, involved neural structures and fusion of the Philadelphia. pp 323-33 involved vertebrae. Reduction of the slippage allows the realignment of the spinopelvic sagittal plane. Interbody fusion is considered where there is a high risk of nonunion, local kyphosis, high- PS04C Acute Peripheral Arterial Insufficiency Presenting As Cauda Equina Syndrome: A Case Report

Loh KW; Daud H; Abdul Rahman I; Nasirudin N Department of Orthopaedic Surgery, Hospital Miri, Jalan Cahaya, Miri, 98000 Sarawak, Malaysia.

INTRODUCTION: team. On the following day, he deteriorated Cauda equina syndrome (CES) due to spinal abruptly and eventually succumbed to his cord ischaemia resulting from acute arterial illness due to cardiogenic shock secondary to disruption is rare. When encountered, it poses myocardial infarction. diagnostic challenge to the clinician due to its rarity, which may lead to incorrect or delayed DISCUSSIONS: diagnosis. Despite the rapid onset and severity of neurological deficit in our case, there was no METHODS: history of trauma or systemic infection, which We report a case of a 79-year-old patient who has raised the suspicion of a vascular presented with an acute CES, which turned out pathology. The case was further complicated to be caused by thrombosis of the right by the presence of degenerative lumbar spine common iliac artery. pathology and disc herniation.

CASE DESCRIPTION: Thrombosis of the right common iliac artery The patient, previously ADL-independent, led to reduced blood flow in iliolumbar and gave a 10-day history of sciatica pain, which lateral sacral arteries, which may cause was aggravated by straining and walking. He ischaemia of the cauda equina, mimicking presented with sudden-onset, weakness of compression. An early MRI spine is useful to right lower limb with calf pain, and inability to exclude compression and subsequent CT ambulate with acute urinary retention. His past angiography would be useful to identify areas medical history were significant for of arterial blockage. hypertension and type II diabetes. Examination revealed impaired sensation of CONCLUSION: right lower limb from L3 to S1 and motor loss Thorough neurological & vascular over L4, L5 and S1, with absent bilateral knee examinations are imperative for timely reflexes and right ankle reflex. No saddle diagnosis and treatment. In patients presenting paraesthesia, however anal tone was weak. with suspected CES without confirmatory radiological evidence, a high index of Lumbar spine radiographs revealed suspicion for vascular pathology is required, degenerative changes. MRI showed L2/3 & particularly in known cases of arterial L4/5 disc bulge and protrusion with nerve root dysfunction. impingements. There was no significant spinal cord, or cauda equina compression. Shortly REFERENCES: after, he developed mottled right foot with no 1. Fraser S, et. al. Arch. Phys. Med. Rehabil. right lower limb pulses palpable. An 2009, 90, 1964-1968. ultrasound Doppler bilateral lower limb was 2. Olearchyk AS. Can J Surg. 2004, 47, 472- done and revealed extensive thrombus at right 473. common iliac artery to popliteal artery and left common femoral artery thrombus. ECG showed left axis deviation with acute ischaemic changes over anterior chest leads, with significantly elevated cardiac enzymes.

He was commenced on heparin infusion and treated for myocardial infraction by medical PS04D Rare Presentation Of Non-Hodgkin Lymphoma With Paraplegia

Ernloong, Chiew; Shamsul, SA; Hishamuddin, Salam Department of Orthopaedic Surgery, Hospital Sultanah Aminah, Jalan Persiaran Abu Bakar, 80100 Johor Bahru, Johor, Malaysia.

INTRODUCTION: Diffuse large B-cell lymphoma (DLBCL) is ensure that the specimen was prepared and the most common type of non-Hodgkin stained correctly and the final results of the lymphoma. It is a high grade lymphoma that histopathologic examination showed high has developed from B-cells. When examined grade B-cell non-Hodgkin’s lymphoma. under a microscope, the cancerous lymphocytes are abnormally large and are diffusely scattered throughout the specimen as opposed to being found in clusters which is found in other types of lymphomas.

CASE REPORT: A 15-year-old boy presented with one-week history of sudden onset persistent back pain and paraparesis. Radiograph of the spine revealed multiple osteolytic lesions of the Figure 1: MRI Figure 2: Post-operative thoracic and lumbar vertebral bodies. The x-rays patient initially refused to be investigated, but DISCUSSIONS: came back two-months later with paraplegia. DLBCL is the commonest type of non- He was cachexic and pale with no enlarged Hodgkin’s lymphoma which usually presents lymph nodes. Highest normal sensory level as a mass typically as an enlarged lymph node was T6. Lower limbs were hypertonic with in the neck, groin or abdomen. Spinal cord complete loss of muscle power and anal tone compression is a rare presentation of non- (ASI=A). Blood investigations were normal. Hodgkin's lymphoma, occurring in 0.1% to MRI (Figure 1) revealed multi-level bony 3.3% of patients1. Proper care during infiltrates involving the body, pedicle and preparation and staining is important with the posterior elements with multiple levels of biopsy specimens because all of our initial compression fracture. Metastases to the spine specimens were decalcified prior to staining with an unknown primary was suspected. and this may have caused extensive artefacts Decompression surgery with biopsy and and degenerative changes to the specimen posterior stabilization from T5 to L4 was even before staining. performed. Histopathological examination revealed “fragments of bony tissue and CONCLUSION: marrow contents with extensive artefacts and Clinical onset of spinal symptoms is not a degenerative changes”, which was common presentation for patients with inconclusive. CT of the thorax, abdomen and DLBCL. Strong suspicion must be taken in pelvis performed to look for a primary site patients whose MRI and CT scan shows multi- showed multiple lytic bony lesions with level bony infiltrates with no primary infiltration into the spinal canal but no obvious malignancy even with a normal blood primary malignancy or significantly enlarged investigation results. lymph nodes. A peripheral blood film was repeated again and it showed presence of 10% REFERENCES: abnormal mononuclear cells which are large in 1M. Popescu et al, Spinal involvement with size. A haematological malignancy was spinal cord compression syndrome in strongly suspected. Subsequently, a trephine haematological diseases, Rom J Morphol biopsy was done and proper care was taken to Embryol 2012, 53(4):1069–1072 PS05A Rugby Sport Injury Resulting In Traumatic Herniated Nucleus Pulposis L2/L3 With Progressive Neurological Deficit In A 15 Year Old: A Case Report

Hashim MH; Lim SW; Chong KL; Kanniah T; Zamyn Z Department of Orthopaedics and Traumatology, Hospital Sungai Buloh, Jalan Hospital, 47000 Sungai buloh, Selangor, Malaysia

INTRODUCTION DISCUSSIONS

Herniated Nucleus Pulposus (HNP) is Traumatic HNP in adolescent first reported by uncommon in children and adolescents Maxter and Barr in 1934 with first reported counting for less than 2%. HNP due to surgical treatment described in a 12 years old traumatic sports injury in adolescent is even boy by Wahren in 1945. Historically, Most of more uncommon. the HNP in adolescent were predominantly male. Firno et al reported the most common CASE STUDY causes of HNP in adolescent are spontaneous, followed by sports injury, weight lifting and A 15 year old Malay boy presented with a fall. Most common level of disc herniation has lower back pain and difficulty walking 1 week been reported in the literature are L5/S1, after he was involved in rugby sports injury. L4/L5 and L3/L4. However, disc herniation of L2/L3 is rare. Thus HNP in adolescent warrant During the competitive rugby game, an an extra awareness so that diagnosis and opponent weighted approximately 80kg treatment are not delayed. tackled him from the back. 1 week later, he developed lower back pain which is localized to his lower back. However, 1 month later, the REFERENCES: pain radiate to both legs with tingling sensation. It was also associated with bilateral 1. Frino J et. al. J Pediatr Orthop lower limb weakness with numbness. He 2006;26:579-581 reported difficulty in walking. Bowel and 2. Komori H et. al. Spine 1996; 21: 225-229 bladder habit were normal. 3. Hood-White R et al. South Med J 2002;95:932-933 Examination revealed, power of grade 4 over bilateral lower limb from L2 to L5 myotome, sensation was reduced with normal reflexes. Anal tone and sensation were intact.

Blood investigations were normal. Inflammatory markers were not raised.

Plain radiograph revealed loss of lordosis of lumbar spine with normal intervertebral disc space. MRI revealed L2/L3 disc herniation and annular tear causing spinal canal stenosis measuring 6mm.

Patient underwent Inter-laminal Decompression and Open discectomy of L2/L3. Post operatively patient’s neurological deficit improved and still under follow up.

PS05B Incidental Dural Tear With CSF Leakage Post Lumbar Decompressive Surgery: A Case Report

Chua CG; Lim SM; Asrul F; N Zarini Y; M Yazid Din Department of Orthopaedic and Traumatology, Hospital Tuanku Fauziah, Jalan Kolam,01000, Kangar, , Malaysia

INTRODUCTION: DISCUSSIONS: Incidental dural tear is a rare and serious Incidental durotomy for degenerative spine complication of lumbar decompressive disease operation occurs in about 11.2%1 of surgery, accounting for about 1-17% cases. This usually occurs immediately after a depending on the types and complexity of the surgical maneuver, such as dissecting adherent spinal surgery performed1. We are reporting a dura from the ligamentum flavum or use of patient with degenerative spine disease with Kerrison rongeur or high-speed drill1. Some of severe spinal canal (thecal sac) and bilateral the authors prefer immediate reoperation once exit foramina stenosis complicated with CSF leakage is detected while others initially iatrogenic dural tear with cerebral spinal fluid start with conservative management. This leakage postoperatively. patient was treated conservatively and it shows a successful result. CASE REPORT: A 75 years old gentlemen presented with CONCLUSION: progressive bilateral lower limbs weakness In conclusion, all incidental durotomies must and numbness for 9 days followed by urinary be repaired primarily2. Despite primary incontinence and unable to pass motion for 5 suturing, CSF leakage may still occur. Instead days. He also had loss of sensation over of repeated surgical procedures, prolonged perianal region and associated with low back subfascial drainage with bed rest is a feasible pain. On examination, the neurological level treatment because success rate is high and it is was at L3. His perianal sensation and a safe and cheap method2,3. bulbocavernous reflex were absent with anal tone laxity. We proceeded with MRI which REFERENCES: showed severe multilevel lumbar spondylosis 1) S.K Kalevski, N.A Peev, M.D, and D.G with spinal canal and bilateral exit foramina Haritonov. Incidental Dural Tears in Lumbar stenosis. Thus, patient underwent posterior Decompressive Surgery: Incidence, causes, decompression and laminectomy of treatment, results. Asian J Neurosurg. 2010 L3L4,L4L5 and instrumentation of L3L4, Jan-Jun; 5(1): 54–59. L4L5, L5S1 and TLIF L5S1. Intraoperatively, 2) Arif ÖSÜN, Ali SAMANCIOĞLU, Tayfun there is severe stenosis at L4L5 and the dura AYDIN2, Umut Ogün MUTLUCAN, Murat mater was accidentally torn about 2cm by KORKMAZ, Ümit ÖZKAN. Managing The Kerrison rongeur during dissection. The dura Cerebrospinal Fluid Leaks After Spinal tear was repaired primarily with suture prolene Surgery By Prolonged Subfascial Drainage. 6-0 and valsalva manaevre was performed to Journal of Neurological Sciences (Turkish). ensure properly sealed dura mater. Post- 2013, Volume 30, Number 4, Page(s) 748-755. operation, patient complained of headache and 3) Wang JC, Bohlman HH, Riew KD. Dural dizziness and there was clear CSF fluid Tears Secondary to Operations on the Lumbar leakage into the drain. We kept the patient in Spine. Management and Results After a Two- Trendelenburg position and strict bedrest. The Year-Minimum Follow-up of Eighty-eight drain was kept free flowing for 3 days then Patients. J Bone Joint Surg Am 1998; removed. Intravenous ceftriaxone was started 80(12):1728-32. and completed for 10 days. Patient remained afebrile throughout and eventually, he was discharged well on day 12.

PS05C Comparisons Of Quality Of Life Of Adolescents With Idiopathic Scoliosis (AIS) Undergoing Anterior Spinal Fusion With Extra Pleural And Transpleural Treatments Using Online SRS-22 Questionnaire

1Ng, Bobby KW; 1Chau, WW; 2Hui, Anna CN; 2Wong, CY; 2 Shit, FKY; 1Zhu, Feng 1Department of Orthopaedics and Traumatology, Chinese University of Hong Kong, Shatin, NT, Hong Kong SAR, The People's Republic of China 2Department of Surgery, Prince of Wales Hospital

INTRODUCTION: DISCUSSIONS: AIS patients undergoing anterior spinal fusion The introduced ASF extra pleural approach (ASF) in the treatment of thoracolumbar showed insignificant difference to the scoliosis is well known for its effect in curve conventional transpleural approach (in all correction. It has the advantage of short fusion SRS-22 mean and all sub-domain scores, and preservation of mobile distal segments. It showing patients could receive the ASF has always been a clinical impression that approach with similar quality of life and these patients recover quickly and have a more satisfactions comparable with PSF approach. flexible spine comparing to patient who had Significant improvements in all mentioned posterior surgery, leading to shorter recovery scores after ASF extra pleural approach further period and their quality of life is virtually the provided evidences on the use of ASF same as normal adolescents. These advantages approach to spinal corrective surgeries in AIS. against patients undergoing transpleural treatment have yet to be documented. CONCLUSION: Quality of life is significantly improved after METHODS: ASF. A more detailed study is planned and Eligible subjects were invited to fill out the underway to look at specifically the pulmonary security enhanced online version of SRS-22 function change in these patients. questionnaire. SRS-22 questionnaire completed before surgery in extra-pleural REFERENCES: treated patients were extracted. Domain and mean total scores were calculated. Student’s 1. Ruf M, Letko L, Matis N, Merk HR, T-tests comparing domain and mean scores Harms J. Effect of anterior mobilization and between trans-pleural and extra-pleural shortening in the correction of rigid idiopathic patients were carried out. Same comparisons thoracic scoliosis. Spine. 2013;38(26):E1662- before and after surgery in extra-pleural 1668. patients were also carried out.

RESULTS: Twenty-eight patients (18 trans-pleural and 10 extra-pleural) were successfully filled out the online SRS-22 questionnaire. Median years since surgery was 7.5. There was no significant difference in function, pain, self- image, mental health, satisfaction with management and mean total scores between patients treated with trans-pleural and extra- pleural. On the other side, all mentioned domains and mean total scores were significantly improved after AIS extra-pleural surgery (all comparisons p<0.01).

PS05D Double Noncontiguous Spinal Fracture Dislocation Of Cervical And Lumbar Vertebra: A Case Report

1KT, Foo; 2CF, Foo; 1Jaafar, MSA; 1Department of Orthopaedic, Hospital Queen Elizabeth II, Lorong Bersatu, Off Jalan Damai Luyang 88300 Kota Kinabalu, Sabah, Malaysia

INTRODUCTION: with axial compression injury of the cervical Double noncontiguous spinal fracture spine more commonly than with hyperflexion dislocation of cervical and thoracic vertebra is or hyperextension injuries of the cervical not uncommon, which is due to high energy spine. trauma. The purpose of the report is to notify With the use of safety belt, the spine will be orthopaedic surgeons and discuss regarding subjected to flexion-distraction injury because the clinical presentation, evaluation and of inertia. It can act as fulcrum over the management of this type of injury, followed vertebra body, causing it to split into 2 parts, by discussion in the respective topic. which is also a possible injury mechanism for this patient too. METHODS: Management of these spinal injuries depends A 32 year old man with safety belt on, was on the nature of the injury. Thus, it is involved in motor vehicle accident where his important to have awareness of the possibility car was hit from the back. Patient was of non-contiguous spinal injuries in the CTJ retrieved and send to Accident and Emergency and upper thoracic spines in the patients with Department immediately. He was conscious cervical trauma. and alert during assessment in casualty. Neurological examination showed patient has CONCLUSION: sensory level of T6 with total paralysis of Double noncontiguous spinal fracture lower limb muscles bilaterally. CT scan dislocation of cervical and thoracic vertebra showed unilateral left facet lock of C6 over injury is not uncommon injury resulted from C7, with grade 2 anterolisthesis of C6 over C7. high energy trauma. Practitioners should have There are multiple fractures of C6, T3, T4 and high level of suspicion during assessment of T5 vertebra, with fragments within spinal patient involved in trauma. Surgical outcome canal. will not be favorable when there is a delay in surgical intervention for patient with spinal RESULTS: cord injury. He underwent Posterior Spinal Instrumentation and Fusion from C4 to T7 REFERENCES: with laminectomy of T4 vertebra a week later 1 Non-Contiguous Spinal Injury in Cervical due to delay in patient’s decision making for Spinal Trauma: Evaluation with Cervical the operation. However, the short term Spine MRI. Soo-Jung Choi, MD,1 Myung Jin outcome for this patient is not favorable, as Shin, MD,2 Sung Moon Kim, MD,1 Sang-Jin there is only slight improvement of sensation Bae, MD3, Korean J Radiol. 2004 Oct-Dec; until T9. Currently patient is still undergoing 5(4): 219–224. spinal rehabilitation program. 2 A Noncontiguous 2-level Spinal Injury in Young Female Driver Due to a 3-point Seat DISCUSSIONS: belt Restrain. Ali Nourbakhsh, MD1, Noncontiguous spinal injury is defined as a Shashikant Patil, MD2,Prasad Vannemreddy, lesion separated by at least one normal MD3, Donald Smith, MD4, Journal of intervening vertebra from the cervical spine Manipulative and Physiological Therapeutics, fracture of subluxation/dislocation. There has 2009-09-01, Volume 32, Issue 7, Pages 592- been several reports about the mechanisms of 596. non-contiguous spinal lesion associated with cervical spinal fracture, particularly associated PS06A Atlantoaxial Rotary Subluxation In A Child After General Anaesthesia. A Case Report.

Roslan AF; C.H. Foo; Jaffar MSA Department of Orthopaedic, Hospital Queen Elizabeth II, Lorong Bersatu, Off Jalan Damai Luyang 88300 Kota Kinabalu, Sabah, Malaysia

INTRODUCTION recommend the protocol as described by Neal Atlantoaxial Rotary Subluxation (AARS) is a and Mohamed. rare condition that can affects adults and children. Non-traumatic AARS or AARS with CONCLUSION minimal trauma is rarer and more common in Early diagnosis and prompt treatment children. There are only few reported cases of improves the outcome of AARS. CT scan is AARS after general anaesthesia. helpful in the diagnosis of AARS. The options of treatment are determined by the duration of CASE the symptom. We recommend the protocol as A 5-year-old child was referred to us with 2 suggested by Neal and Mohamed. weeks history of abnormal neck posture. She complained of neck pain and abnormal neck REFERENCES:(1-5) posture immediately after an operation to 1. Neal KM, Mohamed AS. Atlantoaxial remove right twisted ovarian teratoma. At rotatory subluxation in children. J Am Acad presentation, her head was tilted to the left in Orthop Surg. 2015;23(6):382-92. Epub the classical ‘cock-robin’ position with the 2015/05/24. chin pointing towards the right. She had 2. Pang D. Atlantoaxial rotatory fixation. restricted motion of the neck due to pain. Neurosurgery. 2010;66(3 Suppl):161-83. Epub There was no previous history of neck pain in 2010/03/05. the past. She had no history of trauma or 3. Pang D, Li V. Atlantoaxial rotatory recent infections. fixation: Part 1--Biomechanics of normal rotation at the atlantoaxial joint in children. CT scan confirmed the diagnosis of Fielding’s Neurosurgery. 2004;55(3):614-25; discussion Type 1 Atlantoaxial Rotary Subluxation. 25-6. Epub 2004/09/01. 4. Pang D, Li V. Atlantoaxial rotatory The child was treated with holter traction fixation: part 2--new diagnostic paradigm and under mild sedation in Neonatal Intensive Care a new classification based on motion analysis Unit (NICU). Resolution of torticollis using computed tomographic imaging. achieved after 18 days. Neurosurgery. 2005;57(5):941-53; discussion - 53. Epub 2005/11/15. DISCUSSION 5. Pang D, Li V. Atlantoaxial rotatory Common causes of AARS includes trauma, fixation: part 3-a prospective study of the head and neck surgery, infection, connective clinical manifestation, diagnosis, management, tissue disorder, and idiopathic. and outcome of children with alantoaxial CT scan is useful in diagnosing and to assess rotatory fixation. Neurosurgery. the severity of the condition. 2005;57(5):954-72; discussion -72. Epub Holter traction with mild sedation is a viable 2005/11/15. treatment option for non-traumatic Atlantoaxial Rotary Subluxation in children. Compliance to traction can be an issue in the paediatric group. In our experience mild sedation is safe and effective. The goal of treatment is resolution of torticollis. Early treatment improves the outcome and avoids invasive surgery. We PS06B Nurses’ Experience In Caring For Patients With Traumatic Spinal Cord Injuries

Mohd Arif, Shareena Bibi; Rasmussen, Philippa; McLiesh, Paul; School of Nursing, University of Adelaide, Level 3, Eleanor Harrald Building,The University of Adelaide, South Australia, 5005, Australia.

INTRODUCTION: Trauma is generally linked to terrible events interpretation of the patients and family’, ‘The that occur in a person’s life that produce passage of care’, ‘Patient needs’ and ‘Hope physical and psychological wounds. Patients and grief’. The study revealed the experiences that have a traumatic spinal cord injury have of six nurses, highlighting the passage of experienced a life-shattering event (Hickey nursing care that the nurses underwent while 2002). Undergoing a traumatic event can be a caring for spinal cord injury patients. life-changing experience that has a significant Although these patients had physical impact on the individuals and families disabilities and were dependent physically, the concerned (Thompson & Walsh 2010). nurses in this study showed that their concern Nurses’ involvement in caring for these and attentiveness was directed more towards patients starts from the time the patient is fulfilling their patients’ psychological needs. admitted to the hospital until they end their During the acute phase, the nurses identified rehabilitation (Pellatt 2003; Sheerin 2005). patients that were going through the process of However, there are no studies that specifically grief. They believe in providing patients with examine nurses’ experiences when caring for hope in order to motivate them to move on in these patients. This phenomenon has yet to be their lives; however, they knew that giving explored from the nursing perspective. false hope may have a negative impact. Therefore, this opens an opportunity for the Finally, the experience of caring for these researcher to explore nurses’ experiences in patients and going through the passage of care caring for patients with traumatic spinal cord gave the nurses the opportunity to understand injury that had neurological deficits. their patients and the patients’ families. This Aim: To explore nurses’ experiences when suggests that the time spent with patients and caring for patients with traumatic spinal cord their families gave the nurses a broader injury that had neurological deficit at a spinal understanding of them, which in the long term unit in Australia. helped the nurses to plan the care for future patients, and at the same time help the family MATERIALS & METHODS: members go through the traumatic life Using a phenomenological approach, guided changes resulting from their family member’s by the insights of Hans-Georg Gadamer and injury. Max van Manen, participants were interviewed with their responses being DISCUSSIONS: transcribed into a text. This text has been Spinal nursing care is a complex arena; subject to hermeneutic analysis using the however, the merging of the researcher and Burnard’s (1991) 14 steps approach. This the participants’ experiences brought together approach includes a need to read and reread a beginning understanding of the the transcripts, compress broad conceptual phenomenon. statements into categories and begin to write The passage of care signified the dynamic while reflecting on an initial set of themes. voyage or route that the nurses took while This work was operationalise and further caring for patients with traumatic spinal cord enhanced with the reflective emphasis on injuries that had neurological deficits. The interpretation suggested by van Manen (1997) subthemes generated from analysis are and Gadamer (1975). summarized in Fig. 1.

RESULTS: Four essential themes emerged: ‘Nurses’

ABSTRACT TRUNCATED PS06C TB Spine: Do We Need Biopsies? - A Case Report

YH. Gan; A. Muhammad; S. Jaswindar Department Of Orthopaedics, Hospital Taiping, Jalan Taming Sari, 34000, Taiping, Perak, Malaysia.

INTRODUCTION: well as culturing in order to confirm the The mighty Mycobacterium tuberculosis has diagnosis.2,4 It should be noted though that been around since the advent of mankind.1 such culture yields are significantly lower than Descriptions of TB spine has been seen in pulmonary sites, although use of PCR has many ancient civilizations, with evidence improved yield results.3 found in prehistoric skeletal remains.1 In the olden days, where treatment was primarily CONCLUSION: surgical, mortality and complication rates were As skeletal TB is particularly common in the high. However, discovery of anti-tubercular eastern hemisphere of the world, with TB drugs has changed the landscape of modern spine accounting for >50% of skeletal TB TB treatment and its associated outcome.1 This cases,4 the need for accurate diagnosis and is a case report of a PTB patient who was prompt targeted treatment is mandatory, diagnosed and treated as Pott's disease based especially since TB spine is potentially fatal or on radiological findings. debilitating. However, spine pathology shouldn't be ASSUMED to be due to TB in a CASE REPORT : PTB positive patient, especially in an endemic This is the story of a 45 year old Malay area like ours.5 This case report is designed to gentleman, ex-IVDU, who was diagnosed with generate a healthy discussion as to whether PTB one month ago and was started on anti- treatment can be based solely on radiological TB medication. He presented to the casualty findings, or whether a biopsy would be department of Hospital Taiping complaining beneficial to confirm the diagnosis and rule of a 2 year history of vague back pain, out other causes. worsening over the past month, eventually leading to an inability to ambulate due to the REFERENCES: pain, as well as reduced sensation over 1. Tuli SM. Tuberculosis of th spine : A bilateral lower limbs. Power and reflexes were historical review. Clin Orthop Relat Res. 2007 intact. CXR showed marked opacity over Jul;460:29-38. upper and middle zones of the left lung. 2. CPG Management of Tuberculosis, 3rd Thoracolumbar X-ray showed compression of Edition, November 2012. T9 with acute forward curvature and anterior 3. Bhatia AS, Kumar S, Harinath BC. end plate erosions. A diagnosis of Pott's Immunodiagnosis of tuberculosis: An update. disease was then made. In view of minimal Indian J Clin Biochem. 2003 Jul; 18(2):1-5. neurological deficit, patient was treated 4. Tuli SM. 3rd ed. New Delhi: Jaypee conservatively with a thoracolumbar jacket Brothers; 2004. Textbook- Tuberculosis of the and continuation of anti-TB drugs. skeletal system (Bones, Joints, Spine and Subsequent follow ups showed an Bursal sheaths) improvement in pain, with the patient 5. Zondagh I, Dunn RN. Spinal tuberculosis: regaining the ability to walk. However Diagnostic biopsy in mandatory. SAMJ May sensation was still reduced. 2008;98(5);360-2.

DISCUSSIONS: Reaching an EARLY diagnosis of EPTB can be somewhat challenging due to its lower bacterial load, vague symptoms and sampling problems.2 However, if EPTB is suspected, attempts should be made to obtain a tissue/fluid/biopsy for cytology and HPE as PS06D Leap Of Faith - Cliff Diving: An Avertable Cause Of Spinal Injuries

S. De Silva; G.K. Ooi; J.L. Ling; Alan MS; Z. Zuki Department of Orthopaedics and Traumatology, Hospital Sungai Buloh, Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia.

INTRODUCTION: to land safely in the water. All 3 patients who Cliff-diving has been an adventure sports suffered spinal injuries admitted to slightly activity since the early 1900s, for which flexing their hip prior to impact . This split adrenaline junkies indulge in gravity defying second decision could have contributed to leaps off cliffs into the sea. Cliff diving from their spinal injury from high energy axial- any height can't be considered safe, in fact, loading on their spine. Being intoxicated with most official tourism sites of popular diving alcohol is a common problem as well. At the spots do not promote the activity. We are dive site, little effort is taken to caution divers presenting a case where 3 patients suffered on the risk of spinal injuries. injuries to their spine after diving from 15m height into the sea. CONCLUSION: The dangers of cliff-diving and spine related CASE REPORT: injuries are under-reported. It is important to A 29 year old female presented with lower educate the public and make them aware of the back pain post diving from 15m height at dangers of cliff-diving prior to partaking in Ariel's Point in Boracay. She recalled intense this activity. They should be coached on how pain at her lower back shortly after landing in to protect themselves during the jump and the sea. 3 out of 20 of the Malaysians who prior to impact on water for example : practice jumped from a 15m height that day had similar your pencil-dive from a lower height. Lastly, a complaints. Fortunately, none of them noticeable warning at the jump site should be reported of any neurological deficit. highlighted to the participants prior to their They Sustained: (A 29yo Chinese Female with leap, instead of a fine print disclaimer. T12 burst fracture, No neurological deficit, a Think before you leap, your faith could kill or 22yo Chinese Female with L1 Compression worse, paralyze you. fracture, No neurological deficit & a 34yo Chinese Male with T12 Compression fracture, REFERENCES: No neurological deficit), for which all of them 1. Aito S, D’Andrea M, Werhagen L underwent posterior instrumentation at various Spinal Cord. 2005;43:109–116. doi: institutes. 10.1038/sj.sc.3101695 2. Badman BL, Rechtine GR. Spine J. 2004;4:584–590. doi:0.1016/j.spinee.2004.03.002.

Image above showing a T12 Burst fracture.

DISCUSSION: Previous record holders Rudolf Bok (58.28m jump) and Olivier Favre (53.9m jump) both suffered multiple spinal fractures post dive. Most injuries happen among people who were not trained on their body positioning, and how PS07A Case Series Of 2- 3 Level Thoracic Vertebrectomy And Expandable Cage Insertion Via Posterior Only Approach ; The Sungai Buloh Experience

SW Lim; MG Murali Govindasamy; Z Zuki Department of Orthopedic and Traumatolgy, , Jalan Hospital, 47000 Selangor, Malaysia

INTRODUCTION: DISCUSSION: Expandable Cage is gaining popularity The results from our case series show that especially in multilevel thorasic vertebrectomy overall most patients achieve satisfactory QOL due to relative ease in use and permits optimal score especially with regards to pain. . The fit. This method allows correction of operative time is comparable to those deformity by in vivo expansion of the device. published in literature and no repeat surgeries We would like to share our experience of show that this method of operation may performing this procedure via a posterior only indicate a low complication rate. Isada approach Thongtaran et al , Marcel et al ; Daniel met et al have all shown good outcomes with METHODS: expandable cage. Number of repeat surgeries 5 patients were operated on by same lead & subsidence were minimal. These papers also surgeon using posterior only approach from quote good patient satisfaction post June 2015 till September 2015. 4 patients had operatively. spinal tuberculosis whilst 1 was operated for lymphoma of the spine. All patients had 2 or 3 CONCLUSION: level vertebrectomy done at the thorasic From this small case series, 2 Level vertebra with insertion of expandable cage. Vertebrectomy and Expandable Cage Insertion For all patients T2 altitude expandable cage by Via Posterior Only Approach appears to be a Medtronics was used. For each patient, safe approach for patients with the right operative time, repeat surgeries, and quality of indication. life assessment were monitored ( Via SF 36 scale ) . REFERENCES: 1) Francis h Shen et al: spine journal RESULTS: March–April, 2008Volume 8, Issue 2, Pages The operating time for this procedure ranges 329–339 from 6.5 hours – 7.5 hours. There were no repeat surgeries for any of the patients. Repeat 2) Daniel Met al: neurosurgical journal x-rays show no backing out of cage. April 2007 - Volume 60 - Issue 4 - p 223–231 Summary of results as per table below. 3) Isada thongtaran et al neurosurgical journal Pat Indicati Vertebr Oper Pre Post Functio ient on ectomy ating Operative Operative ning 2003 Article 8, 2003, Level Time Ambulato Ambulato Pain ry Status ry Status ( Sf 36 ) Pat Spinal T11 & 7H Bedbound Walking 55.5 ient Tubercu T12 ( ASIA C ) frame A losis (ASIA D ) Pat Spinal T4 & T5 7H Bedbound Wheel 40.0 ient Lympho ( ASIA B ) Chair B ma (ASIA C ) Pat Spinal T8, T9, 6H Bedbound Wheel 47.5 ient Tubercu T10 ( ASIA B ) Chair C losis ( ASIA C ) Pat Spinal T3 & T4 6H Bedbound Walking 67.5 ient Tubercu ( ASIA D ) Frame D losis ( ASIA D ) Pat Spinal T5, T6, 7.5h Bedbound Deceased ient Tubercu T7 ( ASIA A ) E losis

PS07B Isolated Streptococcus Bovis T12 Spondylodiscitis: A Rare Case Report

MG Murali Govindasamy; SW Lim; Z Zuki Department of Orthopedic and Traumatolgy, Sungai Buloh Hospital, Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia

INTRODUCTION: 2. Cheng-Wei Wang et al. Taiwan Geriatr Streptococcus Bovis is a gram positive cocci Gerontol 2009; 4(4): 274-281 that has been reported to cause infection of the spine, predominantly spondylodiscitis. Most infections are associated with infective endocarditis or colorectal cancer and rarely presents as isolated spine infection. \

CASE: A 68 year old Malaysian lady presented with worsening back pain for 2 months duration causing gradual decline in daily activities and restricted ambulation. Blood investigations revealed raised inflammatory markers. Echocardiogram showed no evidence of infective endocarditis and colonoscopy as well as CT scan did not yield evidence of colorectal malignancy. Blood cultures meanwhile did not yield positive culture. MRI of the lumbosacral region revealed suspicious lesion at T12 vertebra. Image guided biopsy showed no evidence of malignancy. Streptococcus bovis was isolated on sample culture. She was promptly treated with 6 weeks of IV antibiotics. During the course of stay, her pain improved dramatically and she was discharged well. During subsequent follow up, she showed further improvement

DISCUSSION: Streptococcus Bovi although rare can occur as isolated spine infection. Thus early detection and treatment can improve patient outcome. If this organism is isolated it is mandatory for the attending clinician to investigate patient for Carcinoma of the Colon as well Infective Endocarditis. A blood culture must also be done to rule out disseminated disease. There are many literatures highlighting the association with these two conditions.

REFERENCES: 1. Sergio M, Enrico C, Anna P, et al: Spine 2001; 26: 499-500

PS07C Grisel’s Syndrome Is Associated With C1C2 Severe Rotatary Subluxation. An Experience In Managing Severe Deformity In Hospital Kuala Lumpur.

Zakhiri MR; Dzulkarnain A; Manmohan S; JH Goh; Nor Azlin ZA; Fazir M Department of Orthopaedic Hospital Kuala Lumpur, Jalan Pahang 50586 Kuala Lumpur, Malaysia

Keywords: Chronic C1C2 subluxation, pediatric, posterior instrumentation Introduction Fusion C1-C2 (Fig 4). There was no Children with painful torticollis should be complication intraoperatively. Post operatively, subjected to the three-position computed patient was put on halovest and discharged tomographic diagnostic protocol, as to grade well. Patient presented again to us in the severity of the condition atlantoaxial December 2015, with infected halovest pinsite. rotatory fixation (AARF)(1). Closed reduction Halovest was subsequently removed and with traction should be instituted immediately patient was given antibiotics for 2 weeks, and to avoid the serious consequences of chronic was put on cervical collar. AARF. Recurrent dislocation and incomplete reduction should be treated with posterior Discussion C1C2 fusion in the best achievable alignment. Surgical C1C2-stabilization may be Open reduction and halo immobilization to complicated by arterial-arterial embolism or avoid permanent fixation can be tried with arterial injury. Another potential complication select cases. is hemodynamic stroke. In C1C2-stabilization precise analysis of preoperative CTA and Case: intraoperative US are important to detect risk The patient is a 7 year old Malay girl, initially factors of hemodynamic stroke. Using these presented to Hospital Muar, to the ENT data may prevent this rare, but potentially life- department for mumps over left side of neck in threatening complication. May 2015. During assessment, noted patient had torticollis. Further history noted, patient Conclusion has been having left sided neck pain and The most typical neurovascular complications preferred tilting head to the right side to relief in C1C2-fusion are thromboembolic strokes or pain ( Fig 1). Neck became stiff, and unable to arterial injuries (2). Another rare etiology may rotate to the left side. No other siblings with be a positional extrinsic VA compression similar symptoms. CT Neck : Rotatory additionally to a poorly collateralized posterior subluxation of C1 over C2 with malposition of fossa (3). This condition may be recognized by left atlanto occipital and atlanto axial joint subtle analysis of preoperative CTA and (Fig 2). Impression : Grisel’s Syndrome with intraoperative Doppler echography. Awareness C1C2 subluxation.Subsequently she was put and recognition of this pitfall is important to on Halter Traction in Hospital Sultan Aminah prevent stroke. Johor Bahru after being transferred from Muar Hospital. She was then treated conservatively References as there was no neurological deficit . She was 1. Pang D1, Li V. Atlantoaxial rotatory put on traction for 2 weeks, subsequently on fixation: part 3-a prospective study of the hard collar. However no improvement clinical manifestation, diagnosis, management, clinically seen. Hence, referred to HKL for and outcome of children with alantoaxial further management. On presentation, she had rotatory fixation. Neurosurgery. 2005 no neurological deficit. MRI cervical spine Nov;57(5):954-72; discussion 954-72. revealed subluxation of C1 over C2 with 2. Netuka D, Benes V, Mikulík R, Kuba R. possible disruption of anterior atlantodental Symptomatic rotational occlusion of the ligament and left alar ligament (Fig 3). No vertebral artery - Case report and review of the spinal canal stenosis or cord edema. Proceeded literature. Zentralbl Neurochir. 2005;66:217– with Posterior Spinal Instrumentation and 22.

ABSTRACT TRUNCATED PS07D Case Series Of Tuberculous Spondylodisciitis With Asia A

Zakhiri MR; EP S; TL T; Dzulkarnain A; Manmohan S; JH Goh; ZA Norazlin; Fazir M Department of Orthopedic and Traumatology, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia

INTRODUCTION: On average the intraoperative blood loss is Tuberculousis spine is one of the commonest around 600ml to 2000ml. Average operating spine pathology in Malaysia. Tuberculous time is 5 hours . spondylodiscitis makes up 2 % of newly All patients were under follow up for at least diagnosis extrapulmonary tuberculousis each 12 months. Our patients displayed year in Malaysia. Worlwide diagnosed improvement of pain score post operatively. Tubercoulosis spine makes up 40 % of all Neurological deficit improved from ASIA A musculoskeletal tuberculousis. to at least ASIA C. Angle deformity improved Pathophysiologically the insemination of as Cobb’s angle showed a marked reduction of infection takes place leading to marked kyphosis in post operative radiograph . hyperemia and severe osteoporosis takes place Patients’ ESR and CRP showed marked with osseous destruction that will cause reduction in the data that we have collected. deformity and kyphosis of spine Bone HPE results shows foci granulomatous .Intraverterbral disc usually is not involve as it necrosis in keeping with tuberculosis changes is avascular structure. Abcesses, granulation in the bones. tissues and or direct dural invasions will lead DISCUSSION: to spinal cord compression and spinal canal The initiation of chemotherapy in TB narrowing.Site of involvement often is at the spondylodisciitis is the main stay of TB spine thoracic level of spine. Typical complaints of mangement . After over 30 years it remains persistent upper back pain , with or without unchanged1 . However not all cases can be lower limbs weakness will bring patients to solely managed with medications alone , the hospital . especially cases with destructed vertebrae and METHODS: has a loss of kyphosis, and involvement of the Our case series data is collected spinal cord2. Patients with neurological deficit retrospectively from the year of 2013. 10 primarily requires debridement of sequestrum patients with confirmed diagnosis of and infection foci, decompression of cord and tuberculous spondylodisciitis at the level of stabilization of bones3. thoracic and lumbar with neurological deficit CONCLUSION: ASIA A impairment were taken into this Our cases series show that patients who were study. Patients were investigated for TB. started on anti TB chemotherapy and Investigations includes blood parameters of ssubsequently undergone surgery of one stage FBC, ESR, CRP and Mantoux test . anterior debridement and anterior Radiological investigations includes instrumentation has good outcome in terms of radiographs of spine , MRI whole spine and neurological recovery even in patients who CT scan of affect spine area .Thoracic Cobb’s presented with ASIA A impairment. angle were used to measure kyphosis. Surgical REFERENCES: outcomes including pain asessment, 1.Surgical treatment of thoracic spinal neurological function and deformity tuberculosis with adjacent segments lesion via corrections are included in our study findings. one stage transpedicular debridement, All patients were started on anti TB posterior instrumentation and combined medication prior to surgery. All patients had interbody and posterior instrumentation, a undergone anterior debridement with anterior clinical study; Ping Wu et al.; Arch Orthop instrumentation. Trauma Surg(2013)133:134-1350 RESULTS: 2. Surgical management of contiguous multilevel thoracolumbar tuberculous

ABSTRACT TRUNCATED PS08A An Unusual ‘Triple Crush. A Case Report.

MS Othman; FA Ramlee; KN Ibrahim; MH Ariffin; SA Rhani; J Sapuan; A Baharudin Hospital Canselor Tuanku Mukhriz (HCTM), Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Wilayah Persekutuan Kuala Lumpur, Malaysia

INTRODUCTION: providing optimal outcomes for patients Distinct cervical compressive neuropathy with following nerve decompression. peripheral neuropathy at more than two locations along the course of a peripheral DISCUSSIONS: nerve is rare complex nerve compression The presence of multiple distinct nerve combinations. Failure to recognise these compressions may synergistically increase problems may contribute to suboptimal symptom intensity and reflect the challenges outcomes following selective nerve these condition pose even to the most decompression. experienced of surgeons. The main goal of surgical management is to prevent further METHODS: progression of the neurological symptoms. We report the case of an unusual combination of cervical spondylotic radiculopathy of CONCLUSION: C5/C6 with concomitant peripheral nerve The multiple level nerve compressions should compression over the pronator teres as well as be considered when evaluating neurological at the carpal tunnel syndrome over the same symptoms in order to prevent suboptimal upper limb. In this particular case, all three outcomes following the surgery. areas had been decompressed in a single- staged operation. To the best of our REFERENCES: knowledge, we found that the occurrence of 1. Kane PM, Daniels AH, Akelman E. Double triple compressive neuropathies is extremely Crush SyndromeJ Am Acad Orthop Surg. rare and there is no previous similar report 2015 Sep; 23(9):558-62 found in the literature describing the similar 2. Ang CL, Foo LS. Multiple locations of case. nerve compression: an unusual cause of persistent lower limb paresthesia. Foot Ankle RESULTS: Surg. 2014 Nov-Dec; 53(6):763-7. The key point that we would like to highlight 3. Boos, Norbert, Aebi, Max. Spinal here is the importance in recognising the Disorders. Fundamentals of Diagnosis and possible area of nerve compressions, thus Treatment. Springer. 2008.

PS08B Motorcyclist Vs Blocking Bar Accident Resulting In Cervical Bifacetal Dislocation: A Rare Case Report

KW Loh; SW Lim; Y Shahadeevan; ZZM Zuki Department of Orthopaedic and Traumatologi, Hospital Sungai Buloh, Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia.

INTRODUCTION: Figure 1: Most reported cases of cervical bifacetal T2 weighted dislocations are due to fall from height.1 MRI cervical Motor-vechicle accidents due to motorcycle showing versus parking blocking bar is rare. Bilateral C5/C6

facet diathesis, CLINICAL CASE: marrow oedema We reported a case of a 17 years old gentleman who is a recreational illegal of C4 and C5 with mild motorcycle street racer who was speeding up retropulsions of when exiting a car park from a local shopping mall. Without wearing a helmet, his body fractures. bended forward and was trying to bypass the bar at the exit by going below it. Unfortunately his estimation was wrong and his forehead hit the bar in a flexed position, hence thrown down from the motorcycle. He Figure 2: sustained C5/C6 bifacetal fracture dislocation Lateral cervical with C4 complete neurological deficit (ASIA plain radiograph A). He underwent reduction, decompression showing and posterior fusion from C3 to C7. 2 months posterior post-operatively, his neurology has improved instrumentation to ASIA C and was still on follow up. and fusion from

C3 to C7. DISCUSSIONS: In cervical bifacetal dislocation, the vertebral body translation is usually more than 50% of the vertebral body width. It is usually REFERENCES: associated with complete spinal cord injury in 1. Maiman Dennis J, Barolat Giancarlo, 65 to 87% cases, incomplete injury in 13 to Larson Sanford J. Management of bilateral 25% and less than 10% are intact.1,2 locked facets of the cervical spine.Neurosurgery.1986;18:542e545.2. Cervical bifacetal dislocation implicates high Adams CI et. al. Injury 2001; 32: 61-65. morbidity and high economic burden if not 2. Siddhartha S. Sahoo, Deepak Gupta*, A.K. treated early. Education and law Mahapatra. Cervical spine injury with reinforcement must be improved so that the bilateral facet dislocation, surgical accidents rate of illegal street racers can be treatment and outcome analysis: A reduced. prospective study of 19 cases. The Indian Journal of Neurotrauma 9 (2012) 40-44.

PS08C High Single Dose Of Tranexamic Acid Effectively Reduces Perioperative Blood Loss In Scoliosis Surgery Without Compromising Patient Safety

Ibrahim, Kamalnizat; Freddy A; Ariffin MH; Rhani SA, Baharudin A Department of Orthopaedic Surgery, Pusat Perubatan Universiti Kebangsaan Malaysia, Jalan Yaacob Latiff, Kuala Lumpur, 56000, Malaysia.

INTRODUCTION: was no significant change in term of DIVC Tranexamic acid (TXA) is an anti-fibrinolytic profile between both group perioperatively. agent that commonly being used to reduce intraoperative blood loss as well as blood DISCUSSIONS: transfusion requirement. However the dosage The use of TXA in major surgeries has been and the mode of administration were not widely accepted as a method to reduce established. Most of the studies use different intraoperative and perioperative bleeding. loading dose of TXA follows by continuous However, there is no consensus in regards to infusion throughout the surgery, yet the effect dosage and methods of delivery. The on thromboembolic events and mortality complication of thrombolic events is also remains uncertain. Our aim is to determine the under reported. efficacy of single loading dose of TXA using Our study develops a standard of dosage and two different doses per bodyweight in our delivery which could be used as a protocol in scoliosis correction surgery. We hope to performing scoliosis surgery which could be establish the safe and cost effective protocol of extended its indication for other major spinal TXA usage with this study in our centre. surgeries. On top of its advantage in perioperative METHODS: bleeding control, it also reduces infusion This is a prospective randomized, double monitoring burden by the anaesthetist blinded study carried out in the UKM Medical counterpart. Centre (UKMMC). Thirty-six adolescent idiopathic scoliosis (AIS) patients ranging CONCLUSION: from age 12 to 18 years old with Cobb’s angle We conclude that the usage of high single dose of 45 to 75 degree scheduled to undergo of Tranexamic Acid in our scoliosis surgery elective spinal correction surgery from level was sufficient to reduce blood loss and T4-L4, were randomly allocated to receive transfusion. either single dose of TXA 25 mg/kg or 50 mg/kg during induction. Level of hemoglobin, REFERENCES: haematocrit, platelets, fibrinogen and D-dimer 1. Gill JB, Chin Y, Levin A, Feng D. The use (DIVC profile), blood loss and blood of antifibrinolytic agents in spine surgery. A transfusion requirement peri - operatively meta-analysis. J Bone Joint Surg Am. 2008 were recorded and compared between this two Nov;90(11):2399-407. groups. 2. OzierY,Bellamy L. Pharmacological agents: antifibrinolytics and desmopressin. RESULTS: Best Practice & Research Clinical There was significant difference in blood loss Anaesthesiology. 24 (2010) 107-119. (1204 ml : 970 ml) and blood transfusion (1.5 pint : 0.56 pint) between two groups. There was no significant difference between these two groups with regards DIVC profile taken from pre and postoperative period between both groups. The dose of TXA 50 mg/kg has lower blood lost (p < 0.001) and blood transfusion (p < 0.001) perioperatively as compared with dose of TXA 25 mg/kg. There PS09A Rare Three-Level Percutaneous Vertebroplasty: A Case Report

Loi KW Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia.

INTRODUCTION: With the aging population globally, a single session. Recent article reviewed and symptomatic osteoporotic vertebral concluded treating multiple-level osteoporotic compression fractures are more common. vertebral fractures with percutaneous Percutaneous vertebroplasty with has been an vertebroplasty is considered an effective effective treatment symptomatically both in method to improve clinical outcomes single and multiple level osteoporotic regarding pain and morbidity of these patients vertebral compression fractures. We report a 3. rare case of three-level percutaneous vertebroplasty in a single session. Figure 1 and 2: Radiograph of thoraco- lumbar spine post vertebroplasty CASE REPORT: anteroposterior and lateral view 71 year old lady, presented with 1 month respectively. history of progressive back pain after fall. The pain was aggravated by movement and radiated to the sides of the respective level. Radiograph showed level compression fracture of the vertebrae involving T9, T12 and L1. Stress views showed vacuum phenomena in those vertebrae. Three level percutaneous vertebroplasty was performed in a single session with low viscosity poly- methylmethacrylate (PMMA). Her pain score improved immediately and she was allowed home 2 days later with Jewett brace for spine support during ambulation. No complication CONCLUSION: was documented. Percutaneous vertebroplasty with PMMA is a safe and effective treatment for multiple level DISCUSSION: osteoporotic vertebral compression fractures. In the past, osteoporotic vertebral compression It provides immediate pain relief and early fractures were often treated with benign return to their activities of daily living. neglect which included bed rest, analgesics, 1 brace and gradual mobilization . REFERENCES: Unfortunately, many patients still have 1. Hee HT. Percutaneous vertebroplasty: intractable pain and unable to return to their Current concepts and local experience. activities of daily living. One study showed Neurology India 2005; 53(4): 475-82. that these untreated fractures are associated 2 2. Kado DM, Browner WS, Palermo L. with 30% age-adjusted increase in mortality . Vertebral fractures and mortality in older Vertebroplasty was initially applied in patients women: a prospective study. Study of with well-documented single-level osteoporotic fractures researsh group. Arch osteoporotic vertebral compression fractures. Intern MEd 1999; 159: 1215-20. Most of the earlier literatures, case series and 3. Gray LA, et al. Efficacy of percutaneous retrospective studies that have overwhelming vertebroplasty for multiple synchronous and positive clinical responses were on single level metachronous vertebral compression fractures. percutaneous vertebroplasty. With increasing AJNR Am J Neuroradiol 2009; 30: 318-22. dissemination of the procedure, many groups now routinely treat multiple vertebral levels in .  PX01A Acromioclavicular Joint Ganglion: A Rare Presentation Of Chronic Rotator Cuff Tear

Gan JT; Tan TS Department of Orthopaedic Surgery, , Jalan Ulu Oya, 96000 Sarawak, Malaysia.

ABSTRACT We report 2 cases of acromioclavicular (AC) joint ganglion presented with chronic history of right shoulder swelling. Magnetic Resonance Imaging (MRI) showed cystic lesion superior to degenerated AC joint with Figure 1: Right shoulder lump over AC joint rotator cuff muscle tear. Intraoperatively, both Figure 2: Macroscopic appearance with the lesions are communicating with AC joint. gelatinous content Histopathological examination confirmed Figure 3: Proximal migration of humerus with ganglion cyst. communication of glenohumeral and AC joint (Geyser sign) on MRI Key word: Acromioclavicular joint, Ganglion DISCUSSIONS: INTRODUCTION AC joint ganglion is a rare in clinical practice. Ganglion cyst of AC joint was first reported in The postulated pathogenesis is divided into 1984 by Burns and Zvurblis1. A reviewed type-1 cyst associated with degenerative joint changes and type-2 cyst associated with article in 2010 by Hiller reported a total of 2 forty five cases of AC joint ganglion with rotator cuff tear . Due to the torn cuff muscles, 2 fluid from glenohumeral joint can leak into majority associated with rotator cuff tear . We 2 present another 2 cases of AC joint ganglion AC joint and thus communicate with the cyst . with asymptomatic chronic rotator cuff tear. In our report, MRI of both the cases showed Other differential diagnoses for lump arise chronic rotator cuff muscle tear without from acromioclavicular region are communication between cyst and AC joint. osteophytes, synovial cyst and supra-acromial This can be explained by the compression of bursitis. the communicating channel by an enlarging ganglion cyst which later forms a fibrous layer 3 CASE REPORT: that occludes the channel . Case 1 is a 70-year old, gentleman presented with 1 year history of painless right shoulder CONCLUSION: swelling. Case 2 is a 68 years old, gentleman Although rare, clinician should be aware that presented with 6 months history of painful AC joint ganglion can be the first presentation right shoulder swelling. Clinical examination of underlying chronic rotator cuff muscles tear of both patients showed cystic lump as reported in our cases. measuring a golf ball size with tenderness on deep palpation over AC joint. MRI result REFERENCES: showed cyst superior to degenerated AC joint 1. Burns SJ, Zvirbulis RA. A ganglion arising with chronic rotator cuff muscles tear and over the acromioclavicular joint: a case report. atrophy. However there is no obvious Orthopedics 1984; 7: 1002-4. communication between swelling and AC 2. Hiller AD, Miller JD, Zeller JL. joint. Intra-operatively we found both the cysts Acromioclavicular joint cyst formation. Clin arise from the AC joint containing yellowish Anat 2010; 23: 145-52. gelatinous material. Histopathological 3. Cvitanic O, Schimandle J, Cruse A, Minter examination confirmed ganglion cyst for both J. The acromioclavicular joint cyst: cases. Both patients are well and there is no glenohumeral joint communication revealed recurrence up to current 6 months of follow- by MR arthrography. J Comput Assist Tomogr up. 1999; 23(1): 141-143. PX01B

Painful Snapping Hip In Adolescent: Case Report

MF Liong; Ezrat B.Samadi; Felix Y.S Loong Department of Orthopaedic, Hospital Ampang, Jalan Mewah Utara, Pandan Mewah, 68000 Ampang, Selangor, Malaysia

INTRODUCTION: biopsy. Histopathology examination of muscle Snapping hip is described as palpable or biopsy reported as fibrosis features suggestive auditory snapping with hip movements with or of an ongoing reparative process. without pain. The causes of snapping hip are Postoperatively at 6 weeks time patient’s left generally divided into 2 categories: intra- hip pain improved with no residual left lower articular and extra-articular. They are 2 limb weakness and able to walk with normal generally accepted forms of extra-articular gait. snapping hip: external and internal. In the external form, the snapping occur lateral to the DISCUSSION: hip joint, over the region of the greater Asymptomatic snapping hip occurs in 5% to trochanter and is usually attributed to 10% of the population. However, there may movement of iliotibial band (ITB) over the be a higher incidence of painful snapping hip greater trochanter. in those who participate in activities requiring the extremes of hip motion. One of the most MATERIALS AND METHODS: important diagnostic indicators of snapping We reported a case of 15 years old boy hip is the reproduction of audible or palpable presented with left hip pain with abnormal snap and its occurrence with pain. The clicking sound for a year without preceding majority of symptomatic snapping hips trauma. His left hip pain was primarily elicited resolved without surgical intervention. For during activities including squatting, external snapping hip, the goal of surgery is to prolonged sitting and stair climbing. He has lengthen the ITB via Z-plasty procedure been taking oral analgesic regularly to relief which performed to our patient. Although the his left hip pain. He is reported to have results of this procedure have been favourable frequent medical leave due to his hip pain with resolution of snapping and complete which indirectly affected his academic relief in the majority of patients, a mild to achievement. Upon examination, range of moderate Trendelenburg gait is a reported movement left hip is normal with maximal complication. This case highlights the tenderness elicited over lateral aspect left hip importance of surgical intervention in treating with appreciable snapping during extension painful snapping hip syndrome in order to and external rotation of left hip. A plain improve patient’s quality of life. radiograph of the left hip was unremarkable and infective screening revealed normal. We CONCLUSION: proceeded with MRI bilateral hip joint and it Audible or palpable snapping of the hip may reported normal finding. He is treated have intra or extra-articular causes or both. conservatively with physiotherapy and oral Extra-articular snapping usually caused anti-inflammatory medication. laterally by the ITB or anteriorly by the iliopsoas tendon. Dynamic ultrasound can RESULTS: help to detect abrupt tendon translation during In view of no improvement of left hip pain hip movement. The majority of snapping hip after conservative management, thus we cases resolved with conservative treatment. In proceeded with surgical intervention with recalcitrant cases, surgery to lengthen the ITB exploration and Z-plasty of left ITB. Intra- via Z-plasty has produced symptom relief but operative finding revealed tight left ITB with a can result in muscle weakness. tubular-like muscular structure over gluteus muscle insertion which then excised for REFERENCE:

ABSTRACT TRUNCATED PX01C Management Of Multiple Ligament Injuries Of The Knee

Ayob, Khairul; Teo, SH, Alfaiadh, Z; Ali, R; Ng, WM Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

INTRODUCTION Multiple ligament injuries of the knee are rare the specific structural deficiencies is carried injuries. Initial treatment includes reduction of out. The management is tailored to the the knee and exclusion of complications. functional demands of individual patients. Definitive treatment centers on identification and reconstruction of the specifically injured Type Description ligaments with an extensive post-operative KD I Intact posterior cruciate ligament rehabilitation program. with variable injury to collateral ligaments MATERIALS AND METHODS KD II Both cruciate ligaments disrupted A 45-year-old teacher presented with an completely with collaterals intact unstable left knee for more than 5 years KD Both cruciate ligaments disrupted duration, which is associated with a III completely with one collateral mechanical dull aching pain. She had a high- ligament disrupted velocity motor-vehicle accident 20 years ago, KD Both cruciate ligaments and due to the severity of the initial injuries and IV collaterals ligaments disrupted lengthy physical rehabilitation; there was a KD V Dislocation with periarticular significant delay in the recognition of her knee fracture deficit. Figure 1. The Shenck Classification of knee The clinical diagnosis made was of a Grade 1 dislocations posterolateral complex laxity, Grade 2 ACL laxity and a Grade 3 PCL laxity. Patient The aim of treatment is to provide a relatively underwent arthroscopic reconstruction of the pain-free, stable knee to prevent the rapid injured structures. degeneration due to instability. Operative methods of restoring stability are RESULTS direct repair of structures, repair plus The intraǦoperative findings were augmentation, or reconstruction of injured intrasubstance tears of ACL and PCL, medial structures. This needs to be incorporated with meniscus degenerative tears and a Grade I the controlled range of movement, using chondral injury of the medial tibiofemoral braces and proper rehabilitation protocols. compartment. Patient had an anatomical ACL and PCL reconstruction done with Achilles CONCLUSION tendon allografts. The operation was Multiple knee ligament injuries are complex complicated by blow-out of the femoral PCL injury and can easily be misdiagnosed. A tunnel, requiring extension of the PCL systematic approach can prevent devastating endobutton. complications and significant morbidity to patients. Once the acute phase has resolved, DISCUSSION the surgeon needs to thoroughly assess the Multiple knee ligament injuries (MLKI) are specific structures involved and formulate the rarely encountered but can be devastating if surgical plan for the individual patient mismanaged. There is a large variety of utilizing the treatment algorithms as guidance. presenting combinations of knee ligament deficits. REFERENCES Associated popliteal artery or peroneal nerve 1. Fanelli GC, Stannard JP, Stuart MJ, injuries have been described in as high as 30- MacDonald PB, Marx RG, Whelan DB, Boyd 50% of cases. Once excluded, identification of JL, Levy BA, Management of Complex Knee

ABSTRACT TRUNCATED PX02A Unusual Traumatic Locked Young Knee – Our First Experience In UiTM

Miswan MFM; Alsagoff A; Ibrahim MI; Effendi FM; Rozali KN Discipline of Orthopaedic Surgery, Faculty of Medicine, Universiti Teknologi MARA, Jalan Hospital, 47000, Sungai Buloh, Malaysia.

INTRODUCTION: RESULTS: Common causes of locked knee are mechanical blocks from various aetiology1. 85% of patients were found to have distinct pathology causing a mechanical block to full extension while 8% were found to have only degenerative changes1. So, what would be the Fig. 1: Sharp and hard white material at medial next step at making a diagnosis if the and lateral tibia plateau traumatic locked knee is not due to common causes?

MATERIALS AND METHODS: CASE 1: 35 year old man complaints of locked knee and pain following a twisting injury to the left Fig. 3: Thickened synovium and fat tissues on knee two weeks prior to visit. Clinical findings medial compartment were a locked knee at 150 and tenderness over both joint lines. Plain radiograph and urgent DISCUSSIONS: MRI however showed no abnormality. The The most common cause of locked knee in arthroscopy findings showed abundant sharp orthopaedic practice is a bucket handle tear of whitish materials deposited over the articular the meniscus and the less common causes surfaces of both tibia plateau (Figure 1). were osteoarthritis, loose osteochondral Tissue sample for HPE was suggestive of fragments and synovial plicae2. Gouty tophi tophi and post-operative serum uric acid levels can cause locked knee but depending on were significantly high at 747 μmol/l. location. For unknown reasons, synovial lining tissue occasionally undergoes change and CASE 2: becomes diseased. The overgrowth of the joint A 32 year old man missed a step and fell to the lining tissue can occur diffusely throughout a ground with his right knee flexed and joint or form a discrete nodule and remain internally rotated. He presented with pain and attached to the rest of internal joint lining. The inability to extend his knee beyond 300. Initial major predictor for recurrence is the assessment revealed mild swelling and completeness of surgical excision3. tenderness over the medial knee joint. Knee plain radiograph and urgent MRI were normal. REFERENCES: Diagnostic arthroscopy revealed thickened 1. Bansal P et al. Diagnosing the acutely synovium and fat tissue at the medial locked knee. Injury. 2002; 33: 495-498 compartment of the knee (Figure 2), anterior 2. Allum RL, Jones JR. The locked knee. to the medial femoral condyle. We proceeded Injury. 1986; 17: 256-258 with a thorough debridement. Tissue sample 3. Monaghan H et al. Giant cell tumour of revealed inflammed tissue. Patient was tendon sheath (localised nodular discharged well with full range of movement tenosynovitis): Clinicopathological features of of the affected knee. 71 cases. J Clin Pathol. 2001; 54: 404-407

PX02B A Case Report: Traumatic Multidirectional Shoulder Instability

JK Khor; Dzuraimy; Siva.T; Siti Hawa Arthroscopic and Sports Injury Unit, Orthopaedics and Traumatology Institute, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia

INTRODUCTION: Multidirectional Shoulder Instability (MDI) is MRI of Right shoulder (Fig.2): Subluxation of defined as abnormal excursion of humeral glenohumeral joint with anterior & posterior head on glenoid in all directions ie. anterior, labrum tear. Rotator cuff muscles intact. posterior and inferior. It was first described by Diagnostic arthroscopy and capsulolabral Neer and Foster in 1980. repair was done(Fig.3) MDI is a difficult problem to both diagnose and treat. The anatomical characteristic of MDI shoulder is increased capsular volume with widening of rotator interval(1). Conservative treatment is the initial treatment of choice.(2) The key in nonoperative treatment is pain control, scapular stabilization Figure 1: Sulcus sign Positive and wasting of and rotator cuff strengthening.(1) deltoid muscle of right shoulder The indications for surgery are continued pain, functional impairment and failure of adequate rehabilitation.(1) Arthroscopic capsular plication and open capsular shift are the best surgical procedures for treatment of MDI.(3)

Arthroscopic stabilization with labral repair Figure 2: MRI of Right shoulder indicates provided good results in term of pain relief subluxation of glenohumeral joint with and clinical stability at a minimum 2 year anterior & posterior labrum tear. Rotator cuff follow up.(4) muscles intact.

CASE: A 20 year old Indian male was involved in a motor vehicle accident in July 2014 and he sustained right shoulder dislocation. Six months later he presented to sports clinic HKL Figure 3: Artroscopic images shows with complain of persistent pain and weakness capsulolabral repair over right shoulder and recurrent dislocations.

These symptoms affected his daily activities. DISCUSSIONS: Physical Examination(Fig1): Nonoperative management with treatment of choice in MDI patients. However, if nonoperative management failed, arthroscopic treatment may provide satisfactory results.(1)

CONCLUSION: Arthroscopic stabilization with capsulolabral repair is a good option in management of MDI if failed rehabilitation. It provides good result in term of pain relief and clinical stability.

X-Ray Right Shoulder: No fracture seen. REFERENCES: CT scan: No evidence of Hill Sach or bony 1. Michael O’Brien, MD (2014) Arthroscopic Bankart Treatment for Multidirectional Instability

ABSTRACT TRUNCATED PX02C Unusual Cause Of Acute Locked Knee In A 39 Years Old Volleyball Player

Sazali S; Abdullah AR; Siva L ; Siva T; Azrin SH; Moganandas M; Siti HT Arthroscopy and Sports Injury Unit, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia

INTRODUCTION: DISCUSSIONS: A locked knee is a condition in which a knee Acute locked knee can be diagnosed or locked in a certain angles of flexion and was suspected from the history and physical not able to be fully extended. This condition examination and further investigation such as occurs mainly following sports injury to the mri can be done to confirm the diagnosis. knee . Commonest causes are mainly due to However , because mri is not readily available torn intraarticular structures particularly and costly, urgent and faster modality for meniscus, anterior cruciate ligament and diagnostic and treatment such as diagnostic osteochondral loose bodies in the arthroscopy can be offered to patients to intercondylar notch causing mechanical block address the intraarticular pathology. Looking to terminal knee extension. We present our into the literature, there are very few reported experience in a case of acute locked knee cases regarding acute locked knee secondary following sporting injury in an active 39 years to intraarticular gouty tophi. old volleyball player with undiagnosed hyperuricemia. CONCLUSION: Common cause of acute locked knee is due to METHODS: intraarticular injury that needs to be urgently A 39-year-old Malay man recreational volley attended. However, other uncommon causes of ball player with no prior medical illness this condition also needs to be considered. presented to our clinic with 3 weeks history of Acute locked knee due to intraarticular gouty fall from jumping in a volleyball match. He tophi should be suspected especially if patients experienced left knee swelling on the next day. has symptoms and positive history of gouty The knee was painful and he was not able to arthritis that runs in the family. ambulate and straighten the left knee. REFERENCES: RESULTS: 1. Espejo-Baena A, Coretti SM, Examination revealed a swollen left knee that Fernandez JM, Garcia-Herrera JM, Del was locked in 10 degrees’ flexion. Lateral Pino JR -Knee locking due to a single joint line was tender with negative clinical gouty tophus. J. Rheumatol. - January tests for ligament laxity and normal xray 1, 2006; 33 (1); 193-5 findings. Patient was counselled for diagnostic 2. Chatterjee S, Ilaslan H - Painful knee arthroscopy of the left knee. Intraoperatively, locking caused by gouty tophi there were generalized whitish deposits over successfully treated with the articular cartilage of the joints and a allopurinol.Nat Clin Pract Rheumatol - tophaceous lesion arising from the anterior December 1, 2008; 4 (12); 675-9 horn of the lateral meniscus and over Anterior cruciate ligament substance. The lesion was debrided intraoperatively. Both serum and intraarticular fluid uric acid levels for this patients was high. Histopathological analysis of the lesion confirmed presence of uric acid crystals. Postoperatively, he was able to get full knee extension and was started on uric acid lowering agents.

PX02D Medial Patellofemoral Ligament Reconstruction In Medial Patellofemoral Ligament Avulsion Fracture Over Patella With Patella Chondral Injury For A Patient With Recurrent Patella Dislocation

Yeoh KH; Teo SH; Alfaiadh Z; Ali R; Ng WM Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

INTRODUCTION: DISCUSSIONS: Medial Patellofemoral Ligament (MPFL) is a There are 3 types of MPFL patellar injury major soft tissue constraints to prevent patella which are injury with ligamentous disruption lateralization. Meanwhile trochlear is the main at patellar attachement, bony avulsion fracture, body constraint to stablized patella. In a case and bony avulsion involving medial facet with MPFL injury on top of trochlear articular cartilage. A serial of MPFL patellar dysplasia, the risk of recurrent patella injury cases comparing surgical and dislocation undoubtly will be significantly conservative treatment outcome, functional high. The commonest site for MPFL injury score was better in the group with fixation would be femoral attachement. We report an done. In a retrospective study, patients with uncommon case of MPFL avulsion fracture trochlear dysplasia who were treated with over patella with patella osteochondral bone MPFL reconstruction were happy with their injury. functional return and long term pain relieve.

METHODS: CONCLUSION: A 23-year-old lady, with history of atraumatic In a case with trochlear dysplasia with MPFL bilateral patella recurrent dislocation, was Injury. We recommend a direct MPFL presented to us with pain over right knee after reconstruction base on literature support. a fall. It was associated with immediate However, a larger series of study and longer swelling over right knee. Right knee x-ray follow up is require to determine whether it noted laterally displaced right patella which offers a good outcome. was then reduced. Skyline view noted bone fragment within patello femoral region. REFERENCES: Magnetic Resonance Imaging noted right 1. Sillanpaa PJ et. al. Knee Surg Sports medial patello femoral ligament (MPFL) Traumatol Arthrosc 2014; 22910):2414-2418 avulsion fracture over the patella insertion site 2. Steiner TM et. al. Am J Sports Med 2006; with patella chondral injury. She undergoes 34(8): 1254-1261. MPFL open repair over right knee.

RESULTS: Patient was put on knee brace and gradual rehabilitative physiotherapy to gain knee range of motion. There is quadricep muscle wasting which require a longer period of rehabilitation. Her pain was tolerable.

PX03B Arthroscopic Debridement For Elbow Osteoarthritis; The Hospital Serdang Experience

1A Arifaizad; 2AK Johan; 3A Syahril Izwan 1Department of Orthopaedic Surgery, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia. 2Department of Orthopaedics, Hospital Serdang, Jalan Puchong, 43000 Kajang, Selangor, Malaysia.

INTRODUCTION: treatment of choice. Although elbow Arthroscopic debridement of the elbow is one arthroplasty exhibits good outcome especially of the treatment options available for pain in inflammatory arthritis1,2, not all patients relief in elbow osteoarthritis. We wish to share will be suitable due to various factors. Hence our experience in treating 2 patients with elbow arthroscopic debridement can offer pain elbow osteoarthritis and the outcome. relief for patients who are not suitable for arthroplasty yet3,4. However, bear in mind that METHODS: in rheumatoid arthritis it is known that the We performed elbow arthroscopy for 2 benefit may only be short-term5. Therefore we patients. The first patient is a 59 year-old male need to prime these patients regarding the with right elbow osteoarthritis secondary to need for elbow arthroplasty later on. Benefits his underlying rheumatoid arthritis, and the of arthroscopic surgeries are well known, but second patient is a 75 year-old female with challenges for surgeons include a steep primary osteoarthritis of the left elbow. Both learning curve and potential of hazardous patients experienced severe pain which complications6. requires frequent analgesia, and pain relief is poor despite compliance to physiotherapy. CONCLUSION: Arthroscopic debridement and manipulation Following our experience with the good under anaesthesia was done for both patients, outcomes, we conclude that elbow arthroscopy and for the second patient she also underwent should be considered as a valuable option of arthroscopic radial head excision. treatment for arthritic elbow pain.

RESULTS: REFERENCES: Post-operatively, both patients showed marked 1. Angst, F. et. al Comprehensive assessment improvement in pain score. The first patient of clinical outcome and quality of life after also had an additional improvement in range total elbow arthroplasty. Arthritis & of motion (ROM). None of them developed Rheumatism, 53: 73–82. any major post-operative complications so far. 2. Kevin A. Hildebrand, M.D., F.R.C.S.(C) et.al. Functional Outcome of Semiconstrained A/S 59/Male 75/Female Total Elbow Arthroplasty. J Bone Joint Surg Pain pre-op 8/10 8/10 Am, 2000 Oct; 82 (10): 1379 -1379 Pain post-op 2/10 3/10 3. Savoie FH 3rd, Nunley PD, Field LD. ROM pre-op 20 - 80° 10 - 110° Arthroscopic management of the arthritic ROM post-op 5 -90° 10 - 110° elbow: indications, technique, and results. J Follow-up 7 months 2 months Shoulder Elbow Surg. 1999;8:214–219. Table 1 Showing the pre and post-op pain 4. Forster MC, Clark DI, Lunn PG. Elbow score and range of motion (flexion and osteoarthritis: prognostic indicators in extension). ulnohumeral debridement—the Outerbridge- Kashiwagi procedure. Journal of Shoulder and DISCUSSIONS: Elbow Surgery. 2001;10(6):557–560. The main problem in arthritic elbows is pain, 5. B. P. H. Lee, B. F. Morrey. Arthroscopic and after exhausting the conservative Synovectomy of the Elbow for Rheumatoid management, elbow arthroplasty is the ABSTRACT TRUNCATED PX03C Case Report: Bilateral Knee Mucoid Anterior Cruciate Ligament

Aridz, MR; Teo, SH; Al-Fayyadh, Z; Ali, R; Ng, WM Division of Sport Injury and Arthroscopic Surgery, Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

INTRODUCTION: Mucoid degeneration of anterior cruciate ligament (ACL) is a rare cause of knee pain.

CASE REPORT: A 51 year old man presented with bilateral knee pain for 9 months without any preceding trauma. Pain was aggravated by flexion of his knees. On examination, the range of motion was 0 - 105 degrees on the right knee and 0 - 135 degrees on the left knee with posterior knee pain exacerbated by full flexion. Plain radiograph showed mild degenerative changes of both knees. MRI showed thickened ACL with inhomogenous signal intensity and diffuse hypertrophic changes on T1-weighted, proton-density and T2 weighted images. There was a posterior peri-cruciate cyst measuring 1 x 2 cm with intraosseous cyst in tibial eminence and a 6 cm bone cyst at posterior aspect of lateral condyle tibia. PCL showed altered signal intensity.

At arthroscopy, bulky but intact ACL fills the intercondylar notch. Both PCL were soft with degenerative changes seen. Histological findings was consistent with myxoid degeneration.

Post operatively, the patient was able to weight bear and perform knee motion as tolerated.

DISCUSSION: Mucoid degeneration of the ACL is a rare cause of knee pain and was first reported in 19991. Pain is most likely caused by mechanical effect of the bulky ACL. Partial resection of the ACL provide complete relief of symptoms1,2.

REFERENCES: 1. Kumar A et. al. J Bone Joint Surg Br 1999; 81(2):304–305 2. Cho S.D. et. al. Clin Orthop Surg 2012; 4(2): 167-170. PX03D The Outcome Of Medial Patellofemoral Ligament Reconstruction: The Hospital Serdang Experience

RDK Yeak1; Paisal Hussin2; M Zaidi1; NM Nizlan2 1 Department of Orthopaedic Surgery, Serdang Hospital, Jalan Puchong, 43000 Kajang, Selangor, Malaysia. 2 Department of Orthopaedics, Faculty of Medicine, University Putra Malaysia, Serdang 43000 Selangor, Malaysia.

INTRODUCTION: RESULTS: The MPFL is essential for the maintenance of Data were collected from 7 patients. There correct biomechanical function of the knee. In were 4 male and 3 female patients. The patella dislocation, the MPFL may be torn but average age was 23 years old at the time of the in most instances, this can be treated with surgery with a range of 16 to 34 years old. activity modification and physical therapy. There were one delayed cases and six chronic Occasionally, the reconstruction of MPFL may cases. The time of injury to surgery ranged be needed but is commonly done for recurrent from 7 months to 10 years. There were 3 cases dislocation of the patella which can otherwise that were reconstructed with gracilis, 3 cases lead to patellofemoral instability. The purpose with semitendinosus and one case with of this study is to report the clinical outcomes allograft. All 7 cases showed good patellar post MPFL reconstruction. mobility, normal lateral patellar glide with negative patellar apprehension test. All the METHODS: patients did not report a recurrence of patella Patients who underwent surgical treatment of dislocation and were able to return to their MPFL reconstruction between January 2011 activities of daily living. As for the range of and December 2015 at Hospital Serdang were motion, the patients had an average of 139 retrospectively reviewed. All patients had degrees. No loss of extension was reported. MPFL tear as demonstrated by a reverse ‘J” sign and positive apprehension test. The DISCUSSIONS AND CONCLUSION: demographics and interval from time of injury Our small series study suggests that the timing to surgery were recorded. All the patients had of surgery does not affect the outcome in terms traumatic tear of the MPFL. The patients were of stability as well as range of motion of divided into two groups with those who had MPFL reconstruction. The chronic cases surgical intervention delayed (less than one showed similar good clinical outcomes year) and chronic (more than one year). The comparable to the delayed case. The type of surgical technique involved anatomic MPFL graft does not show any difference in terms of reconstruction with either autograft (gracilis or the good clinical outcome in our study. semitendinosus) or allograft. Patients who had prior knee surgery on the affected knee were REFERENCES: excluded. Only patients with recurrent 1. Evan Larson, Alan Edwards, ,John Albright. dislocations of more than three times were FUNCTIONAL OUTCOMES OF MPFL included in the study. The patients were RECONSTRUCTION VS. GRAFT TISSUE followed up for an average of 9 months PLACEMENT. Iowa Orthop J. 2014;34:38-43. ranging from 3 months to 18 months. At the 2. Schöttle PB, Schmeling A, Rosenstiel N, time of follow-up, the patients were reviewed Weiler A. Radiographic landmarks for femoral by a sports surgeon and a sports physician, and tunnel placement in medial patellofemoral the clinical outcomes were recorded. Outcome ligament reconstruction. Am J Sports Med. measures were determination of the patella 2007 May;35(5):801-4. Epub 2007 Jan 31. stability as well as the range of motion.

PX04A Arthroscopic Release Of Elbow Arthrofibrosis; The Hospital Serdang Experience

1AK Johan; 1A Arifaizad; 2JA Tan 1Department of Orthopaedic Surgery, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia. 2Department of Orthopaedics, Hospital Serdang, Jalan Puchong, 43000 Kajang, Selangor, Malaysia.

INTRODUCTION: *ROM deteriorated to pre-op condition after 4 Elbow arthroscopy is one of the treatment months of follow-up **Arthroscopy just options available for elbow arthrofibrosis. We recently performed wish to report a case series of arthroscopic releases that were done for 5 of our patients DISCUSSIONS: who experienced post-traumatic elbow Post-traumatic elbow stiffness greatly limits stiffness. patients’ activities of daily living and this is troublesome for our patients especially the METHODS: younger age group who has a long life We performed elbow arthroscopy for 5 expectancy ahead of them. Arthroscopic patients, with ages ranging between 18 to 50 release of elbow arthrofibrosis is one of the years old. All had injury over the elbow. 3 of available options of treatment and has shown them sustained open fractures which were good outcome in terms of improvement in treated with delayed internal fixation, and 2 range of motion and pain control1, 2. It has more sustained closed fractures; 1 treated many advantages; for example it can be both conservatively and 1 with internal fixation. All diagnostic and therapeutic tool. Being of them developed elbow stiffness which was minimally invasive, it also produce small scar detected during follow-up, 4 of which are hence less post-operative pain and less risk of painless stiffness. All patients underwent surgical site infection3. However the skills arthroscopic release of arthrofibrosis and needed for the procedure may require a higher manipulation under anaesthesia, with 2 of learning curve and poor technique may result them requiring excision of bony spurs during in undesirable post-operative complications. the procedure. CONCLUSION: RESULTS: Following our experience with the good Post-operatively, 4 of the patients showed outcomes, we wish to highlight that elbow marked improvement in range of motion. The arthroscopy can be offered as a viable patient with the painful stiff elbow was treatment option to patients with post- improving post-operatively but after 4 months traumatic stiff elbow. of follow-up his elbow became stiff again due to non-compliance to physiotherapy. None of REFERENCES: them developed any major post-operative 1.Nguyen D, Proper SIW, MacDermid JC et al complications. (2006) Functional outcomes of arthroscopic capsular release of the elbow. A/S Pre-op Post-op Follow-up Arthroscopy 22:842–849 18/M 10 - 60° 10 - 110° 11 months 2.Van Zeeland NL, Yamaguchi K (2010) 23/M 80 -90° *50 - 120° 9 months Arthroscopic capsular release of the elbow. 26/F 30 - 90° 5 - 100° 2 months J Shoulder Elbow Surg 19:13–19 32/M 90 -110° ** 1 months 3.Edward W. Kelly, MD; Bernard F. Morrey, 50/M 10 - 45° 5 - 110° 2 months MD; Shawn W. O'Driscoll, PhD, MD. Table 1 showing the pre and post-op range of Complications of Elbow Arthroscopy. J motion (flexion and extension). Bone Joint Surg Am, 2001 Jan; 83 (1): 25 - 25

PX04B Repair Of Contracted Degenerative Achilles Tendon Avulsion Rupture With Augmentation Using Plantaris Tendon And V-Y Lengthening: Surgical Technique

Yusof, Mohd Rusdi; SH Teo; Zubair; Ali, Razif; WM, Ng. Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

INTRODUCTION Neglected Achilles tendon rupture treatment is RESULTS: challenging. Here we present our His recovery was uneventful. His ankle reconstructive technique that we use for a dorsiflexion was increased by 10 degree every patient with a neglected Achilles tendon 2 weeks. The cast was removed after 6th week rupture with 8 cm gap. and he was allowed for full weight bearing. At the 12th week follow up the plantar flexion OPERATIVE TECHNIQUE power of the operated leg was grade 4+. We performed gastrocnemius VY plasty, anchor suture Achilles tendon repair and DISCUSSION: augmentation with plantaris tendon (figure 1) For Achilles tendon rupture with a large gap, on a 65 years old technician that referred to us V-Y plasty is one of the favourite technique to with 6 month old neglected left Achilles restore tendon length.1 tendon rupture. Intraoperatively the proximal The use of plantaris tendon in augmentation of stump was noted contracted proximally Achilles tendon rupture was demonstrated to leaving 8 cm gap. Tendon rupture was noted at be practically good.2 the insertional site over the calcaneal with 4 cm gap with maximum plantar flexion of the CONCLUSION: ankle. There was no distal stump noted. V-Y plasty of gastrocnemius tendon, Achiles Plantaris tendon was identified and the tendon repair with anchor suture and proximal part of the tendon was harvested. augmentation with plantaris tendon are viable Modified Krackow locking loops were made option to treat patient with contracted over each side of the tendon using anchor neglected Achilles tendon rupture with large suture 5/0. Two anchor suture screws were gap. inserted into calcaneal tendon insertional site. A serial study with larger number of subject An inverted V-Y plasty was made over and longer follow up is required to determine musculotendinous junction of gastrocnemius long term risk of re-rupture. muscle. The proximal tendon stump was approximated to calcaneal tendon insertional REFERENCE: site by tying the anchor suture. The harvested 1. A.K. Us, S.s. Bilgin, T.Aydin, E. Mergen. proximal part of plantaris tendon was weaved Repair of neglected Achilles tendon through Achilles tendon and they were sutured ruptures: procedures and functional results. together using Vicryl 2/0. Postoperatively, the Arch Orthop Trauma Surg, 116 (1997). foot was put in full equinus position using 2. Theodore A. Lynn. Repair of the torn below knee full cast. Achilles Tendon, using the plantaris tendon as a reinforcing membrane. J Bone Joint Surg Am, 1966.

Figure 1

,5 PT01A

Strontium Ranelate Reduces Duration Of Consolidation Phase In Bone Transport: Case Report

Kishan Rao; Ashwini Sood; Chuah SK Department of Orthopaedics, Hospital Kulim, 09000 Kulim, Kedah

INTRODUCTION: Patient 2 In bone transport, there are 3 main phases; latent phase, distraction phase and consolidation phase[1,2]. Patient has to be on external fixator (eg: ilizarov, LRS etc) for the entire duration of the bone transport until bone consolidation is achieved. From these case reports, we have found that strontium ranelate given to patients at the end of distraction phase have significantly reduced the duration of 6 weeks post 13 weeks post consolidation phase. Thus, reducing the strontium strontium duration the patients have to be on external fixator. Total length corrected = 7.0 cm MATERIALS & METHODS: Total duration of lengthening = 72 days These are case reports of 2 patients who were Expected duration of consolidation phase = diagnosed with chronic osteomyelitis of femur 72 x 2 = 144 days and underwent bone excision and distraction Expected total duration patient on TSF( osteogenesis. Strontium ranelate was started at lengthening+ consolidation) = 216 days the end of distraction phase and serial xrays Total duration of consolidation after and clinical examination were performed strontium = 91 days every 4 weeks to asses consolidation. Total = 163 ( save 53 days!) RESULTS: Patient 1 DISCUSSION: As a general rule, the duration of consolidation phase is usually twice the duration of distraction phase. For example, if the bone gap is 10 cm, the duration of distraction phase is 100 days (1mm/day) and the duration of consolidation is 200 days, which is a total of 300 days on external fixator! Many methods Docking 14 weeks post have been introduced to improve bone strontium. Bone consolidation in bone transport, such as low consolidated. LRS intensity ultrasound therapy, BMP-2 injection, removed platelet rich plasma (PRP) injection, auto graft etc[3]. Unfortunately these methods are Total length transported = 8.5cm invasive and not cost effective. Strontium Total duration of transport (0.5mm BD) = ranelate has both anabolic and anti-catabolic 87 days activity towards bone healing (DABA)[4,5]. Expected duration of consolidation phase = They stimulate production of osteoblast and 87x2= 174 days increase mineralisation of the transported Expected total duration patient on LRS( site[6,8]. This enhances new bone formation at transport + consolidation) = 261 days transported site. Total duration of consolidation phase after CONCLUSION: strontium = 98 days Strontium ranelate is a cost effective and non Total = 185 days ( save 76 days!) invasive alternative. Thus,can be used to

ABSTRAT TRUNCATED PT01C Malunited Neglected Tibia Shaft Fracture Treated With Osteotomy And Reamed Intramedullary Nail: A Case Report

YH Foo; TS Chong; Qureshi AS; YD Wong Department of Orthopedic, Hospital Sibu, Sarawak, Malaysia

Introduction: to be obliterated with callus. The medullary Tibia shaft fractures result in severe pain, canal at both ends of the fracture was inability to bear weight on the affected leg and recanalized using a drill to allow passage of a often a visible deformity of the leg. The guide wire. The medullary canal was reamed severity of these symptoms will usually drive and a cannulated tibial nail was inserted. the patient to seek medical treatment and the Results: long term outcome of tibia shaft fractures is Figure 2. Postoperative plain radiograph of good. However, there are various reasons for right tibia at Day 1 and at 3 months. the fracture to be neglected, resulting in malunion. Malunited fractures can lead to significant morbidity, alteration in gait and significant limb length discrepancy. Reamed intramedullary nailing has been shown to be an effective method for the treating tibia malunion. Case Report: A 56 year-old woman sustained an injury to the right leg after she was hit by a car. Post trauma, she had pain, swelling and deformity Day1 3 months of the right leg and was unable to walk for 1 There is both clinical and radiological month. Unfortunately, she did not seek evidence of union at 3 months after surgery. treatment because of the lack of transport to On followup at 6 months, the patient had fully the nearest healthcare facility. She first recovered and was able to walk normally with presented after a delay of 7 months after the a normal gait. initial trauma, complaining of persistent pain Discussion: and deformity of the right leg. By this time, Mayo et al recommended that a closed the fracture had already malunited with an technique should be used where possible. In anterior angulation of 50 degrees and varus this case, closed reduction was not feasible angulation of 7 degrees. and the obliterated medullary canal Figure 1. Preoperative plain radiograph of necessitated an open reduction. Soft tissue right tibia dissection was deliberately kept to a minimum. Outcome of surgery was satisfactory for this patient. Conclusion: Reamed intramedullary nail is an effective method of treating malunion of neglected tibia shaft fracture. Closed reduction should be performed whenever possible to minimize soft tissue trauma. References: Intraoperatively, closed manipulation of the 1. Milner SA et al. Long-term outcome after fracture was unsuccessful. Osteotomy of the tibial shaft fracture: is malunion important? J fibula was performed via a lateral incision. Bone Joint Surg Am. 2002 Jun;84-A(6):971- Fracture site over the tibia was accessed via an 80 anteromedial incision. Tibia osteotomy was performed and the medullary canal was found

ABSTRACT TRUNCATED PT02A Conservative Treatment Of Traumatic Hip Dislocation With Acetabular Both Column Fractures: A Case Report Ong CS; Ruzaimi MY; Mashayati M; Anuar A Department of Orthopaedics, Hospital Kajang, Jalan Semenyih, Bandar Kajang, 43000 Kajang, Selangor, Malaysia

Introduction An acetabular fracture with hip dislocation is typically the result of high-energy trauma resulting in joint incongruity, usually associated with other injuries with high incidence of long-term serious sequelae. Open reduction and internal fixation has been the standard treatment for displaced acetabular fractures. We report the case of a patient with both columns acetabular fracture with posterior hip dislocation managed Figure 1 – Antero-posterior pelvic X-ray conservatively with good functional outcome. showing fracture-dislocation of the left hip Case Report A 32-year-old male alleged a motor vehicle and complications. In view of that, many types accident while riding a motorbike. He of fractures are being treated by more sustained a posterior dislocation of the left hip conservative methods.1 Letournel introduced with a fracture of an acetabulum, together with the concept of “secondary congruence” in both a chip fracture of the femoral head. The column fractures of the acetabulum with dislocation was reduced without difficulty acceptable results after conservative treatment with the patient under sedation within two which can lead to an extra-anatomical hours of injury. There was presence of deep orientation around the femoral head with the abrasion wound over the surgical site which possibility of healing in secondary has a very high risk of infection, the possible congruence. NK Magu et al. highlighted that complications were explained to the patient small osteochrondral fragments in the cotyloid and he was agreed for conservative fossa or non-weight part in a congruous joint management. Subsequent follow-up in clinic do not adversely affect the functional revealed both column acetabular fractures outcome.2 However, long-term follow-up is healing in secondary congruence with an required to justify the current treatment extra-anatomical orientation around the concept. femoral head with full range of motion of his Conclusion left hip joint without pain. Conservative treatment of both column Discussion acetabular fractures can lead to high rate of Motor vehicle accidents are the cause of up to secondary congruence with acceptable long- 93% of hip fractures and dislocations. Sixty- term good functional outcome in selected six percent of posterior dislocation result in patients. displaced fractures of acetabulum or the References proximal femur. This patient had sustained 1. Alonso JE, Volgas DA, Giordano V, comminuted both column acetabular fractures. Stannard JP. A review of the treatment of hip It has an incidence of approximately 22%. The dislocations associated with acetabular majority of both column fractures are treated fractures. Clin Orthop Relat Res 2000; 377: operatively. However, the surgical procedure 32-43. is associated with extensive surgical trauma 2. NK Magu, Rajesh Rohilla, Sanjay Arora. Conservatively treated acetabular fractures: A retrospective analysis. Indian J Orthop. 2012 Jan-Feb; 46(1): 36-45

ABSTRACT TRUNCATED PT02B Heterotopic Ossification Of The Hip: A Case Report And Literature Review

1Kow RY; 2Low CL; 2Jaya Raj J; 2Jacob Abraham VA 1Department of Orthopaedic Surgery, Hospital Kuala Lipis, Kuala Lipis, 27200, Malaysia 2Department of Orthopaedic Surgery, Hospital Tengku Ampuan Afzan, Jalan Tanah Putih, Kuantan, 25300, Malaysia

Introduction: cord injury, prolonged immobilization, Over the years, reamed intramedullary nail mobilization after prolonged immobilization (IMN) has evolved to become the “standard of as well as parathyroid and calcitonin care” in the treatment of diaphyseal femur imbalances.3 In this patient, prolonged fractures.1 Heterotopic ossification of the hip immobilization post-trauma and proximally- post-IMN is not uncommon. With this case reamed IMN contribute to the formation of report and literature review, we would like to HO. bring to attention another common but usually Diligent soft tissue care during the nailing neglected complication of IMN. procedure can help reduce the incidence of HO. Prophylactic NSAIDs can reduce the risk Materials & Methods: of HO in patients with total hip arthroplasty Mr VN, a 21-year-old gentleman, sustained an but it is not applicable in patients with femoral open comminuted fracture of the left femur fractures due to high risk of non-union. grade IIIa in a motor-vehicle accident. Left Passive range of motion exercises are femur proximal reamed intramedullary nail recommended to prevent the complication of was inserted one week post-trauma once the HO such as peripheral nerve entrapment, wound was clean. He was well until he started pressure ulcers and functional impairment if complaining of left hip pain at 8 months post- joint ankylosis developes.2 IMN insertion. There was an ill-defined bony In symptomatic patients, the mainstay mass palpable at the left hip. Radiographs of treatment of HO is surgical resection with his left hip showed heterotopic ossification of post-operative NSAIDs and/or radiotherapy to the left hip which became more radio-opaque prevent recurrence.2 with time. Conclusion: There is still lack of understanding of the exact pathophysiology of HO formation in patients undergoing IMN. Physiotherapy plays a role in the management of HO.

Figure 1: Radiograph of his left hip on day- 1 post reamed intramedullary nail. References: Figure 2: A fully ossified heterotopic 1.Botolin S et al.Heterotopic ossification in ossification of the left hip (black arrow). the reaming tract of a percutaneous antegrade femoral nail: a case report. Journal of Medical Results: Case Reports 2013;7:90. The patient claimed that his left hip pain subsided after about 1 year of physiotherapy 2.Shebab D et al. Heterotopic ossification. J and his activities of daily living were not Nucl Med. 2002;43:346-353. affected. 3.Bossche LV et al. Heterotopic ossification : Discussions: a review. J Rehabil Med 2005;37:129-136. Heterotopic ossification (HO) occurs when bone forms in soft tissues abnormally, usually close to a joint.2 Factors associated with HO formation include hypercalcemia, hip abductor hypoxia, spinal PT02C Bone Lengthening With Monorail External Fixator System In Chronic Osteomyelitis Of Tibia

Elaine SZF; Manas; Ammar; Suhana SB; Richford J; A Muttalib Department of Orthopaedic, Hospital Segamat, 85000 Johor, Malaysia

Introduction: Chronic osteomyelitis remains a big challenge in Orthopaedics despite Fig 1: X ray advancement in surgical techniques and showing modern antibiotics.Bone defect and limb lengthening of right shortening due to chronic osteomyelitis need tibia with distraction to be addressed to regain good functional osteogenesis outcome of the patient.

Methods: A case report of a case of chronic Fig 2: Picture osteomyelitis of tibia , the management and showing clinical outcome of bone lengthening with supplementary monorail external fixator . bone graft being inserted

Results: Discussions: Mr H is a 20 years old gentleman who Chronic osteomyelitis has been a challenge. sustained open fracture Gustillo Grade II of Treatment includes sequential debridements right tibia and fibula. Early wound and antibiotics either local or systemic. debridement and fracture stabilisation with 1Bone transport used in the treatment of uniplanar external fixator was performed. It bone defect in infected nonunion of tibia has was subsequently converted to acquired satisfied results.2 intramedullary nailing after soft tissue healed. Unfortunately,he developed chronic Conclusion: osteomyelitis and the intramedullary Aggressive treatment with debridement, implant was removed. He was treated sequectrectomy and antibiotics are effective aggressively with multiple debridements and in chronic osteomyelitis. Managing the bone sequestrectomy. He also received courses of defect and limb lenthening by monorail antibioitics including oral, parenteral, external fixator requires strong patient's antibiotic infused beads and antibioitc commitment and showed desirable clinical impregnated collagen implant. Subsequently outcome. right tibia osteotomy was performed, and with shortening of 6cm , he undergone limb References: lengthening by distraction osteogenesis with 1 .Rodney K Beals et al. The treatment of monorail external fixator system. He showed chronic open osteomyelitis of the tibia in a good result of lengthening. Supplementary adults. Clinical Orthopaedics and related iliac bone graft and dimeneralised bone Research 2005, (433): 212-7 matrix was inserted later. Currently, at 11 2.Yin P et al. Infected nonunion of tibia and months post lengthening, he showed a good femur treated by bone transport. J Orthop progress with callus consolidation and Surg Res. 2015 Apr 10;10:49. started back on full weight bearing.

PT02D Open Reduction And Internal Fixation Of Post Trauma 2 Month Acetabulum Fracture: A Case Report

Firdaus Z; Ramesh N; Gerry M; Arauf A Hospital Tuanku Jaafar, Jalan Rasah, 70300 Seremban, Negeri Sembilan, Malaysia

Introduction: Figure 3: Post Acetabulum Fixation Accurate reduction and rigid internal fixation can decrease the incidence of post-traumatic arthritis and improve functional outcome. Treatment of acetabulum fractures includes open reduction and internal fixation should be performed within the first 10 days of trauma (1) however surgery may be delayed if patient is not fit, but it is advisable to

perform the surgery within three weeks as there are difficulties in accurate reduction Discussions: after this period (2) Most common complication of acetabulum fracture was osteoarthritis, heterotopic Case Report: ossification and avascular necrosis of the A 30 years old male with poly trauma was femoral head. However in a long term referred to out center for the right follow–up study, indicated that the results of acetabulum fracture after 7weeks post non-operative treatment in displaced trauma. Patient surgically fit for operation acetabular fractures were inferior compared after 8 weeks of post trauma. Patient to those of operative treatment (30% underwent open reduction and plating of satisfactory results versus 80% satisfactory right acetabulum via combined Kocher- results in the surgical group) (3). Mean hip Langenbach with illioinguinal approach. scores were significantly better in patients who underwent fixation within 5 days from Figure 1: Post Trauma the time of injury (4). Early intervention facilitates early limb mobilization and subsequently faster functional recovery .The aim of surgical intervention for this patient was to achieve the most accurate redution of the fracture and to restore hip joint congruence which is easier for total hip replacement later.

References: Figure 2: Post trauma 7 week 1.Letournel E. Acetabulum fractures: classification and management. Clin Orthop. 1980;151:81–106. [PubMed] 2. Brueton RN. A review of 40 acetabular fractures: the importance of early surgery. Injury. 1993;24:171–174. [PubMed] 3. Kebaish AS, Roy A, Rennie W. Displaced acetabular fractures:long-term follow-up. J Trauma. 1991;31:1539–1542. [PubMed] 4. SS Sathappan, CM Qi, A Pillai Surgical Stabilization of Pelvic and Acetabular Fractures: A Review on the Determinants of

ABSTRACT TRUNCATED PT03A Fat Embolism In Post Operative Case Of Tibial Fracture

Chelsia Ezrin Gibbs; Lingeswaran; Normawaty; Abdul Aziz Yahaya Department of Orthopaedic, Hospital Seberang Jaya, Jalan Tun Hussein Onn, 13700 Seberang Jaya, Pulau Pinang Malaysia

Abstracts: blood transfusion, antibiotic, the patient Fat embolism syndrome is frequently allied subsequently recovered. with surgery for large bone fractures. Last 20 Discussions: years of studies have shown that the In biochemical theory, the time required to occurance of FES is scaled down by early produce these toxic intermediaries explains stabilization of the fractures.We present a the delay in development of symptoms. case with fat embolism syndrome due to Among the justifications for the difficulty in tibial fracture post operation-intramedullary diagnosis of FES is the complication of nailing , in which patient return Day5 post widely different clinical conditions that may motor vehicle accident & Day4 diversify in severity. Diagnosis fulfill criteria postoperative later with FES. of Gurd’s. Imaging studies are the most Introduction: useful in diagnosis of FES.The timing and Approximately 90% of the cases are the type of surgery for fractures constitute associated with trauma, especially fracture or modifiable factors for the development of surgery of a large bone.As a result of the FES. Previous studies have revealed that disrupted bone, the bone marrow fat after a traumatic injury, early surgical particles escapes into circulatory. Symptoms fixation in patients with isolated of fat embolism mostly ensue 12–36 hours femoral/tibial fractures could prevent the after a traumatic injury. development of FES. However, in our case, Case Report: even though early surgical stabilization was A 19-year-old male was transferred to the performed 10 hours after injury, the emergency room after an accident- development of FES was not prevented. pedestrian hit & run. The patient suffered Conversely, a number of studies have open fracture left tibia fibula and was pointed out that surgical treatment, hemodynamically stable, without any especially intramedullary nailing, is deterioration of consciousness. Chest associated with a higher probability of fat radiography and arterial blood gas analysis embolism and pulmonary complications revealed normal findings. 23 Hours later such as ARDS, due to the release of fat post trauma, reamed tibial nailing was emboli from the bone marrow of the performed .Patient was discharged 2 days medullary canal.In a study by Wozasek et post operation. Forty-eight hours after al, medullary nailing found to be associated discharge, the patient return to emergency with severe increasing in intramedullary room,with manifested fever (38.6 degree pressure during first reaming celcius),tachycardia (>130/minute), dyspnea, procedure.Particle /fat intravasation did not and hypoxemia( SPO2 = 74% under room depend on rise in intramedullary pressure. air). The patient was put on supplemental Conclusion: oxygen (PO2 = 96 mmHg, PaCO2 = 24.8 FES may occur even with early stabilization mmHg, pH = 7.55) Full Blood Count ( Hb = of fracture. The key for diagnosis of FES 8.4,WBC = 10.5). The echocardiography after post operation is high index of showed right ventricular dilatation. Chest X- suspicion confirmed with blood ray showed the appearance of ARDS, investigation and radiological investigation. requiring mechanical ventilation of the References: patient.CTPA findings show fat embolism 1.Wozasek, Gerald Eliot MD; Simon, Paul with aspiration pneumonia,prompted a MD; Redl, Heinz PhD; Schlag, Günther diagnosis of FES. With supportive treatment MD.Intramedullary pressure changes and fat in the intensive care unit (ICU), good intravasation during intramedullary nailing. hydration, cortisone therapy, ABSTRACT TRUNCATED PT03B Proximal Humeral Locking Plate – An Alternative To Proximal Femur Locking Plate For Subtrochanteric Femur Fracture In An Adolescent Boy

Lau FHY; HP Tan; Kamarulzaman SK; Singh A Department of Orthopaedics, Hospital Tengku Ampuan Rahimah, 42100 Klang, Selangor Malaysia

Introduction: commonly used in subtrochanteric femur A 13-year-old boy was involved in an alleged fracture in adults3,4,5 is not suitable for road traffic accident and sustained paediatric cases because of the design of the subtrochanteric femur fracture AO 32-C3 IO1- plate. Principles of Titanium Elastic Nail MT1-NV1. Wound debridement and pinning System (TENS) could not be applied for of the tibia was done with commencement of comminuted subtrochanteric fracture. prophylactic antibiotic1. Plating of the femur Conclusion: was done after a few days after once the soft We like to highlight the option of Proximal tissue was permissible. Humeral Locking Plate as an alternative Methods: extramedullary fixation device. Fixation of the subtrochanteric femur fracture References: was done with a 3.5mm Proximal Humeral 1. British Orthopaedic Association. Standards Locking Compression Plate. for the management of open fractures of the Results: lower limb. 2009 Anatomical reduction and stable fixation was 2. Jarvis J, Davidson D, Letts M. achieved using the above mentioned plate. Management of subtrochanteric fractures in skeletally immature adolescents. J Trauma. 2006 Mar; 60(3):613-9. 3. Sun-jun Hu, Shi-min Zhang, and Guang- rong Yu. Treatment of femoral subtrochanteric fractures with proximal lateral femur locking plates Acta Ortop Bras. 2012 Dec; 20(6): 329–333. doi: 10.1590/S1413-78522012000600003. 4. Hasenboehler EA, Agudelo JF, Morgan SJ,

Picture 1. Preoperative radiograph of the Smith WR, Hak DJ, Stahel PF. Treatment subtrochanteric fracture of complex proximal femoral fractures with the proximal femur locking compression plate. Orthopedics. 2007 Aug; 30(8):618- 23. 5. Saini P, Kumar R, Shekhawat V, Joshi N, Bansal M, Kumar S. Biological fixation of comminuted subtrochanteric fractures with proximal femur locking compression plate. Injury. 2013 Feb; 44(2):226-31. doi: 10.1016/j.injury.2012.10.037. Epub 2012 Nov 30.

Picture 2. Postoperative radiograph of fracture fixation

Discussions: The method of fixation for subtrochanteric femur fracture in paediatric group are limited2. Proximal Femur Locking Plate (PFLP)

PT03C Removal Technique For A 45 Degrees Bent Intramedullary Femoral Nail: A Case Report

HM How; MY Abdul Hamid; MY Sharizan; MA Kamalruzaman Department of Orthopaedics, Hospital Enche’ Besar Hajjah Khalsom, Jalan Kota Tinggi, Kluang, 86000 Johor, Malaysia

Introduction: Intramedullary nailing is the gold standard and preferred method for fixation of femoral shaft fractures1 with 98% union rates and with few complications2. However, refracture and bend intramedullary nail that result from secondary trauma can be devastating depending on the degree of bend. Numerous literatures reported variable (a) (b) technique of removal of a bent femoral intramedullary nail. In this case, we report a Fig 1 (a); Plain radiograph showed implant case of removal technique for 45 degrees failure with bent ILN at 450 bent titanium femoral interlocking nail. Fig 1 (b); extracted femoral nail

Case Report: concentrated at the apex of the deformity We report a case of a 21 years old man, and minimizes soft tissue damage2. alleged motor vehicle accident and had Nonetheless, we have retracted the bent sustained a re-fracture of right femur and intramedullary nail without prior implant failure, which was a 450 bent straightening of the nail. This is thought to intramedullary nail. This nail was inserted 8 be due to the flexibility and elasticity of the months ago following initial trauma. He had titanium nail. However, dealing with such undergone removal of bent intramedullary cases remains a great challenge for nail and reinsertion of nail 5 days later. orthopaedic surgeons. Intraoperative, patient was put on traction table and traction applied. Attempts were Conclusion: made to straighten the nail, but were futile. None of the described method always works After a failed manual manipulation as for all cases. Removal of the bent described by Patterson1, extraction of the interlocking nail remained a great technical nail using the removal jig was successful and challenge to those involved. uneventful. The bent interlocking nail showed an elastic property whereby it References: straightens during its passage out of femoral 1. Patterson RH, Ramser JR. Technique for canal and then returns to its bent state after treatment of a bent Russell-Taylor successful extraction. femoral nails. J Orthop Trauma 1991; 5(4): 506-8. Discussions: 2. Michael J. Heffernan, Walter Leclair, Various methods for the removal of a bent Xinning Li: Use of the F-tool for the intramedullary nail have been described. removal of a bent intramedullary femoral Patterson and Ramser reported in situ nail with a sagittal plane deformity. straightening through the application of a Trauma 2012:35(3); 438-41 substantial external force1. Michael J. Heffernan use F-tool allows forces to be

PT03D Damage Control Orthopaedics In A Complex Pelvic Ring Fracture With Obturator Artery Laceration

Mahendran S; Abilash K; Manoharan K Department of Orthopaedics, Hospital Raja Permaisuri Bainun, Jalan Hospital, 30990 Ipoh, Perak Malaysia

Keywords: fracture with right lateral compression injury, Complex pelvic fracture, DCO, obturator bicolumnar involvement type Tile B. (figure 1) artery Fast scans of the abdomen were negative for Abstract: free fluid. Its a major challenge for the orthopaedic The patient was diagnosed with Hypovolumic surgeon in managing high velocity polytrauma shock secondary to a right pelvic ring fracture. patients. Damage control surgery has been He was sufficiently resuscitated and taken to proven to be the ultimate approach in saving the operating theatre for an emergency pelvic these patients. external fixator keep in view open and pack. Introduction: Post external fixation, his vitals stabilized and Pelvic ring fractures are usually caused by hemodynamic status improved hence we high energy blunt trauma. This sort of injury decided against packing. The patient was then is usually associated with head injuries (most taken to the theatre about a week later for common) and intraabdominal injuries. The plating of the posterior column. Intra- reported prevalence of associated organ operative findings: lacerated right obturator injuries ranges from 11% to 20.3%. Pelvic artery (ligated) (figure 2) fractures have long been associated with Figure 1: Computer tomography of the significant mortality, which ranges from 5.6% pelvis to 15% . Life-threatening hemorrhage related to pelvic fractures may originate from fractured bone, the pelvic venous plexus, major pelvic veins, and/or iliac arterial branches. Arterial hemorrhage is the most serious problem associated with pelvic fractures, and it remains the leading cause of death. Several authors have suggested that external fixation is not likely to be sufficient to stop arterial bleeding. Urgent angiography and subsequent transcatheter embolization are Figure 2: xray of the pelvis post op currently accepted as the most effective methods for controlling ongoing arterial bleeding in pelvic fractures. Patient death caused by the hemorrhage of a pelvic fracture frequently occurs within the first 24 hours of injury. Case Report: 52 year old male, alleged road traffic accident, presented to the emergency department with chief complains of pain over the waist and lower limbs. He was hypotensive and Discussion: tachycardic. On general examination he had a Pelvic fractures are notoriously known to Glasgow come score of 15/15, Morel Lavallee cause hypovolumia in patients which if lesions over the right iliac region and scrotal undiagnosed or not dealt with urgently and swelling. Plain radiographs of the pelvis efficiently would inammicably lead to death. showed a comminuted open book pelvic Hence, it is of utmost importance to resuscitate the patient adequately with proper ABSTRACT TRUNCATED PT04A Medial Condylar Hoffa Fracture With Posterior Cruciate Ligament Avulsion Fracture In Right Knee Joint

Lingeshwaran R.Arunasalam; Chelsia Ezrin Azlan; Leow VC; Abdul Aziz Department of Orthopaedic, Hospital Seberang Jaya, 13700 Prai, Pulau Pinang Malaysia

Introduction: with physiotherapy of left knee.At the 8 Hoffa fracture is a type of supracondylar weeks follow up ,patient started on Partial femur fracture and is characterised by an weight bearing cruchers continued at 12 associated coronal plane(1).While they are in weeks,full weight bearing done.In 1 year absolute numbers,they are account for ,patient has full range of movement of knee approxiamtely 40% of intracondylar (0-140 degree) without pain,deformity or fractures(3).Its typically seen in adult after laxity..Radiographs showed no signs of higher-energy trauma(3).Hoffa fragments are avascular necrosis,osteoarthritis or implant more commonly unicondylar and usually breakage. orginate from the lateral femoral Diagram: condyle(3)They can be accasionally bicondylar We describe a rare case of medial condyle Hoffa fracture with posterior cruciate ligament avulsion injury with its management and outcome. Case Report: Discussions: NW, 18 years old Male,Malaysian athlet was Hoffa fractures are intra-articular and are involved in motovehicle accident.He is the characterised by a fracture in the coronal (1) motorbike rider who has high impact injury plane .Hoffa fracture usually results from to his semi-flexed left knee.Local high energy trauma and can be missed with (4) examination of his left knee,its swollen plain knee xray .High index of suspicion, ,tender and decrease range of movement further imaging with CT scan / 3D with no wound or neurovascular reconstruction. Open reduction and internal compromised.Plain xray of the left knee fixation is necessary for good outcome noted medial condyle Hoffa fracture with following these types of fractures.Patient's suspicious anterior cruciate ligment self hardwork,physiotherapist and family injury.Computed Tomography(CT) scan support are important to go thru the difficult finding shows comminuted left medial rehabiltation period. femoral condyle fracture.The patient was Conclusion: operated in supine position.Anterior midline We described a rare case of a medial medial parapatellar incision used.Upon condylar Hoffa fracture with posterior exposing the knee,fracture involving medial cruciate ligament avulsion fracture managed condyle femur with bone loss over posterior successfully by open reduction and internal aspect of medial condyle and posterior fixation with good clinical outcome at 12 cruciate ligament avulsion fracture at months of follow-up and excellent long term femoral insertion noted.Fracture was outcome reduced and temporally stabilized with K- References: wire and fixed with cannulated cancellous 1.Flanagin BA, Cruz AI, Medvecky MJ. screw.PCL screw fixation done by Hoffa fracture in a 14-year-old. Orthopedics. cancellous screw and bone loss packed with 2011; 34 (2): 138. autologous bone graft harvested from left 2.A Mootha, A Gupta, R Saini, V Kumar. iliac crest.Post operative Day 1,patient Coronal fracture of medial femoral condyle: started with continous passive a case report and review of mechanism of movement(C.P.M) exercise from 0 to 30 injury. The Internet Journal of Orthopedic degree.Wound inspection done in Day 3 and Surgery. 2008 Volume 14 Number 2. discharged with non weight bearing cruches

ABSTRACT TRUNCATED PT04B Bilateral Proximal Femur Fracture In A Patient With Renal Tubular Acidosis: A Case Report

1Charl Satpal; 1Farid FF; 1A Rusdi; 2H Shahrul 1Department of Orthopaedic Surgery, Hospital Selayang, Lebuhraya Selayang-Kepong, 68100 Batu Caves Selangor, Malaysia. 2Department of Orthopaedic Surgery, Universiti Teknologi Mara Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia

Introduction ions or reabsorb bicarbonate ions1. This results Renal tubular acidosis is a disease that in a state of chronic normal anionic gap involves an accumulation of acid in the body hyperchloremic metabolic acidosis2. Primarily due to failure of renal system to appropriately being a genetic defect, it is also known to be acidify urine. associated with other clinical syndromes such Materials and methods as Lupus, hepatitis, vasculitis and other We are presenting an interesting cases of a 44 autoimmune pathologies1. Historically and years old female patient who sustained closed functionally it has been classified into a group bilateral proximal femur fractures following of four distinctive types based on their initial an alleged trivial fall in a sitting position at discovery and pathological defects2. Majority home due to a presyncopal attack. She is a of the symptoms arise from the chronic state known case of Type 1 Renal Tubular Acidosis of metabolic acidosis and when left untreated (RTA) with multiple episodes of hypokalaemia leads to its complications. RTA type I is more and chronic metabolic acidosis due to poor likely to result in decreased bone compliance. Besides that, she also had a mineralization and growth retardation with previous surgical history of a closed Rickets in children or osteomalacia in undisplaced left neck of femur fracture in adulthood1.Chronic acidosis leads to various 2012 which was internally fixed with 2 processes of bone demineralization. It has also cannulated screws in a different centre. For been suggested that chronic metabolic acidosis this current episode she was treated in our may also affect vitamin D metabolism and the centre and these fractures were internally fixed increased urinary losses of calcium causing with a total hip arthroplasty for the right femur hypocalcemia leads to secondary due to the neck involvement and proximal hyperparathyroidism4. Besides that, bone is a femoral nail for the left femur within the same critical partaker in buffering of excess acid setting. which also contributes to its demineralization3. Results Therefore, the genesis of the resulting The surgery was a successfully done without demineralization cannot be singled out but intra-operative complications. The radiological studies do mention that chronic acidosis as the outcome showed acceptable fixation post main instigating culprit3,4,5. It eventually leads operation. to osteamalacia where patients are at risk of pathological fractures. The patient above had suffered from a pathological fracture due to the multitude of physiology defects occurring due to RTA.

Figure 1: AP Pelvis on presentation

Discussion Renal tubular acidosis is characterized as a syndrome encompassing a group of tubular Figure 2: AP Pelvis at 8 weeks post fixation defects resulting inability to secrete hydrogen

ABSTRACT TRUNCATED PT04C Salvaging Tibial Interlocking Nail Cut Out With In-Situ Plating: A Case Report

P. Sankar; A.Muhamnad; S.Jaswindar; N.Prashant; K.Manoharan Department of Orthopaedic Surgery, Hospital Taiping, Jalan Taming Sari, 34000, Taiping, Perak, Malaysia

Introduction: Discussion: The intramedullary nail has it roots back to Nail cut out in fractures involving proximal the early days of Aztec physicians who used third of tibia is a known complication due to wooden sticks in the medullary canal of the pull of quadriceps tendon via patellar patients with long bone non union. Fast tendon attached to the tibial tuberosity. forward to current setting, Kuntscher Nailing Ideally such fractures may be treated by by Gerhard Kuntscher introduced in the plating or interlocking nail with 2 proximal 1940s paved way for interlocking nail that is screws with or without temporary tubular used currently. Intramedullary nail is plate fixation to maintain reduction prior to currently the prefered method for the insertion of the nail. Here we have a case treatment of long bone fractures¹. where a segmental fracture of tibia which is Nail cut out in proximal third tibia fracture is yet to unite present with proximal nail cut a known complication.Here,we present an out. The method used above was ideal in this alternative method to manage tibial situation as the interlocking nail still served interlocking nail cut out in a segmental tibia its purpose for the distal tibia fracture.With fracture. this relatively simple approach,we were able to maintain reduction and later,achieve Case Report: union. 19 year old male,with no comorbid, alleged motor vehicle accident,presented to the Conclusion: emergency department with open segmental There are various methods to manage a fracture involving proximal and distal third proximal tibia interlocking nail cut out such right tibia,distal third left fibula and left third as revision of interlocking nail or removal of metacarpal bone fracture.He initially the interlocking nail and plating.The purpose underwent wound debridement and above of this case report is to highlight the knee backslab and subsequenty once the alternative approach in managing a proximal initial wound healed, interlocking nail of the tibia interlocking nail cut off in a segmental right tibia and screw fixation of left 3rd fracture tibia which is yet to unite. metacarpal bone. He was discharged well with advice for strict non weight bearing References: ambulation. Eight weeks later, he presented 1. Leung, Kwok-Sui; Kempf, Ivan; Alt, with swelling over the proximal 3rd of right Volker; Taglang, Gilbert; Haarman, leg after undergoing range of motion H. J. Th. M.; Seidel, Hartmut; exercise for his right knee. Patient denied Schnettler, Reinhard (15 February any fall or weight bearing ambulation. X ray 2006). Practice of intramedullary noted proximal tibial nail cut out and the locked nails: new developments in previous fracture was not united. ESR was techniques and applications. within normal range. The patient then Birkhäuser. p. 100. ISBN 978-3-540- underwent open reduction and dynamic compression plating of the proximal tibia 25349-5V with removal of proximal screw of the interlocking nail. During subsequent follow up, noted the fracture has united with good alignment and patient achieved good knee range of motion.

PT04D Concomitant Ipsilateral Fractures Of Proximal And Distal Ends Of The Radius: A Rare Injury

Chung WH; Randhawa SS; Sim SE; Adnan YK; C Sankara Kumar Department of Orthopaedic Surgery, University of Malaya, Lembah Pantai, 59100 Kuala Lumpur, Malaysia.

Introduction: head and dislocating the elbow; and (3) Individual fractures of either proximal or avulsion distal radius are commonly encountered in clinical practice. However, ipsilateral proximal and distal radius fractures are rare. Up to date, only a few cases have been reported.

Materials & Methods: We report a case of a 31 year old lady who Figure 1: Ipsilateral fractures of distal radius sustained closed ipsilateral fractures of the and radial head with posterolateral elbow proximal and distal ends of the left radius. The dislocation and ulnar collateral ligament distal radius was intraarticular and avulsion fracture. comminuted (Melone type II), while the proximal radius fracture involved the radial head (Mason type II), associated with posterolateral elbow dislocation and ulnar collateral ligament avulsion fracture. Immediate reduction was performed. CT scan was performed to delineate the fracture configuration. We performed a volar locking plate fixation to the distal radius first then Figure 2: Radiographs taken at three months followed by miniplating to the proximal after plating proximal and distal radius radius. There was no elbow instability; hence, showed fracture union. the avulsion fracture was not fixed. Assisted active range of motion was commenced of the ulnar collateral ligament. We believed immediately after surgery. that anatomical reduction and stable fixation is crucial in these injuries to allow early Results: rehabilitation though some authors treated Three months after surgery, she regained good them conservatively. range of motion of both elbow and wrist (elbow joint: 135° flexion, -5° extension, 45° Conclusion: supination, 75° pronation; wrist joint: 75° Concomitant ipsilateral fracture of proximal dorsiflexion, 75° palmar flexion). She has and distal radius is uncommon. Great good results (85 points) on Mayo Elbow emphasis should be focused on the clinical and Performance Score. Radiographs showed radiographic examination of the elbow in wrist fracture unions. fractures and vice versa.

DISCUSSION: References: The exact series of events in this injury is not 1. Agarwal A: Ipsilateral fracture of distal and known. It is postulated that the axial loading proximal ends of the radius: Does this injury from a fall on outstretched hand leads to (1) pattern deserve special attention? Eur J Orthop fracture of the distal radius; (2) the elbow is Surg Traumatol (2007), 17:181–187. forced into valgus position, fracturing the 2. Nagaya H, Saito Y, Warashina H: radial Simultaneous ipsilateral fractures of distal and

ABSTRACT TRUNCATED PT05A Outcome Following Surgical Fixation Of Patella Fractures

Rex Premchand, Antony Xavier; Raghunathan, Rangan; Seah Wee Teck, Victor Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828

Introduction: The aim of this study is to assess the outcome of surgical fixed patellar fracture patients, discuss the literature review and discuss about the future plans to improve the outcomes

Methods: Operation theatre electronic data of our hospital was reviewed using the patella fracture ORIF code over a period of 3 years for the patients. Data collection was based on x ray records in the system and clinical Fig 1- Ideal model for patella fracture fixation records. Conclusion: Results: Our complication rate is in line with the recent Demographics: Out of a total 91 patients, 83 meta-analysis. Literature review on patients had at least 1 month follow up (range: biomechanical and clinical studies has 1 month to 2.5 years; mean 7 months ; median suggested the possible advantage of 4 mm 5 months ; mode 4 months), with equal cannulated screw + TBW, + / - cerclage, with distribution of males and females. horizontal figure of 8 model. Alternate Predominant mechanism of injury being materials may have some role in future. mechanical fall (64 patients) followed by RTA (17 patients) and others (10 patients). Closed References: injuries noted in 58 patients, abrasion in 23 1. Dy CJ et al J Trauma Acute Care Surg. patients and open in 10 patients. There is no 2012 Oct; 73(4):928-32. difference noted in outcome with regards to 2. Dargel et al Injury 2010 Feb; 41 (2):15660. sex, mechanism of injury, open or closed 3. Hoshino CM et al. J Bone Joint Surg Am. injury. Analysis of 83 patients revealed that no 2013 Apr 3; 95(7):653-9. difference in outcome whether splint used or 4. Chen CH et al Injury. 2013 Oct; not, as it was decided based on fracture pattern 44(10):1309-13 and stability. Failure of fixation was noted in 18 patients predominantly in comminuted or inferior pole fractures (15 patients). Reoperation was done in 11 patients, majority had either 8, 11 fixation (5 patients) or 0, 8 fixation (4 patients)

Discussions: Based on literature review of clinical and biomechanical results an ideal model of patella fracture fixation, for appropriate and relevant pattern of injuries.

PT05C Contralateral Footdrop Post Intermedullary Nailing Of Femur: A Case Report

Nasruddin AR; Nur Rahimah AR; Felix Y.S Loong Department of Orthopaedic Surgery, Hospital Ampang, Jalan Mewah Utara, Pandan Mewah, 68000 Ampang, Selangor, Malaysia

Introduction: the leg (tibialis anterior, extensor digitorum A foot drop is describes as inability to perform logus, extensor halliucis logus and peroneus a dorsiflexion of an ankle. The foot drop most tertius. Neuropathy of the common peroneal commonly associated with nerve pathology nerves can impaired the function of muscle at specifically sciatic or common peroneal anterior and lateral compartment of the leg and nerves. Post operative contralateral results in foot drop. complication is not common and it is believed There are many factors contribute to common to relate with position of the unaffected leg peroneal nerve neuropathy, including external during operation compression (cast or brace), direct trauma, traction injury, and entrapment in the fibular Materials & Methods: tunnel. In this case direct compression of the We reported a case of 17 years old male who common peroneal nerves extrinsically by the had periprothetic fracture with implant failure calf support and prolonged knee flexion of left femur and was planned for removal of position are the main causes. plate and intramedullary nail. Patient was positioned semilithotomy with the Conclusion: affected side on traction and the unaffected Contralateral foot drop is a known side hanging on calf support with knee in complication after surgery of lower limbs that flexion. The operation was done under CSE involved with traction table and semi and total operation time was 4 hours. lithothomy position.The total duration of On day one post operation, noted patient operation also contributes to the complication. unable to perform ankle dorsiflexion and The complication can be avoided by regular absent of sensation of dorsal surface of release of external compression and reduction unaffected foot. The ankle plantar flexion was of the total surgery time. normal. Treatment for neuropathy is basically observation and neurosupplement medication Results: is essential. Physiotherapy will helps in The patient was observed with ward for 1 maintaining muscle mass and joints range of week and started on T methylcobalt 500mg movement. TDS. He was also referred to physiotherapy for ankle exercise and foot drop splint applied. References: After 1 week observation he regains the 1. Flierl MA, Stahel PF, Hak DJ, Morgan SJ, sensation at dorsum of right foot but the foot Smith WR. Traction table-related drop still present. complications in orthopaedic surgery. J Am Acad Orthop Surg. 2010;18(11):668–75. Discussions: Common peroneal nerves lies between the 2. Tait GR, Danton M. Contralateral sciatic tendon of the biceps femoris and lateral head nerve palsy following femoral nailing. J Bone of the gastrocnemius muscle. It winds around Joint Surg Br.1991;73(4):689–90. the neck of the fibula and divides into the superficial peroneal nerve and deep peroneal nerve. The superficial peroneal nerves innervates muscle at lateral compartment of the leg (peroneous logus and peroneous brevis). The deep peroneal nerves innervated muscle at anterior compartment of PT05D Bicondylar Hoffa Fracture - A Rarely Occurring And Commonly Missed Injury

Randhawa SS; Chung WH; Wong TS; Bong CP; Ling XW; Sankara Kumar C Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia

Introduction functional rehabilitation. Application of 3 Bicondylar Hoffa fractures are a rare cannulated headless compression screws size occurrence and this fracture has implications 4.5mm from the intact anterior cortex to both with regards to preoperative planning, the Hoffa fragments provide rotational stability. choice of surgical approach, implant selection and functional outcomes. Thus far there have only been scant reports of this fracture type. Here we report our experience of a bicondylar Hoffa fracture that was managed using two incisions and successfully treated with headless compression screws.

Materials and Methods A 30 year old lady with no past medical history presented to our emergency Figure 1: AP and lateral radiographs revealing department with pain and swelling of her right a bicondylar Hoffa fracture knee following trauma. Local examination revealed a painful and swollen right knee with restricted range of motion. Radiographs revealed distal end femur fractures but were inadequate, whereby CT scans performed established the diagnosis of a right bicondylar Hoffa fracture. Open reduction and internal fixation were performed with cannulated cancellous screws that were passed from anterior to posterior direction through the Figure 2: Radiographs taken at 3 months nonarticular part under fluoroscopy control. postoperatively Assisted active range of motion exercises were begun immediately after surgery. Conclusion Coronal fractures of the femoral condyles are Results uncommon injuries that require a high index She achieved a speedy recovery post of suspicion. A dual incision with anterior to operatively and was able to partial weight bear posterior headless compression screws is our at 6 weeks. Radiographs at 6 weeks and 3 preferred method. months revealed evidence of fracture healing. Range of motion of her knee was 10- 110 References degrees at 3 months. 1. S. L. Lewis, J. L. Pozo, and W. F. G. Muirhead-Allwood, “Coronal fractures of the Discussion lateral femoral condyle,” Journal of Bone and Hoffa fractures can often be missed on plain Joint Surgery B, vol. 71, no. 1, pp. 118–120 radiographs. This necessitates a CT scan. 2. R. Ul Haq, P. Modi, I. Dhammi, A. Jain, Management of Hoffa fractures is essentially and P. Mishra, “Conjoint bicondylar Hoffa surgical with open reduction and internal fracture in an adult,” Indian Journal of fixation as suggested by most authors. We Orthopaedics, vol. 47, no. 3, pp. 302–306, prefer to do a meticulous anatomic restoration 2013 of the joint and firm stabilization of the condylar fragments. This allows early PT06A A Rare Case Of Floating Elbow Injury In Adolescent

Raghavan, S; Kamarulzaman MS Kadir Department of Orthopaedics, Hospital Tengku Ampuan Rahimah, 42100 Klang, Selangor Malaysia

Introduction: compartment syndrome (1). Management has Floating elbow is an uncommon yet severe evolved from conservative to operative injury of the upper limb in children. Stanitski treatment over the years, with 100% non union and Micheli introduced the term ‘floating rate with non rigid fixation (2). All authors elbow’ to describe the injury pattern of have emphasized the complexity of these ipsilateral supracondylar humerus and forearm injuries and the potential unpredictable long- (3) axis fractures that ‘disconnect’ the elbow from term functional results . In this case we the remaining limb in children (1). The injury opted for early internal fixation as it has commonly involves a supracondylar humerus shown to allow early mobilization and hence fracture with ipsilateral distal third forearm better functional outcome. fractures. In this case report, we report an adolescent boy with a combination distal Conclusion: humerus fracture and proximal third radius Early recognition and treatment is paramount and ulna fracture, a much rarer subgroup of to provide pain relief and prevent floating elbow injuries. complications. Management mostly involved internal fixation however there is no Methods: consensus in the literature on the methods. We We report a case of a 14 year old Malaysian thus believe treatment modality should be boy who was involved in a motor vehicle individualized based on patient age and accident. X-rays showed a supracondylar fracture patterns. humerus fracture with intercondylar split and ipsilateral transverse fractures of proximal References: third radius and ulna. Patient also sustained 1. Stanitski CL, Micheli LJ. Simultaneous open fracture of right 1st to 5th metatarsal neck. ipsilateral fractures of the arm and forearm His injuries was stabilized with a long arm in children. Clin Orthop Relat Res slab and below knee slab and planned for 1980;153:218-22 operation the following day. 2. Rogers JF, Bennett JB, Tullos HS. Results: Management of concomitant ipsilateral Patient was taken to theatre on day 1 of injury fractures of the humerus and forearm. J however during induction, patient developed Bone Joint Surg Am 1984;66:552-6. malignant hyperthermia hence the procedure was abandoned. Once stabilized, patient 3. Simpson NS, Jupiter JB. Complex fracture underwent plating of right radius and ulna patterns of the upper extremity. Clin with small DCP plates and the metatarsal Orthop Relat Res 1995;318:43-53. fractures fixed with Kirschner wires. We also did open reduction and double recon plating of the suparacondylar humerus fracture with screw fixation of the intercondylar split. Intraoperatively, we also noted that there was an undisplaced olecranon fracture for which we did a .

Discussions: Floating elbow injuries in children results from high energy trauma. This carries high incidence of soft tissue injury such as open fractures, neurovascular injury and PT06B Bywaters’ Syndrome Exacerbated by Alcohol Intoxication: A Case Report

1Ramesh M, 2Surekha K, 1Suresh A, 1Anna R, 1Nisha T, 1Firatul A, 1Asyraf W 1Department of Orthopaedic Surgery, Hospital Tuanku Ampuan Najihah, 72000, Kuala Pilah, Malaysia 2Department of Emergency Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia

Background: compressed limb in a tight bandage for long Bywaters’ syndrome or traumatic hours can worsen the Bywaters’ syndrome. rhabdomyolysis was first described after the Central venous line (CVL) should be inserted Battle of London by Bywaters and Beall in to all crush injury patients followed by 1941. It refers to the damage resulting directly aggresive resuscitation with i.v. fluids to from the crushing force over the soft tissues, prevent Bywaters’ syndrome complicated with principally skeletal muscle. Rhabdomyolysis renal failure unless contraindicated. results in increased permeability of the cell membrane and release of potassium and Table 1. Investigations Performed myoglobin from within cells leading to acute tubular necrosis and uremia. Nontraumatic Items Day 1 Day 3 Day 6 exertional and nontraumatic nonexertional are WBC 8.9 10 11.6 other potential causes of rhabdomyolysis. In Urea 5.5 8.4 26.9 many cases of alcohol-related nontraumatic Creatinine 77 128 690 rhabdomyolysis reported in the literature, K+ 3.3 3.9 4.5 patients have typical history of short-term Total CK 1270 36210 136800 alcohol intoxication and alcohol-induced coma. Prolong immobilisation causes muscle compression and ischemia which will accelerate alcohol-induced myotoxicity.

Objective: To access the severity of the clinical manifestation in patient presented with multiple causes of rhabdomyolysis.

Case Report: The left hand of a 32-year-old alcohol intoxicated patient was crushed between steel and rubber rollers. Meticulous debridement of all devitalised tissue was done. Creep bandage was applied around the debrided limb. Crush injury subsequently developed into crush syndrome. On day 3 of admission, noted deterioration of kidney function hence, aggressive fluid resuscitation was initiated followed by multiple haemodialysis. A below elbow amputation was done in view of worsening of the wound after initial wound debridement.

Conclusion: Physicians should have high index of suspicion to make an early diagnosis of rhabdomyolysis in crush injury and alcohol intoxicated patient. Alcoholic patient with PT06C Case Study: Modified Dimon- Hughston Osteotomy With Proximal Femoral Locking Plate For Unstable Intertrochanteric Femur Fracture

Khaw YC; Or SY; Ong TK; A. Aziz Y Department of Orthopaedic, Hospital Seberang Jaya, Jalan Tun Hussein Onn, Seberang Jaya, 13700 Pulau Pinang, Malaysia.

Introduction: Figure 1: Majority of intertrochanteric (IT) femur Severely fracture occurs in women age 50 years and 1a 1b comminuted above. These fractures are usually due to low left IT energy falls from standing height. Unstable IT femur femur fracture is a challenge to manage as fractureFigure 2: comminution over the posteromedial cortex Post- will cause the fracture site to collapse into operative varus and retroversion upon weight bearing. 2a 2b X-ray The treatment aim is to obtain rigid and stable fixation. This would enable patient for earlier ambulation and return to their prefracture level Discussions: of function without long term disability. There is a dilemma in deciding on surgical Materials & Methods: treatment for patient with mental challenge. A 53 year old, mentally challenged lady with Total hip replacement is not suitable as high an unstable comminuted left IT femur fracture risk of dislocation due to poor compliance. (AO Classification 31-A2.3) was selected for Modified Dimon-Hughston osteotomy was this case study. Patient sustained injury due to used as medial cortical contact to obtain more a trivial fall in bathroom 2 weeks prior to stable fixation & provide valgus realignment. presentation. Due to unstable nature of the Loose bony fragments were left in situ as fracture & late presentation, modified Dimon- autologous bone graft. Synthetic bone graft Hughston osteotomy and left proximal femoral was used to fill up the fracture site which had lockplate was used to fix the fracture. Patient extensive bone loss at lateral cortex. Proximal was follow up for a year post operatively. femoral locking plate was used to replace Results: lateral cortex stabilizer, by acting as a fix At 2 months post operation, patient was angled internal fixator to achieve more stable allowed for partial weight bearing ambulation. fixation. Hip abductors were tied to the Patient was able to full weight bear and walk proximal femoral locking plate by non- with walking frame at 3 months post absorbable sutures, so that patient able to operation. 5 months after the operation, patient perform hip abduction. was able to walk independently without any Conclusion: support. However patient has a limping gait Modified Dimon-Hughston osteotomy with due to the limb length discrepancy. On proximal femoral lockplate is an effective & examination, left lower limb was shorter by 4 alternative surgical treatment for unstable cm. Left hip active range of motion: comminuted IT femur fracture. Abduction 0˚-45˚, Adduction 0˚-45˚, Flexion References: 0˚-90˚, Extension 0˚-15˚, Internal rotation 0˚- 1. Thomas A Russel.Intertrochanteric 20˚, External rotation 0˚-30˚. Latest X-ray Fractures. Rockwood & Green’s Fractures in shows that callus has formed & fracture is adults, vol 2, 7th ed. 1598-1637 united. Harris Hip Score for this patient at 1 2. David G. LaVelle. Hip Fractures. year post operation is good (80 points). Campbell’s Operative Orthopaedic, 11th ed, 3237-3241

PT07A Retrograde Femoral Nailing In Femoral Segmental Fracture Involving Subtrochanteric And Supracondylar Regions: A Case Report

Chuah S.K; Jesslyn Lim; Mikhail Raj; Kishan Rao; Ashwini Sood Department Of Orthopaedics, Hopital Kulim, Jalan Mahang, 09000 Kulim, Kedah, Malaysia

Introduction: various implants. These techniques carry Interlocking nailing (ILN) is a gold standard for disadvantages of extensive surgical exposure, treatment of femoral shaft fracture. There are soft tissue damage, more blood loss, higher two methods of locked intramedullary nailing: non-union and implant failure rate. Whereas, antegrade and retrograde. With the different intramedullary nailing devices have more locking possibilities and entry points, ILN has biological and mechanical advantages, such as: extended the indication to include metaphyseal ˗ without periosteum stripping, hence retain fracture, such as subtrochanteric and blood supply supracondylar fractures. ˗ fracture hematoma not disturbed ˗ less operative blood loss Materials And Methods: ˗ load sharing device We report our experience of a 16 years old boy ˗ allow immediate weight bearing who was treated in district hospital. He had mobilization motor vehicle accident with closed transverse subtrochanteric fracture of left femur with Conclusions: ipsilateral open comminuted supracondylar Retrograde femoral nailing can be a good and fracture(Gustilo IIIA). On day 1 of trauma, time saving option for simple femoral wound debridement and crossed left knee metaphyseal fracture at district hospital. It does external fixation was done. Followed with left not require traction table and is less surgical tight unreamed retrograde femoral nailing(RFN) skill demanding. On top of that, RFN also on day 8. Left RFN inserted percutaneously carries superior biological and mechanical through the knee at anterior tip of Blumensaat’s advantages as compare to extramedullary intercondylar roof line in the middle of devices. However, careful fracture assessment intercondylar notch under x-ray image and patient selection is crucial in this technique. intensifier. Hollow reamer and tissue protector were used. Only 2 distal locking screws were References: fixed with tip of RFN penetrated out through 1. Giddie J, Sawalha S & Parker M (2015) piriformis fossa with gentle malleting. Total Retrograde nailing for distal femur fractures operative duration is 2 hours 01minutes. A long in the elderly. SICOT J, 1, 31 Targon RFN was used with closed reduction. 2. M Wani, M Wani, A Sultan, T Dar. Subtrochanteric Fractures- Current Results: Management Options. The Internet Journal Fracture union achieved at day 86 for closed of Orthopedic Surgery. 2009 Volume 17 subtrochanteric fracture of left femur and at day Number 2. 172 for ipsilateral open comminuted 3. Chakraborty M.K., Thapa P. Fixation of supracondylar fracture(Gustilo IIIA) by Subtrochanteric Fracture of the Femur: Our evidence of check X-ray with presence of Experience Journal of Clinical and bridging callus across 3 cortices. At eleventh Diagnostic Research. 2012 February, Vol- month post-trauma follow up at clinic, left hip 5(9): 76-80 and knee are pain free with ability of full squatting. Left femoral shortening of 2cm.

Discussions: The treatment of femoral metaphyseal fractures were mainly focus on ORIF by using

PT07B

A Rare Scapula Fracture Associated With Acromion Fracture: A Case Report

IM, Azahari; A, Ahmad Tajudin Department Of Orthopedic, Hospital Sultanah Nur Zahirah, Jalan Sultan Mahmud, 20400 Kuala Terengganu, Terengganu, Malaysia

Introduction: Acromion fracture of scapula are rare condition and usually associated with ipsilateral glenoid, neck or body of scapula fracture. Majority of cases either undisplaced or minimally displace. Non operative treatment was performed. We reported a case of undisplaced acromion fracture associated with glenoid fracture treated non operatively.

Figure 2: Radiograph at 2 month post Case Report: trauma show united acromion and glenoid A 79-year-old man admitted to ward for mild fracture head injury following a Motor Vehicle Accident (MVA). The mechanism of injury Discussion: was direct blow of the right shoulder on the Acromion fracture is very rare condition. road during MVA. Examination showed Scapula fractures account for only 1% of all minimal bruises and tender over tip of right fractures. In patients that present with a shoulder with limited movement of the scapular fracture, body and spine are involved shoulder. Neurovascular examination was in 50 %, the scapular neck (25%), glenoid intact. Right shoulder radiograph (Figure 1) fossa (10%), and the acromion and coracoid show minimally displaced acromion fracture process (7%) [1]. This low incidence of and glenoid fracture of the scapula. Patient scapular fractures may be due to its thickened was treated non operative with arm sling and edges, its great mobility with recoil, and its regular analgesic. position between muscle layers [2]. The vast majority of acromial fractures are non- displaced or minimally displaced, and respond well to initial symptomatic treatment. Operative treatment is recommended for substantive displaced acromion fractures with subacromial space narrowing, painful stress fractures, or nonunion with pain and dysfunction[2].

Conclusion: Figure 1: radiograph show undisplaced Undisplaced acromium fracture are rare acromion fracture with ipsilateral glenoid condition which can be treated non operative fracture, with normal subacromial space with satisfactory result and good shoulder motion. Patient was review at clinic at 1 month after discharge. There were no more tenderness References: over the fracture site and range of motion 1. Zuckerman JD, Koval KJ, Cuomo F (1993) much improved. Good shoulder motion and Fractures of the scapula. Instr Course Lect bony union without displacement were 42:271–281 achieved at 2 month. 2. Hardegger FH, Simpson LA, Weber BG (1984) The operative treatment of scapular fractures. J Bone Joint Surg Br 66(5):725–731 PT07C Lengthening Of Ulna By Ilizarov Technique In Hereditary Multiple Exostosis

Thinesh VS; Kularaj S; Ramesh NA; Abdul Rauf HA Department Of Orthopaedics, Hospital Tuanku Ja’afar Jalan Rasah, 70300 Seremban, Negeri Sembilan, Malaysia

Introduction: range of pronation. Patient was put on Plaster Hereditary multiple exostosis is an autosomal of Paris for consolidation of ulna. dominant type of developmental anomaly characterized by metaphyseal protrusions of cartilage-capped bone. Exostoses are usually seen around the joints and cause various deformities of the epiphysis. 30% to 60% of patients with hereditary multiple exostosis have deformities of forearm. Exostosis in the distal ulna causes relative shortening of ulna, ulna tilt at wrist joint, bowing of either or both of the forearm Figure 1: Comparing bilateral forearms bones, cubitus varus, dislocation of head of and X rays before operation radius and translocation of carpus towards the ulna. These deformities affect radial deviation and pronation- supination movement of forearm. They may be cosmetically disturbing and may undergo malignant degeneration to chondrosarcomas. Surgical treatments in the past include excision of the exostoses, radial shortening, stapling half of the distal radial epiphysis and resection of dislocated radial head. Figure 2: Post-operative 10 weeks with Distraction lengthening of ulna using Ilizarov Ilizarov fixation and gradual correction technique is another surgical option available to correct forearm deformities. Discussion: Exision of exostosis and distraction Case Report: osteogenesis of ulna using Ilizarov technique A fifthteen year old boy with underlying has given satisfactory results and is an hereditary multiple exostosis presented with effective method of treating complex forearm worsening deformity of left forearm and deformities in patients with hereditary limitation of pronation. Examination findings multiple exostosis. include bowing of left radius, cubitus varus, Ilizarov technique improves the deformity by loss of radial deviation at wrist and pronation normalization of the relationship of the radius range of 30° with instability of radial head. and ulna. Thus, stability of wrist and elbow The X- ray showed radius articulating angle joint, movement of forearm, cosmetic and was 40°, Carpal slip was 71%, ulnar radiological appearance is all improved. shortening was 20mm and widened proximal Excision of exostosis or resection of radial radio-ulnar joint. head alone is not useful in suppressing the Intraoperatively, the range of pronation progression of the deformity of forearm. increased to full after excision of the Meanwhile, radial hemi-epiphyseal stapling exostosis. Ilizarov fixation was applied to the with or without ulnar lengthening has been ulna. The correction was started at the rate of effective but causes shortening of the forearm. 1mm per day after a waiting period of 14 days. Ilizarov technique gives high satisfaction to The ulna was lengthened 40mm. Ilizarov the patients because it improves the fixation time was 120 days. At the most recent appearance and function of upper extremity. follow up, patient was pain free and unlimited ABSTRACT TRUNCATED PT07D Case Study: A Rare Case Of Traumatic Lateral Dislocation Of The Elbow

Mustapa Nadia; Rifa AS; Vincent, J; Danappal, S; Karrupiah, V Department of Orthopaedic Surgery, Hospital Tengku Ampuan Rahimah, Jalan Langat, 41200, Klang, Selangor, Malaysia

Introduction: Discussion: Dislocation of the elbow joint is a common This rare variant of elbow dislocation is the injury however an isolated lateral dislocation outcome of an extensive soft tissue damage. In of the elbow joint is a rare encounter. In view view of the extent of damage to the soft tissue, of the rarity of this variant of elbow joint an easy CMR is anticipated. However, dislocation, the manoeuvre for closed difficulties are often encountered during CMR manipulative reduction (CMR) has yet to be due to soft tissue interposition. fully established. Among those few rare cases seen, most has ended up with an open In the paediatric age group, an avulsed fracture reduction following an unsuccessful CMR. fragment is a more common cause of failed This case illustrates a rare case of pure lateral CMR. dislocation of the elbow. The challenges and difficulties encountered in approaching this Conclusion: particular case are discussed. A CMR done under controlled environment may be successful however an open reduction Case Summary: must always be anticipated in view of high A 47 year old year old gentleman was incidence of soft tissue interposition. involved in a motor vehicle accident. He was a motorcyclist who fell off his motorcycle and References: had a direct trauma/impact to his right elbow 1. E. J. Exarchou (1977) Lateral dislocation upon landing. He received frontline treatment of the elbow, Acta Orthopaedica 2 hours post trauma where it was found that Scandinavica, 48:2, 161-163 his right elbow was swollen and deformed. His 2. Sameer K Khan Successful CMR of pure forearm was in mid pronation and had a slight lateral traumatic dislocation of the elbow varus deformity. joint using modified Stimson’s technique: A case report, J Med Case Reports. 2008; Radiographs and CT scan of the elbow 2: 170. showed a pure lateral dislocation of the elbow without any fractures. A closed manipulative reduction was attempted under sedation in the emergency room however it was unsuccessful. Patient was not fully relaxed and was still able to resist the traction applied. Subsequent attempt of CMR under general anaesthesia was successful. Slight traction was applied and the forearm was manipulated into full pronation. Following this, pressure was applied directly over the head of radius to allow successful reduction. The upper limb was then immobilized with an above elbow backslab. Post CMR the elbow was unstable however patient has refused any other intervention other than the CMR and has opted for traditional and complementary medicine PT08A Long Segment Bone Loss! – Teluk Intan Experiences

Thanesh A.; Shukur A.; Sharifudin S. Hospital Teluk Intan, Jalan Changkat Jong, 36000 Teluk Intan, Perak, Malaysia Perak Darul Ridzuan

Introduction Long segment bone loss needs either a long segment cortical bone graft or Iliazarov bone transport. Bone transport offers an exciting new treatment alternative for the difficult segmental bone loss. This case study meant to share experiences regarding long segment bone loss treated with Illiazarov bone transport technique and the complication arise.

Case We present a case of a 40 years old woman, with history of open fracture tibia and fibula grade 3a that was treated with wound debridement and external fixator. It was complicated with long segment osteomyelitis whereby sequestrectomy was done leaving behind a 700 mm of bone loss and later proceed with Illiazarov bone transport. A few problems occur with this type of management. Main complication was long segment soft tissue collapse with impending bone protrusion through skin. The problem was treated with cement spacer and overhanging suture (new suture technique to support soft tissue collapse). The other problem was equinus deformity that was treated with percutaneous archilles tendon tenotomy. Currently, docking site are well united and waiting for the whole segment to consolidate.

Conclusion Long segment bone transport can be considered as problem of soft tissue and bone. Any complication must be tackled as early as possible to prevent further morbidity to patient.

Reference 1. Prokuski LJ, Marsh JL, Segmental bone deficiencyafter acute trauma: The role of bone transport. The Orthopedics of North America, 1994,25(4):753-763 PT08B Percutaneous Bone Marrow Grafting For Large Bony Defect. A Case Report

YK Lee; MR. Ab Razak; Z. Ab Zawawi; S. Shafei Department Of Orthopaedic, Hospital Kuala Krai, 18000 Kuala Krai, Kelantan, Malaysia

Introduction: union/delayed union fracture with a large bone Massive diaphyseal bone defect cause by defect. However, patient selection is a key trauma, infection, congenital deformity and factor for the best treatment option. malignancy are common and present a formidable challenge to orthopedic surgeon. In References: most cases, restoration of alignment and stable 1.Connolly JF, Guse R, Tiedeman J, Dehne R. fixation of the bone is all that necessary to Autologous marrow injection as a substitute achieve a successful reconstruction. for operative grafting of tibial nonunions. Clin This report highlights a case of large bony Orthop 1991; 259—70. defect treated with a less invasive technique 2. Lindholm TS, Urist MR. A quantitative call Percutaneous Bone Marrow Grafting. analysis of new bone formation by induction in composite grafts of bone marrow and bone Case Report: matrix. Clin Orthop 1980; 150:288. Our case was a 19-year old boy who involved 3. Paley D, Young MC, Wiley AM, Fornasier in a motor vehicle accident and sustained an VL, Jackson RW. Percutaneous bone marrow open fracture mid-shaft right tibia and grafting of fractures and bony defects. An supracondylar fracture with intercondylar split experimental study in rabbits. Clin Orthop of right femur. He was treated with wound 1986; 300—12. debridement and external fixator of femur and 4. Phemister DB. Treatment of ununited tibia. After a few months post operation, fractures by onlay bone grafts without screw external fixator of femur was removed but was or tie fixation and without breaking down of kept further for tibia. the fibrous union. J Bone Joint Surg 1947; After six month post trauma, his tibial fracture 29:946–53. shown no sign of union. Then, he was 5. Charnley J. The Closed Treatment of arranged for percutaneous bone marrow Common Fractures, 3rd ed. Edinburgh: injection. A total of 2 injections with 6 weeks Churchill Livingstone, 1974:205–40. interval were done. 6. Hernigou P, Mathieu G, Poignard A, A regular follow up was done under an Manicom O, Beaujean F, Rouard H. orthopaedic surgeon in charge to monitor Percutaneous autologous bone-marrow healing progression. grafting for nonunions. Surgical technique. After serial radiographic monitoring, the bony J Bone Joint Surg Am 2006; 88(Suppl. 1 defect area was markedly increase in bone (Pt2)):322–7. density, and patient almost tolerate full weight 7. Hernigou P, Poiguard A, Beaujean F, bear after 2 months of injection. Rouard H. Percutaneous autologous bone marrow grafting for non-unions influence of Discussions: the number and concentration of progenitor Percutaneous bone marrow grafting can cells. J Bone Joint Surg Am 2005; provide similar biological response to assist 87(7):1430–7. fracture union. It appeared to be as effective as open technique and possessed considerable advantages. Overall, it is safe, time saving, economical and more important it’s cause a minimal trauma to the fracture site as well as donor site morbidity.

Conclusion: Percutaneus bone marrow injection is one of the treatment option in dealing with non PT08C Percutaneous Bone Marrow Aspiration And Grafting For Delayed And Non Union Long Bone Fracture – A Case Series

YK Lee; MR. Ab Razak.; Z.Ab Zawawi; S.Shafei Department Of Orthopaedic, Hospital Kuala Krai, 18000 Kuala Krai, Kelantan, Malaysia

Introduction: fracture union was developed for further Delayed or non-union fracture is a common evaluation on the effect of it. complication following long bone fracture. We recognized that our study is lack of sample There are various factors that influence union as well as our criteria to justify union are such as inadequate biomechanical stability and based on clinical and radiological assessment. biological response. An autologous bone Eventhough CT scan is a good modality to grafting is a basic treatment that widely use confirm a fracture union, it is not routinely worldwide. However, an open technique of done due to it’s cost and radiation exposure. bone grafting always accompanying with high risk of complications such as infection and Conclusion: donour site morbidity. To minimize those An open technique cancellous bone grafting is complications, a less invasive technique – a gold standard treatment in a delayed/non- Percutaneous Bone Marrow Grafting is union fracture. However, we still highly introduce as an alternative of treatment. recommend percutaneous bone marrow grafting as an option of treatment due to least Methods: invasive techniques, safe and an effective Total five patients were included from January method. 2015 to December 2015. All patient were diagnosed to have non-union long bone References: fracture regardless closed or open fracture 1. Paley D, Young MC, Wiley AM, Fornasier with/without fixations. Those patient was VL, Jackson RW. Percutaneous bone marrow scheduled for bone marrow injection after grafting of fractures and bony defects. An consent been taken. A total of 15cc bone experimental study in rabbits. Clin Orthop marrow was injected to the fracture site and 1986; 300—12. followed by cast application. Serial X-ray 2. Hernigou P, Mathieu G, Poignard A, were taken to monitor the union progress . Manicom O, Beaujean F, Rouard H. Percutaneous autologous bone-marrow Results: grafting for nonunions. Surgical technique. Bone union following percutaneous bone J Bone Joint Surg Am 2006; 88(Suppl. 1 marrow injection was achieved in four cases. (Pt2)):322–7. One case showing non union. There were no 3. Hernigou P, Poiguard A, Beaujean F, infection as well as other complications from Rouard H. Percutaneous autologous bone the donor and recipient site reported. marrow grafting for non-unions influence of the number and concentration of progenitor Discussions: cells. J Bone Joint Surg Am 2005; Numerous bone substitutes was advocated for 87(7):1430–7. the treatment of delayed union and non-union long bone fracture. An open technique of cancellous bone graft is commonly applied due to it biological properties . Bone marrow aspiration has been shown to contain osteoprogenitor cells and osteoinductive but no osteoconductive properties. It was started by Paley D in 1986 from his experimental study. Afterward, multiple research regarding bone marrow for PT08D A Rare Case Of Traumatic Floating Clavicle

Lee.HS; Vicknesh A Hospital Keningau, Peti Surat, 11, 89007 Keningau, Sabah, Malaysia

Introduction clavicular joints(Fig three). At 6 months post- Simultaneous dislocation of both ends of the surgery, he showed no signs of arthritis and clavicle is a rare injury. Also known as has since successfully returned to his previous panclavicular or bipolar clavicular dislocation, job. it is generally related to high velocity trauma on to the shoulder. While the best treatment for this injury still remains controversial, conservative therapy is the mainstay of treatment. We present a unique case of this injury of a young man following a blunt force trauma to his left shoulder which was successfully treated surgically.

Case A 32 year-old construction worker was hit by a fallen large tree branch on his left shoulder. He sustained a left acromioclavicular joint(ACJ) dislocation (Rockwood Type IV) with concomitant left sternoclavicular Discussion joint(SCJ) antero-superior dislocation and left Floating clavicle can be managed by either 2nd rib fracture. The injury (Fig.one) was conservatively or surgically depending on age, treated conservatively with arm sling and symptoms and demand of joint. However, physiotherapy. Unfortunately he presented there is lack of study in proving the gold with persistent left ACJ pain and deformity standard due to the rarity of the injury.Surgical associated with reduced range of movement of modalities include hook-plate, Mersilene-tape, shoulder. Plain radiograph showed persistent anchor suture and k-wire. In our case, K-wire dislocation. Hence surgery was done on him. was the choice of implant due to financial constrain. Ultimately all post surgery patients must do physiotherapy to achieve good functional outcome and prevent joint stiffness.

Conclusion Floating clavicle can be easily missed and is a potentially disabling injury. The treatment of choice depends on symptoms and functional

demand of patient. Methods Incisions were made over both clavicle ends. Reference Reduction was achieved and stabilized with 1)Arenas AJ, PamPliega.T, Iglesias,J. Surgical 2.0mm Kirschner wires under fluoroscopic management of bipolar clavicular dislocation. control(Fig.two). Wires were removed at Acta Orthopaedica Belgica. 1993; 59(2): 202- 6weeks post surgery. Patient was referred for 5 physiotherapy. Follow-ups revealed normal 2)Choo CY, Wong HY, Nordin A. Traumatic and painless shoulder movement. He was able floating clavicle:A case report. MOJ 2012. to perform cross arm adduction. There was no 6(3): 57-9 ACJ and SCJ tenderness and he continued to 3)Gearen PF, Petty W. Panclavicular show good reduction on both ends of dislocation. Report of a case. J Bone Joint Surg Am. 1982; 64(A): 454-5 PT09A Luxatio Erecta: Understanding Its Unique Features, Mechanisms And Two-Step Reduction Maneuver

SM, Faisal Amir; M, Kartinawati Department Of Orthopaedic, Hospital Sultanah Nur Zahirah, Jalan Sultan Mahmud, 20400 Kuala Terengganu, Terengganu, Malaysia

Introduction: The unique characteristic of inferior shoulder dislocation (luxatio erecta) was first described in 1859. The incidence of luxatio erecta has been estimated to be 0.5% of all shoulder dislocations.

Case Report: A 25 year-old gentleman was referred from district hospital for right upper limb injury following a Motor Vehicle Accident (MVA). Figure 2: Inferiorly dislocated right shoulder Patient sustained painful right shoulder and joint (Luxatio erecta) inability to lower his elevated right arm. Patient presented with unique attitude of Discussions: abducted right shoulder, flexed elbow, There are two mechanisms proposed for pronated forearm with hand resting near his luxatio erecta – indirect and direct. Indirect head (Figure 1). No neurovascular injury mechanism, which is more common, occurs in seen. hyperabducted limb so that the proximal part of humerus is levered over acromion. Direct mechanism on the other hand occurs with direct axillary loading force in fully abducted limb.

This entitiy is usually treated with overhead traction-counter traction method. However, Nho et al. in 2006 described a specific two- step reduction maneuver that involves converting the inferior to anterior dislocation Figure 1: Unique clinical features – abducted before reduction to its anatomic position1. shoulder, flexed elbow and hand resting near patient’s head Conclusion: Luxatio erecta has distinctive clinical Radiographic examination showed inferior appearance in which failure to recognize this dislocation of right humeral head with respect appearance could lead to incorrect diagnosis, to the glenoid fossa with small fragment incorrect reduction technique and possibly avulsion of greater tuberosity (Figure 2). lead to neurovascular injury.

Closed manipulative reduction was done using References: two-step reduction maneuver. The luxatio 1. Nho SJ, et al. The Two-Step Maneuver for erecta was first converted to an anterior Closed Reduction of Inferior Glenohumeral dislocation. The second step reduced the Dislocation (Luxatio Erecta to Anterior anterior dislocated humerus into glenohumeral Dislocation to Reduction). J Ortho Trauma. joint as usual method. Subsequent radiograph 2006; 20:354-7. revealed anatomic reduction. PT09B Case Series: A Modified Judet Approach To The Scapula In Floating Shoulder

SC Ho; CL Ooi; KS Ong; Zulkiflee O Department of Orthopaedic Surgery, Hospital Pulau Pinang, Jalan Residensi, 10450 George Town, Pulau Pinang, Malaysia

Introduction: Results: Floating shoulder with displaced ipsilateral Patients wound healed in 2 weeks. Able to fractures of the clavicle and the glenoid neck have active full range of motion over affected are a complex injury pattern that is usually the shoulder at one month post operation. result of high-energy trauma. It is an unstable injury which indicated for stable fixation and hence early rehabilitation. Operative treatment of scapula fractures is uncommon. Judet approach has been the standard approach for scapula and is excellent in exposing infraspinatus fossa, but this approach would potentially lead to atrophy of infraspinatus muscle due to dissection of infraspinatus muscle. We describe a modified Judet approach in 3 patients who had floating shoulder. This modified Judet approach has minimal trauma to rotator cuff musculatures by limiting muscular dissection, by following muscular planes, which can potentially Discussions: improve rehabilitation and limit morbidity of The modifications of this approach are smaller the operation. skin incision, with a vertical skin incision instead of boomerang skin incision along the Methods: scapular spine and the medial border, and the Open reduction and internal fixation of infraspinatus muscle is not dissected out of the clavicles were done for all 3 patients before scapular fossa. This modified approach has we re-position patients to lateral. Description the benefit of preserving the rotator cuff of the approach: Vertical lateral skin incision musculature. However this approach might not starting 2cm distal to tip of the acromion suitable for fracture patterns involving posteriorly and proceeds towards the scapular displacement of the scapula spine, medial angle parallel to the lateral border of the border of the scapula, or anterior articular scapula. Inferior border of deltoid muscle involvement of the glenoid. identified and reflected superiorly. Interval between infraspinatus and teres minor muscles Conclusion: identified and split, retracted superiorly and Operative stabilization of floating shoulder is inferiorly respectively to expose the lateral important for early rehabilitation and yield margin of the scapula. Reduction of glenoid good clinical results. Modified Judet approach articular fracture can be verified with posterior is a good option enabling fixation of lateral arthrotomy and intraoperative fluoroscopy. border of scapula and glenoid from posterior. Fracture reduction is facilitated by the insertion of K-wires. Reconstruction lockplate is placed along the lateral border of the scapula. Subcutaneous tissues and skin were then closed.

PT09C Kickstand Modification External Fixation For Impending Open Distal Tibia Spiral Fracture

LT, Ling; TS, Tan; YD, Wong; YH, Foo Department Of Orthopaedic & Traumatology, KM 5 1/2, Jalan Ulu Oya, 96000 Sibu, Sarawak, Malaysia

Introduction: Skin necrosis from impingement at the fracture site is devastating complication in distal tibia fracture which converts a closed fracture to open fracture. We describe a case of closed fracture distal left tibia with impending skin necrosis whose skin condition Figure 1 Figure 2 improved after application of kickstand Discussions: modification over spanning external fixator. The true direction of the displacement of the proximal tibia fragment in relation to the distal Case Report: fragment is always medial and anterior – due Patient is a 46 years old gentleman sustained to interosseous membrane avulsion/ tear1. The closed fracture of left distal 1/3 tibia/fibula, displacement may be worsened by inadvertent laceration wound over the dorsal aspect of left loading of limb while in cast or even external foot with extensor tendon cut and open fixator and causing skin necrosis as in our th metatarsal. He was planned fracture left 4 patient. Study regarding the benefits of for distal tibia anterolateral locking kickstand modification external fixator mostly compression plate and fibula plating. 2 to prevent decubitus calcaneal ulcer , we However there was skin tenting over the modified it for pressure relieving from anteromedial shin at fracture site with displaced fracture fragment Outcome in our impending skin necrosis. Emergency patient was promising. The diagram 1 below spanning ankle external fixation was done. explains the principle of pressure relief to the However, skin condition worsened due to skin. inadequate pressure release. Kickstand Skin modification was applied onto the external Proximal Distal fixator. Clinically improvement over the skin tenting area noted after kickstand modification Skin external fixator application. Definitive internal fixation was done after one week. Proximal Distal (Act as lever) Technique: The kickstand is added to distal part of an Diagram 1 external fixator which act as a lever to reduce Conclusion: the pressure onto the overlying skin. Kickstand modification external fixator is To build a kickstand 3 additional rods and 4 simple and quick to apply. It improves skin rod to rod clamps are needed. tenting from displaced fracture fragment of 1. Short rod is connected vertically to distal tibia, and hence avoid complication of both sides of calcaneal pin skin necrosis. 2. Another longer rod is connected to References: both short rod 1. Bostman O.M. Spiral Facture of the 3. The longer rod is place on the Bohler shaft of the tibia; initial displacement Braun frame (as shown in figure 1,2) and stability reduction; J Bone Joint Surg 1986:68-B:462-466. 2. Oscar E, Jay H. The Use of a Kickstand Modification for the

ABSTRACT TRUNCATED PT10A Ossification Of Coracoclavicular Ligament Post Acromioclavicular Disruption: A Case Report

M Husyaini H; A Mahyuddin M; M Yusof A Department Of Orthopaedic, Hospital Sultan Haji Ahmad Shah, Jalan Maran, 28000 Temerloh, Malaysia

Introduction: Table 1. Range of motion for patient’s left Hypertrophic ossification (HO) in shoulder. coracoclavicular (CC) ligament is a rare Range of motion left shoulder Degree condition. There are limited cases documented Flexion 0-180° in available literature. Current literatures associate the calcification or ossification of the Extension 0-60° coracoclavicular region with trauma and renal failure.1 This findings are often found Abduction 0-180° incidentally in patient with central neurological disorder.2 Adduction 0-30°

Methods: Internal rotation 0-90° 32 years old Bidayuh male with no medical illness was followed up post allegedly External rotation 0-90° involved in a motor vehicle accident and sustained a closed left acromioclavicular joint Discussions: disruption (Rockwood III). There are limited case studies and researches He was treated conservatively with arm sling, regarding ossification of coracoclavicular analgesic and physiotherapy. ligament. There was no clear etiology of this Subsequently he was assessed in our clinic at condition and the group of patients that are 1 week, 2 months, and 5 months. During each more susceptible to it. Neither any clear consultation the condition of his shoulder was correlation implicating fractures with the assessed together with serial x-ray of left development of this condition.3 shoulder. Our experience shows no limitation of function with ossification of coracoclavicular Results: ligament. At 1 week post trauma he was able to flex and Conclusion: abduct to 90 degrees. Review at 2 months he Ossification of coracoclavicular ligament has demonstrated full range of motion the left limited research in regards to etiology, shoulder. Radiograph of the left shoulder complication and treatment. Further researches reveals early process of coracoclavicular are needed in this area. ligament ossification. References: At 5 months he has no shoulder pain. There 1. Chen, Y., & Bohrer, S. (1990). was only minimal deformity of the Coracoclavicular and coracoacromial ligament acromioclavicular joint with no tenderness or calcification and ossification. Skeletal limitation of movement. The coracoclavicular Radiology Skeletal Radiol., 19(4). ligament ossification had became substantial. 2. Lacout, A., Mompoint, D., Perrier Y., Vallee C.A., Carlier R.Y. (2008). Coraco- or costoclavicular paraosteoarthropathies in patients with severe central neurological disorders. Acta Radiol, 49, 167–171. 3. De Haas, W.H.D, Kingma, M.J, Drucker, F (1965) The coracoclavicular joint and related Figure 1: Ossification of left coracoclavicular pathological conditions, Ann. Rheum. Dis, 24, ligament 257. PT10B Development Of Management Algorithm On Scapulothoracic Dissociation

Vernon Tan; Yeo Siang Yew; Sia Ung; Nazari Ahmad Tarmuzi; Faris Kamaruddin Department of Orthopaedic Surgery, Sarawak General Hospital, Jalan Hospital, 93586, Kuching, Sarawak, Malaysia

INTRODUCTION: Traumatic scapulothoracic dissociation is a rare but devastating injury, posing a challenge to Orthopaedic surgeons. We present 2 cases of traumatic scapulothoracic dissociation encountered in our center within 3 months, one sustained an open injury while the other sustained closed injury. Based on present literatures, we developed an algorithm for From left to right: Figure1: amputated non- future references in managing scapulothoracic viable right upper limb (Case 1); Figure2: dissociation. chest x-ray revealed scapulothoracic dissociation with lateral third right clavicle CASES: fracture (Case 1); Figure 3: CT angiogram CASE 1: A 37-year-old factory worker showed right axillary artery thrombosis (Case presented with open traumatic scapulothoracic 2) dissociation of right arm following high speed DISCUSSIONS: tractional force acting onto his right upper Scapulothoracic dissociation is extremely limb. Examination of the injured site revelaed mutilating with the mortality rate of 10%. avulsed but thrombosed axillary artery and Hemodynamic status of the patient and the vein and brachial plexus was completely extent of brachial plexus injury are the key- determining factors in managing avulsed. Chest x-ray showed amputated lateral 1 third of right clavicle with neither rib fracture scapulothoracic dissociation . Vascular injury nor lung injury. Decision of wound involvement also contribute to the treatment debridement and refashioning was made in plan and yet viable upper limb with full neurological deficit in such cases renders the view of severe mangled limb with complete 2 brachial plexus avulsion. patient to have functionless limbs. Present CASE 2: A 23-year-old worker presented literature reviews do not show proper with closed scapulothoracic dissociation after treatment algorithm in such injuries. Hence, alleged motor vehicle accident with unknown development of treatment algorithm of mechanism of injury. Examination revealed scapulothoracic dissociation is the main aim in closed right scapulothoracic dissociation with this study. compelete pre ganglionic upper trunk but CONCLUSION: incomplete lower trunk brachial plexus We developed a management algorithm and injuries and pink pulseless right upper limb. systematic approach to guide clinicians in the CT angiogram showed right axillary artery treatment of acute scapulothoracic thrombosis. Chest x-ray showed comminuted dissociation. With this, prompt resuscitation fracture of right scapula blade and subluxation and intervention could be practiced to improve of right acromio-clavicular joint. No surgical the survival rate of the patients presented with intervention was planned as the right upper this fatal injury. limb remains viable. REFERENCES:

1. Zelle, B.A., Pape, H.C., Gerich, T.G. et al, Functional outcome following scapulothoracic dissociation. J Bone Joint

Surg Am. 2004;86:2–7. 2.Sampson, L.N., Britton, J.C., Eldrup-

Jorgensen, J. et al, The neurovascular outcome

ABSTRACT TRUNCATED PT10C Case Report: A Lucky Man With Foreign Body Transversing The Spinal Canal

Lee KW; Yasser AK Department Of Orthopaedics, Hospital Duchess of Kent, KM3.2 Jalan Utara, 90000 Sandakan, Sabah

Introduction: unsuccessful. From the CT scan done , it was A case report of a man with foreign body obvious that although the foreign body was transversing C6/C7 vertebrae post-assault from the front , it had gone deeper than without neurological deficit. expected. This probably explains why it could Materials And Methods: not be located from the front. Foreign body 47-year-old gentleman post-assault by a was subsequently removed via posterior homemade weapon from the front of the neck. approach . MRI was not ideal as it might pose He was initially referred to the surgical team. a danger to patient if the material is Neck exploration was done based on X-ray ferromagnetic . According to Jarraya.et.al, finding via anterior approach but they were proper screening of suspected metallic object unable to locate the foreign body. Patient was is required before MRI, or else it will pose subsequently referred to us. There was a considerable risk to the patient 2. It also states wound at the anterior aspect of the neck , but that CT scan is suitable for foreign body otherwise no neurological deficit . CT scan which is radio-opaque, which in our case has showed that the foreign body transversed been confirmed on X-Ray .With different C6/C7 vertebrae and went through the spinal window settings, different materials can be canal, from the left splenis capitis muscle to visualized without the risk of foreign bodies just behind the right thyroid cartilage. The dislodging in the case of MRI3.Studies foreign body was removed via posterior reported that penetrating spinal injury has approach of the neck. Patient was discharged more favourable outcome than other types of day 2 post-op. Subsequent follow ups in traumatic injuries to the spine. An insult revealed no abnormal findings and no usually takes a posterior route and due to the neurological deficit. natural bony protection of the vertebra, it does not cross the midline4 . However, in this case, the natural protection of the vertebra was negated as the insult took an anterior approach. It has been reported that patients with sharp objects transversing the spinal cord, has a high incidence of incomplete spinal cord lesion5 . Our patient did not have any form of SCI nor neurological deficit, defying the odds. Conclusion: For any foreign body embedded in the spinal canal, it is vital to have proper radiological investigation prior to the surgical intervention. CT scan prior to first exploration might have prevented patient from going through operation twice. References: 1. R.E.Burney,Maio,Maynard,etal.Incidence,c Figure 1: CT scan showing foreign body (left) haracteristics,and outcome of spinal cord foreign body measuring 7.5cm (Right) injury at trauma centers in North America Discussions: .Arch Surg, 128(1993), pp. 596–599 Spinal cord injuries (SCI) secondary to stab 2. Mhm Jarraya, Hayashi , et.al. injuries are relatively rare .Only 1% of SCI are 1 Multimodality Imaging of Foreign Bodies of attributed to stab wounds . Initial anterior the Musculoskeletal System. American approach exploration based on X-Ray was

ABSTRACT TRUNCATED PT11A Bedside Continuous Irrigation And Drainage: A Treatment For Septic Arthritis Of The Knee In Patients “Unfit For Surgery And Anaesthesia”

Ngim HLJ; Khoo SS; Suhaeb AR; Simmrat S Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

Introduction: Case 3: Septic arthritis is a surgical emergency as joint A 60 year old man with underlying ishaemic destruction occurs rapidly and can lead to heart disease and congestive cardiac failure, significant morbidity and mortality. The most presented with a neglected left parapatellar commonly affected joint is the knee joint.[1] laceration wound from a road traffic accident Mainstay of treatment of septic arthritis of the 2 week ago. He also had lethargy, shortness of knee are joint washout, either arthrotomy or breath and drowsiness. Due to poor GCS, he arthroscopic washout and intravenous was intubated and admitted to ICU. His left antibiotics. [2, 3] However for patients who knee was warm with necrotic skin over the were deemed unfit for surgery and laceration wound, surrounding cellulitis and anaesthesia, we suggest that beside continuous knee effusion. Empirical intravenous antibiotic irrigation and drainage can be used as an was started. Debridement and arthrotomy alternative to joint washout. washout was done and the joint fluid was turbid. The cellulitis persisted and left knee Case 1: effusion recurred 1 week post-operation. A 60 year old man with underlying coronary Bedside continuous irrigation and drainage heart disease with 3 vessel stenosis, presented was done because the patient was unfit for with right knee pain, fever and shortness of another surgery. breath for past 3 days. He was unable to Discussions: ambulate due to the right knee pain. This method of treatment can easily be set up Examination revealed warm and tender right using commonly available items. Under knee with effusion and limited movement. aseptic technique, two 14 gauge cannula are Right knee aspiration revealed straw coloured inserted to the knee: inflow at the medial fluid but was not turbid. Empirical intravenous suprapatellar; outflow at the anterolateral knee antibiotic was started and an emergency joint. A 3 liter sodium chloride 0.9% bag is arthrotomy knee washout was planned. placed at a height of 1.8meters connected to a However his surgery was cancelled due to standard drip line is attached to the inflow. high cardiac risk. Bedside continuous Outflow cannula is attached to a three-way irrigation and drainage was done for 3 days, stopcock and drip line to a standard urine relieving his right knee pain. drainage bag. Intermittent saline distension and drainage is performed once a day for 30 Case 2: minutes, maintaining continuous drainage by A 52 year old man with underlying HIV gravity at other times for a range of 1 to 3 infection presented with a painful swollen days. This method is suggested as an interim right knee and fever for the past 2 days. measure for ill patient. Surgical joint washout Examination showed a tender, warm knee with should be done once the patient is fit for limited movement and aspiration revealed surgery. 60ml of pus. Arthrotomy washout was References: planned, but he was unfit for surgery as he 1. Stott, P.M., C. Tamura, and G.A. Semple, A developed acute myocardial infarction on technique of arthroscopic knee washout for admission. Bedside continuous irrigation and septic arthritis. Injury Extra, 2007. 38(12): drainage of the septic knee was done for 4 p. 474-475. days in addition to intravenous antibiotic. He 2. Sharff, K.A., E.P. Richards, and J.M. was later discharged well and defaulted his Townes, Clinical management of septic follow up appointments.

ABSTRACT TRUNCATED PT11C “I Survived A Parasailing Fall”

NA Faruk; M Firdaus A; Khoo EH Department Of Orthopaedic Dan Traumatology, Hospital Pulau Pinang Jalan Residensi,10990 George Town, Pulau Pinang, Malaysia

Introduction: after the initial surgery. Open reduction and Para sailing is a popular water recreational plating of right calcaneum with bone sport. Injuries may happen during the grafting was eventually done. takeoff, flight or landing. The most common injuries are fractures; dislocation or sprains All fractures have now united and he is able in the extremities, followed by spinal and to ambulate independently without any aid. head trauma. Discussions: Case Presentation: Parasailing is a recreational sport that is We report a case of a 31 years old male who popular in coastal cities. Passenger safety had an alleged fall from about a 100 feet may be compromised, as this sport is not height while parasailing in Batu Feringghi heavily regulated at the state, or federal Penang, He sustained multiple ipsilateral level. bone fractures; open book pelvis fracture and right sacral wing fracture with intact SI joint In this case, we decided to fix all the (APC type II), left superior and inferior fractures to help improve his quality of life. pubic rami fracture with pubic diasthesis, Timing for the surgery is very important as right transverse process L4 &L5 fracture, we applied the principles of damage control right acetabulum fracture (transverse), orthopedic in his case, to avoid serious closed right subtrochanteric femur fracture consequences (The first and second-hit (Russel-Taylor type 1A), and closed phenomena) that may lead to acute organ comminuted fracture right calcaneus (Sander failure and early death. Eventually we type IV). There were no brain, chest and managed to stage the surgeries, even though abdominal injuries. He had no neurological it took about 4 weeks before it could all be deficit. settled.

Due to the complexities of his injuries, we Conclusion: decided that all the injuries had to be Parasailing activity came with a risk of addressed in a staged order to allow for serious injuries if accidents happen. Good nursing care and rehabilitation. operative planning will provide a much better outcome for post operative The femur was fixed with a long PFNA2 and rehabilitation and quality of life of the posterior right unilateral lumbo-iliac fixation patient. with L4, L5 pedicle screws and iliac screws was performed to address the sacral wing References: fracture. The posterior instrumentation of the 1.Unfallchirurg, Injuries caused by spine had to be done in a lateral position as parasailing, the patient was not able to be laid prone as 1989 Jul;92(7):346-51. there was ventilation issues.

He was ventilated for about one week after the initial surgery before recon plating of the acetabulum was done via the Stoppa approach to restore the pelvic ring. As he was still in critical condition, fixation of the calcaneum was delayed to one month PT12A Outcome Of Tibial Plateau Fractures Treated With Ilizarov Fixator

Paul S; Gurjit Singh; Zamyn Zuki Department Of Orthopaedics, Hospital Sungai Buloh, Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia

Introduction: Discussions: Tibial plateau fractures can be managed using The management of intraarticular fractures in various methods.However,for complex the tibial plateau is inherently fractures,Schatzker IV-VI,management complex.Restoration of articular congruity is becomes more difficult.If soft tissue is not mandatory,and careful treatment of soft tissues compromised,internal fixation can be is as important as the bone.Not all fractures considered.However,the dilemma is when soft will reduce with ligamentotaxis alone,and a tissue is compromised and not favourable for limited open reduction with minimal periosteal internal fixation. stripping is sometimes necessary.Use of Ilizarov fixation allows a better choice of Methods: incision since internal fixation will not be We report the outcome of seven used.Ilizarov ring fixators allow early cases(retrospective) of isolated tibial plateau movement and early weight bearing.The value fractures done in Hospital Sungai Buloh using of early movement has been well Ring Ilizarov fixators from January 2014 till established,but early loading of fractures of September 2015.Of these 7 cases,5 were the tibial plateau has generally been avoided closed and 2 were open fractures.Six of them because of concern that the reduction may be were Schatzker VI and one was Schatzker lost,resulting in depression of the articular V.Of all this cases,we had to use a mini open surface or a valgus deformity. technique to reduce the fracture and restore congruent articular surface in 3 of them.Three Conclusion: of our patients were in the age group of 40- Ilizarov ring fixators are an ideal treatment of 55years,another three in the 70-80years group choice for complex tibial plateau fractures and one of them in the 60-70 years group. when extensive dissection and internal fixation are contraindicated due to trauma to the soft Results: tissue,deficiency of bone stock and bony Average time taken for union is 20 comminution. weeks(radiological) from the date of Ilizarov fixation irrespective of being Schatzker V or References: VI.A mini open technique had to be used for 3 1.Complex tibial plateau fractures treated with of our patients.Post operatively,we removed Ilizarov Fixator,International the fixators after radiological union was Orthopaedics(SICOT),(2005)29:182-185 achieved.Average ROM of the knee in our patients was 0-75 degrees with almost all of 2.Treatment of high energy tibial plateau them having some degree of knee fractures by Ilizarov circulator fixator,Journal stiffness.None of our patients had developed of Bone and Joint delayed or non-union.There were no skin Surgery,Vol.78-B,No.5,September 1996 sloughs or severe wire-tract infections.No patient developed osteomyelitis or septic arthritis.None required removal of the fixator before healing of the fracture.We did not encounter significant stiffness of the ankle or hindfoot since we took great care in placing the wires and paid particular attention to the maintenance of mobility of these joints.All of our patients were fairly satisfied with their functional outcomes. PT12B Case Series Of Distal Humerus Fracture With Chevron Osteotomy Technique: Experience In Tertiary Hospital In East Coast

HH Hazizul; MR Zaraihah; IM Anuar Ramdhan, Department Of Orthopedics, Hospital Sultanah Nurzahirah, Jalan Sultan Mahmud, 20400, Kuala Terengganu, Terengganu

Introduction major surgical step in this technique is The elbow is a complex joint and vital in posterior trans-olecranon and reflection of the positioning the hand in space. Distal humerus extensor mechanism and triceps mobilization. fractures contribute 0.5 to 2% of all fractures, The osteotomy site is subsequently fixed using but up to 30% of the fractures involving the tension band principle either with K-wires or elbow.1,2 In addition, the incidence of distal screw after the fixation of distal humerus humerus fractures among the elderly seems to fracture done. be increasing. Intra-articular fractures of the The essential principles in managing these distal humerus required surgical intervention injuries are: identification and protection of to restore anatomical reduction and regained the ulnar nerve, adequate exposure of the its function. We are reporting case series of fracture, anatomic restoration of the articular ‘T-/Y-pattern’ of intra-articular distal humerus surface,rigid or stable fixation fractures which fixed with Chevron osteotomy technique. Case Report Three cases were reviewed and required open reduction and plating distal humerus combined with Chevron osteotomy. The mean duration 1a 1b follow-up was 1 year with average age of 66.7 years (range 57-79 years). Two patients were male and 1 patient female. At 4 months follow-up the patient`s fractures were clinically well united evidenced by 3a 3b radiographic assessment. They had 0-110 degree of elbow range of motion (ROM) under regular physiotherapy treatment and gained 2a 2b back their daily activities requirement. Thus, we used Mayo elbow performance score

(MEPS) to evaluate the functional outcome post-operatively. All the patients had scored between 90-100, in which means excellent performance outcome.

Discussion 4a 4b

“Chevron”- Olecranon osteotomy is one the approach to intra-articular distal humerus Fig.1a, 1b) Pre operative right elbow x-ray fractures. Some literatures reported AP/lateral view. Fig. 2a, 2b) Right elbow x-ray complications related to this technique, post plating and Chevron osteotomy with tension include non-union of ulna (site of osteotomy). band wire. Fig.3a,3b) CT scan right elbow In our series, all ulnar osteotomies were well showed severely comminuted fracture united with excellent functional outcome of supracondylar and intercondylar right humerus. the elbow joint. Fig.4) Patient’s picture 4 months post operatively One of the great advantages of this Chevron a) full degree of extension (right side), b) elbow Osteotomy surgery is accessibility and flexion up to 110 degree. adequate exposure to the fracture site, in which important to visualize the fracture of both columns, and the institution of early fragments during reduction and fixation. The range of motion post-operatively.3 ABSTRACT TRUNCATED PT12C Exceedingly Rare Procedure: Post Traumatic Hemipelvectomy

HH Hazizul; MR Zaraihah; AR Ruh Akmal; I Isnoni; K Suzanah Department Of Orthopedics, Hospital Sultanah Nurzahirah, Jalan Sultan Mahmud, 20400, Kuala Terengganu, Terengganu

Introduction surgeries and follow-up. Currently, he able to Traumatic hemipelvectomy is exceedingly do daily activities semi-independently and rare, and life-threatening injury. Traumatic ambulate with walking frame. hemipelvectomy also known as hindquarter Discussion amputation, is usually caused by high-energy Traumatic hemipelvectomy is a catastrophic injuries resulting from traffic accidents, injury of pelvic fracture that characterized by motorcycle accidents, in which the rider is not the complete distruption of hemipelvis from protected, and machinery accidents.Traumatic the pubic symphysis to the sacroiliac joint.1 hemipelvectomies comprise less than 2% of The most common cause of the injury was a all pelvic fractures. Whereas mortality in open motor vehicle accident involving either pelvic fractures is around 40%, this figure is pedestrians or cyclists.4 Most survivors are 60 to 100% in traumatic hemipelvectomies.3 young, healthy individuals, who are able to The integrity of the blood vessels in the tolerate massive haemorrhage and soft tissue retroperitoneal area may be compromised and destructions.2,4 Accordance to Faisham et al, the extremity may become pulseless and complete hemipelvectomy seemed to have unsalvageable. higher survival rate as compared to partial Case Report hemipelvectomy, due to incomplete A 35 year old gentleman, had involved traffic transaction of the vessles.2 Thus, early road accident, which his motorcycle collided haemorrhage control and vigorous with a car. He was brought immediately to resuscitation with good vascular hemostasis casualty with nearly circumferential jagged are the major determinant of the survivors. dirty wound at right groin with complete The requirement good coverage of the disruption through right symphysis pubic and wound plays an important role in patient’s sacroiliac joint. The wound was extensive, morbidity. The vital structures need to be heavily contaminated and extending protected to prevent further infection. The posteriorly to perianal area with completely posterior gluteus flap done, followed by avulsed external and internal iliac vessels as vacuum assisted closure (VAC) dressing for well as the femoral and sciatic nerve. He also temporary coverage in the management of the had ipsilateral open comminuted fracture large wound defect. Furthermore, importance proximal third tibia and segmental fracture of nutrient support need to be addressed as fibula. well as the issue of phantom limb pain, Aggressive initial resuscitation carried psychological support and rehabilitation issue out since patient hemodinamically unstable (eg.prosthesis). with blood pressure ranging between 80- 100/50-90mmHg. He was transfused with 4 pints blood and 1 cycle of DIVC regime. He was intubated for airway protection. The 1a 1b pelvic was stabilized on pelvic binder. Emergency wound debridement and hemipelvectomy amputation done, combined with surgical team for exploratory laparotomy, 1c 1d ligation of iliac vessels, permanent supra pubic cathether (SPC) and diversion colostomy. Postoperatively, he required multiple debridement due to infected wound and had 2a 2b completed several course of antibiotics. Patient managed to survive despite of multiple ABSTRACT TRUNCATED PT12D Intramedullary Kirschner Wires for Clavicle Fracture: Case Report

MR Zaraihah; HH Hazizul; IM Azahari; AA Tajuddin Department Of Orthopedics, Hospital Sultanah Nurzahirah, Jalan Sultan Mahmud, 20400, Kuala Terengganu, Terengganu.

Introduction Although the anatomically contour Fractures of the clavicle are common in adults plate is now available, the incision is usually and children, and they account for long to facilitate the plate and later patient approximately 10% of all bone fractures.1,2 might end up with scarring that may cause Out of that, middle third of the clavicle is most painful neuroma as well. The advantages of common and risk of malunion is high. using intramedullary fixation are minimally Fractures of the clavicle are usually managed invasive and the incision is relatively small, conservatively, but internal fixation is safe and cost effective. It also allow essential in certain specific indications. We are intramedullary compression with minimal reporting a case of clavicle fracture, fixed with stripping of periosteum, good cosmesis intramedullary Kirschner wires (K-wires). outcome and rapid recovery. Case Report The radiograph had shown sign of uniting A 20 years old lady, who involved in motor fracture with bridging callus after 6 weeks vehicle accident, sustained severe head injury post operatively and no complication with open fracture middle third left clavicle. encountered such as infection or migrating of There’s small punctured wound measuring the wires. about 0.5cm x 0.5cm over the clavicle area. Apart from that, she also had multiple left rib fracture with left haemothorax and closed fracture midshaft of left humerus. She was intubated due to poor GCS and ventilated in Intensive Care Unit (ICU). Patient had 1 undergone emergency wound debridement and K-wire insertion of the right clavicle along Fig.1. Chest x-ray on admission with plating of the left humerus. After wound is debrided, two K-wires (diameter 2.0mm) were inserted. The first wire was inserted retrogradely and the other wire is parallel to the first wire, from the lateral to the medial until it hit the cortex over the medial end. 2 Postoperatively arm sling was applied for 3 weeks. The wires were then removed after 6 Fig.2.Left shoulder x-ray post weeks when radiographs showed good operation:wound debridement and K-wire bridging callus. After 8 weeks of fixation, she insertion. Two wires were inserted achieved full range of motion of the left antegradely,parallel to the clavicle bone. shoulder without any pain and subsequently had to return to her daily activities. Discussion Fractures of the clavicle are usually managed conservatively. Surgical intervention was opted for this patient since it is open displaced middle third fracture. In this case, primary 3 surgical stabilization done with intramedullary Fig.3. Left shoulder x-ray after 6 weeks post K-wires. The wires which was inserted fixation. The wires is insitu and callus retrogradely is parallel to the clavicle bone, formation seen. aimed to resist the rotation and increased the stability. ABSTRACT TRUNCATED PT13A Excellent Temporary Short Term Outcome With Masquelet Technique In Long Bone Defect Following An Open Fracture Grade IIIA: Case Report

MR Zaraihah; HH Hazizul; K Suzanah; M Kartinawati Department Of Orthopedics, Hospital Sultanah Nurzahirah, Jalan Sultan Mahmud, 20400, Kuala Terengganu, Terengganu

Introduction significant soft-tissue injury. The goal of Segmental bone defects resulting from management of these open long bone defects traumatic injuries are complicated problems is to provide stable fixation with maintenance with significant long-term morbidity. The of limb length and adequate soft tissue treatment of critical sized segmental defects coverage. The 8cm bone loss in this patient in long bone is a complicated and challenging were filled up temporarily with the antibiotic issue. We are reporting a case of post bone cement which also act as structural traumatic long segmental femoral bone defect support while the rigid anatomical fixation is with Masquelet technique in open fracture achieved with long distal locking plate. grade IIIA. The vascularized bone graft is used in long Case Report bone defect that are more than 5cm in length, A 16 years old lady, presented to casualty however in this case the Masquelet technique with bleeding wound and deformity of the is used successfully to tackle the larger left thigh following a motor vehicle accident. defect. This technique is a viable option that She had sustained open fracture is based on two principal steps: a) the supracondylar and intercondylar of left femur formation of induction membrane and b) grade IIIA with wound at the anterolateral cancellous bone grafting.1,2,3 The cement is aspect the distal third of left thigh which is kept for a period of eight weeks. This allows exposing the femoral bone and grossly the formation of induction membrane, which contaminated. She underwent emergency functions as a bone-forming chamber1,2 and wound debridement. Intraoperatively we significant for vascularization of cancellous noted the fracture was comminuted with bone bone which placed inside the induction loss over the lateral cortex about 8cm in membrane in order to achieve union. length. The area of bone loss was carefully debrided and irrigated. Debris and non viable tissues were removed. The condylar fragments was addressed temporarily to the femoral shaft using Kirschner wires (K- wires) 2.0mm. She was immobilized with 1a 1b 2a skeletal traction and intravenous antibiotics (cefuroxime and metrodinazole) was given. She had undergone another operation about 2 weeks after the initial operation for open reduction and distal femoral locking plate (9 holes) of left femur with antibiotic (gentamycin) bone cement (Palacos), to fill up the gap and substitute the long segmental loss. Her active range of motion (ROM) of 3a 3b 2b left knee ranging 0-90 degree (during follow up). She was planned for removal of bone cement, with autologous bone graft (bilateral iliac) on next operation.

Discussion The severe long bone defects are often related 4b to high energy trauma and associated with a 4a

ABSTRACT TRUNCATED PT13B Management Of An Unstable Hip In A Psychiatric Patient

Vincent Jeremy; Singh. A; Mustapa. N, Danapal.S Department Of Orthopaedic Surgery, Hospital Tengku Ampuan Rahimah, Taman Chi Lung,, Jalan Langat, 41200 Klang, Selangor, Malaysia

Introduction: cultures were Escherichia Coli with extended This case illustrates the complications and spectrum beta lactamase producing activity. complexities in the management of an Appropriate intravenous antibiotic unstable hip fracture dislocation in a patient (meropenem) was administered based on the suffering from acute delirium. culture and sensitivity for 3 weeks. The Case Summary: infective markers and clinical findings The patient was a motorcyclist indicated improvement in sepsis. The patient involved in a high energy motor vehicular was discharged from the ward at day 48 of accident. He sustained grade II open fracture trauma. The LRS was removed at 4 months of the left tibia and left hip dislocation with a post trauma. At the time of removal, there was fracture of the posterior column of the no signs of infection and the hip was reduced acetabulum. ankylosed. At 7 months follow-up, the patient The open left tibial fracture was was ambulating unaided. managed surgically by performing emergency Discussions: debridement and stabilization with an external This case illustrates the difficulties faced in fixator. Closed manual reduction of the left the management of an unstable hip in a patient hip was performed followed by application of with a psychiatric illness. When patients are traction. not compliant to medical advice encompassing Post operatively the patient was bed rest, hygiene and traction, the traditional restless and was non-compliant to the approach in the management of this patient placement of the traction device. The with traction and internal fixation may not be psychiatric team diagnosed the patient with a viable option. The source of the sepsis acute delirium and prescribed haloperidol and (E.coli) is very likely urine contamination of Seroquel. The hip re-dislocated as the patient the wounds as the urine C&S also grew the sat and stood on his bed. similar organism. By immobilizing the hip At day 11 of trauma, open reduction with LRF, the patient was then able to comply and plating of the acetabulum was performed. with resting the affected joint. The patient was not compliant to bed rest and Conclusion: he sustained a re-dislocation of the affected Early involvement of the psychiatric team hip after a fall in the ward. Closed manual with more aggressive intervention might be reduction was attempted to reduce the hip. able to improve patients’ compliance to initial However it failed. management. LRS fusion and immobilization At day 18 of trauma, open reduction of of the hip joint might be the only viable option the hip and reconstruction of the posterior wall if patients continue to be delirious and non- defect with an iliac bone graft was performed. compliant. Intra-operatively there was a 30% defect of the References: head of femur. 1. James L. Levenson Psychiatric Issues in The left hip joint showed sign of sepsis Surgical Patients, Primary Psychiatry. 2007; at post trauma 22. The patient was still 14(5):35-39 delirious but less than initial presentation. The 2. Nagarajah et al., Iliofemoral distraction and post-operative x-ray showed the hip was still hip reconstruction for the sequalae of a septic subluxated. dislocated hip with chronic femoral At post trauma day 25, arthrotomy osteomyelitis. Journal of bone and joint washout of the left hip joint, debridement and surgery. 87-B (6), 863-866. (2005) immobilization (fusion) of the left hip with an LRS (Limb Reconstruction System) was performed. The organism isolated from the PT13C Chronic Morel-Lavallée Mimicking A Soft Tissue Tumour – A Case Report

Rabin V; Ngiam A; Ganaisan P Department Of Orthopaedic, Hospital Tengku Ampuan Rahimah, Taman Chi Lung, Jalan Langat, 41200 Klang, Selangor, Malaysia

Introduction: Morel-Lavallée lesion is a post traumatic closed degloving soft tissue injury, as a result of sudden separation of skin and subcutaneous tissue from the underlying fascia. This condition was first decribed by French physician Maurice Morel-Lavallée in the year 1853. Early diagnosis and management of the lesion is essential so as to prevent Figure 2: 3 stab incision minimally invasive complications like infections or extensive skin technique to evacuate the haematoma necrosis. Discussions: Materials & Methods: Morel-Lavallée lesions may be initially missed 65 year old male patient who was referred to because it may take some time to develope. In us for a soft tissue swelling of the upper thigh chronic cases these lesions may become for 4 months with a differential of a soft tissue enlarged, painful and limit movement. They tumour. As patient had a history of a prior fall require surgical interventions to prevent with no history of malignancy, we suspected a infection. With a minimally invasive chronic morel-lavallée due to the nature of the technique such as stab incisions may be swelling and on clinical findings of a soft, beneficial for wound healing and also prevent boggy, fluctuant swelling. Subsequently an re-bleeding. ultrasound was ordered. Conclusion: Results: Morel-Lavallé may be missed clinically at Ultrasound findings of the left thigh noted a early presentation due to it’s slow large subcutaneous heterogenous, developement over time. Early diagnosis is predominantly hypoechoeic collection seen at essential to prevent delayed morbidity. the antero-lateral left thigh extending from the Surgical drainage via stab incisions is a viable left hip to upper 1/3 of the left thigh with no option as it minimizes surgical time, re- intramuscular extension indicating a bleeding from surgical wound and shortens haematoma. The haematoma was evacuated post op care. with a minimallyinvasive technique by doing 3 stab incisions over the swelling to minimize References: the size of the wound and chances of re- bleeding. During follow up in the clinic the 1. Anirudh V Nair et al., Morel-Lavallée swelling did not recur and patient was able to lesion: A closed degloving injury that requires resume his normal lifestyle. real attention Indian J Radiol Imaging. 2014 Jul-Sep; 24(3): 288–290. 2. Hak DJ et al., Diagnosis and management of closed internal degloving injuries associated with pelvic and acetabular fractures: the Morel-Lavallée lesion. J Trauma 1997 Jun;42(6):1046-51.

Figure 1: Pre-op presentation PT14B Ipsilateral Femoral Head And Neck Fracture-Dislocation And Concomitant Shaft Fracture: A Rare Encounter

Eo CK; Lim HC; Sharveen G; Haryati MY; Suresh C Department Orthopaedic and Traumatology, Hospital Sultanah Bahiyah, Jalan Langgar, 05460 Alor Setar, Kedah, Malaysia.

Introduction: We had a rare encounter on ipsilateral femoral head and neck fracture-dislocation associated with concomitant shaft fracture.

Methods: We are reporting a case of a 17 year-old male sustained a motor vehicle accident. He Figure 2: CT scan (axial) showed the suffered multiple lacerations over the scalp, femoral head was impinged at the posterior right ankle and fingers over the right hand. He acetabular wall. was unable to dorsiflex his right ankle. There was a puncture wound over right thigh. Radiographs showed dislocation of the right hip with femoral head and neck fracture as well as comminuted fracture of midshaft of right femur. The wound over the right thigh was debrided and retrograde femoral nail was inserted. Subsequently, the patient was Figure 3: Post-op check radiographs. repositioned and right hip was exposed via Kocher-Langenback approach. Femoral neck Discussions: was fractured and the proximal fragment was Report on concomitant femoral head and neck impinged against the posterior acetabular wall. fracture with ipsilateral femoral shaft fracture There was infrafoveal femoral head fracture. was scarce. There was no case series found The head was reconstructed with headless during our literature review. compression screws and neck was reduced and There was foot drop most probably due to fixed with cannulated screws. Sciatic nerve stretching of sciatic nerve during dislocation was intact. causing neurapraxia. Patient did not complain of hip pain. Results: Conclusion: We are following up this patient to review the long term outcome. Proper planning and early surgical intervention is essential in the management of this complex fractures.

References: Figure 1: Hip (left) and femur (right) 1. Duygulu F et. al. Journal of Trauma radiographs. 2007.61 (6): 1545-1548. 2. Sharma G. et. al. Acta Orthopaedica et Traumatologica Turcica 2014. 48(6): 698-702. PT14D Open Comminuted Extrarticular Distal Femur Fracture: A Cost Effective Method Of Treatment

Md Yusoff, Z; M Shariff, M S; Felix LYS Department Of Orthopaedic Surgery, Hospital Ampang, Jalan Mewah Utara, Pandan Mewah, 68000, Selangor, Malaysia

Introduction: Reduction successfully obtained length and Distal femur fractures are rare and can be near anatomical alignment of the femur. Post severe. It is descibed as occuring in roughly operatively, distal pulses were intact and 0.4% of all fractures and 3% of all femoral wound inspection of day 2 post trauma were fractures. satisfactory. The patient was discharged There is a classic bimodal distribution in from hospital on day 4 post trauma with oral terms of the group of affected individuals, antibiotics and planned for daily dressing of with a peak frequency in young men (in their the wound. He remains under follow up. 30s) and elderly women (in their 70s). Discussions: The AO classification divides distal femur Extra-articular fractures of distal femur can fractures into extra-articular (A), partial be treated by minimally invasive methods, or articular (B) and intra-articular (C). Type A by conservative management for simple non fractures are sometimes amenable to non displaced fractures. However, for more surgical treatment provided they are stable complex fracture patterns, there are a myriad and minimally displaced. of treatment options available such as Materials & Methods: locking plates, intramedullary nails, angle We present a case of a 29 year old non- blade plate, dynamic condylar screw, screw Malaysian patient who presented to a fixation and external fixation with or without government hospital in Ampang, Selangor. a hydrid device. The patient had just arrived in Malaysia for Conclusion: one month and worked in a metal factory. For simple extraarticular distal femur He was admitted in January 2016 following fractures, conservative management with an alleged occupational injury where his casting is an option. When wound right femur was hit by a metal rod that fell debridement is necessary such as in cases of from height. open fractures, Kirschner wires can be used He sustained an open comminuted fracture to augment reduction before casting. It is an of right distal femur (Gustillo II), AO option for patients who cannot afford better Classification 3-3-A-1.2 with a small implants. However, some drawbacks of this puncture wound over the lateral aspect of the treatment option is that the patient may right femur. develop knee stiffness after prolonged A decision was made for k-wiring of the immobilisation, risk of pinsite infection and fracture during the wound debridement and sores while in the cast. for application of full length cast of the right References: lower limb. This decision was made in view 1. M. Ehlinger et al., Distal femur fractures. of the patients’s poor financial status and Surgical techniques and a review of the lack of employer support, while also literature considering the fracture pattern. Orthopaedics & Traumatology: Surgery & Results: Research May 2013, Vol.99(3):353–360 Surgery was done within 12 hours of initial 2. Gwathmey FW Jr et al, Distal Femoral trauma. A medial para-patellar incision was Fractures: Current Concepts made to approach the fracture. Thorough J Am Acad Orthop Surg. 2010 wound debridement was done. Reduction Oct;18(10):597- was held with five k-wires size 2.5mm, and a full length cast was applied. 607

PT15A Fat Embolism Syndrome In A Unicortical Fracture Of The Tibia – A Case Report

Eva Mahirah Zulkifli; Tan Hin Pan; Mohd Ghazali Abdul Ghani; Tiew Sei Kern Department Of Orthopedic Surgery, Hospital Tengku Ampuan Rahimah, Taman Chi Lung, Jalan Langat, 41200 Klang, Selangor, Malaysia

Introduction Discussion Hospital Tengku Ampuan Rahimah Fat embolism syndrome is a rare (HTAR), Klang, manages a high number of clinical condition in which its pathophysiology trauma cases involving long bone fractures is still poorly understood. Although it and their associated complications. Fat commonly occurs in patients with multiple embolism syndrome is one such complication long bone fractures associated with substantial which typically occurs in young patients with injury to the soft tissues, it may also occur in long bone fractures of the lower limbs. those with seemingly trivial fractures as In this case report, we would like to evidenced by this case report. highlight a case of fat embolism syndrome Early clinical diagnosis is essential as occuring in a patient with unicortical fracture we could not rely on laboratory and of the distal third tibia. radiographic findings. Swift and optimal support of pulmonary and cardiac functions Case Summary along with any other organ system affected A 14-year-old boy sustained a fall after ensure good prognosis for this patient. which he complained of left ankle pain. He seeked treatment from a traditional medicine practitioner and was prescribed massage and rest. He was brought to our hospital the next day in respiratory distress. He also had tachycardia, hypotension and petechiae over his chest. The boy was intubated and started on inotropic support. He was then transferred to our Intensive Care Unit (ICU) for close supportive management. Pulmonary embolism was ruled out by an urgent Computed Tomography Pulmonary Angiogram (CTPA). Xray of the left ankle showed a unicortical, nondisplaced fracture of the distal third tibia. The condition of the soft tissue of the left leg is good with no swelling or skin break and good circulation. He was put on left above knee cast. In view of the clinical findings and the recent history of trauma, the patient was treated as having pulmonary fat embolism syndrome. The patient was extubated on day four post trauma with other body systems (including heart, liver and kidneys) improving. The prognosis is good.

PT15C Bilateral Humerus Fracture: A Case Report

Suresh A; Adnesh K; Ramesh M; Suriya K; Noramirah D; Lidiana A; Asyraf W Department Of Orthopaedic Surgery, Hospital Tuanku Ampuan Najihah, 72000 Kuala Pilah, Negeri Sembilan, Malaysia

Background: classification) can be treated conservatively Fractures of the bilateral humerus are provided an acceptable closed manual uncommon in young patients. Bilateral reduction is achieved followed by early humerus fractures are usually associated with rehabilitation and physiotheaphy. Some degree shoulder dislocation and rarely reported and of stiffness is nearly expected after all consists approximately 5% of the extremity proximal humerus fractures. Early fracture. Common etiology of bilateral mobilization is the best method to prevent humeral fractures in younger patients are best stiffness in the bilateral proximal humerus described using the Triple E syndrome; fracture treated without surgery. epilepsy, electrocution, or extreme trauma. Restoration of a pain free shoulder movement Reference: is the goal of treatment. Treatment option can 1.Brackstone M, Patterson SD, Kertesz A. be divided to conservative and surgical Triple “E” syndrome: bilateral locked intervention based on the classification and posterior fracture dislocation of the shoulders. displacement of fracture segments. Many Neurology 2001;56(10):1403-4. literatures are recommending for open 2. Court-Brown CM, Garg A, McQueen MM. reduction and internal fixation of bilateral The epidemiology of proximal humeral humeral fractures in young patients, however, fractures. Acta Orthop Scand 2001;72 (4):365- we report of a case being treated 71. conservatively with good outcome. 3. Leyshon RL. Closed treatment of fractures of the proximal humerus. Acta Orthop Scand Case Report: 1984;55(1):48-51. A 30-year-old male patient presented to the 4. Young TB, Wallace WA. Conservative emergency department with pain, swelling and treatment of frac- tures and fracture- marked reduced mobility over the bilateral dislocations of the upper end of the humerus. J shoulder joints. He sustained injury after being Bone Joint Surg Br 1985;67(3):373-7. involved in motor vehicle accident where he landed on an outstretched arms causing bilateral proximal humerus fracture with no neurological deficit. At the emergency department, his arms were immobilized with slings. Bilateral shoulder radiographs revealed a 3 part fracture neck of humerus with mild displacement. Closed manual reduction of both humerus were successfully attempted. Check radiograph revealed acceptable reduction. The fracture was treated conservatively using U-slab which was applied to immobilize the fracture site together with bilateral arm sling for 3 weeks. Patient achieved 80-90% of range of motion of bilateral shoulder joints after early rehabilitation and physiotherapy.

Conclusion: We are recommending that a 2 part and 3 part proximal humeral fracture (Neer PT15D A Traumatic Inferior Hip Dislocation

CL Lau; Tan HL; Shukri Y Department Of Orthopaedic Surgery, Hospital Sultanah Nur Zahirah, Jalan Sultan Mahmud, 20400 Kuala Terengganu, Malaysia.

Introduction: sedation needs to be done to reduce the risks Inferior hip dislocation is an extremely rare of avascular necrosis of the head of femur. incident, besides the two usual types of Open reduction is indicated in failed closed dislocations, which are the posterior (90%) reduction or dislocations, which are associated and anterior (10%) dislocation (1). Most of the with fractures. literatures reported earlier were mostly in Figure 1: X-ray on admission pediatric age groups. A case series by Aggarwal S reported that they had only encounter 4 cases of inferior hip dislocation with the mean age of 33.8 years old, where all were successfully reduced with closed reduction (2). Case Presentation: A 41 year old Malay male, with no known medical illness alleged motor vehicle accident where his car skidded and hit the side of the road while cruising at 140 – 150km/h. He Figure 2: X-ray post closed reduction sustained pain and deformity over left hip and unable to move his left lower limb. There was period of loss of consciousness too. On examination, patient’s vital signs were stable with full . Examination of the lower limb showed that there was obvious shortening over the left side with the attitude of that limb being in abduction and externally rotation. Range of motion of the left hip joint was limited with no neurovascular injury. Conclusion: X-rays revealed inferior left hip dislocation Inferior hip dislocation is a rarest type of hip with no acetabulum fracture (Figure 1). Closed dislocation, however it is still an orthopedic reduction of left hip was done under sedation. emergency, which leads to the same No complications seen intra and post- complications like any other types of hip procedure. Check x-ray post reduction (Figure dislocation such as AVN of femoral head, 2) showed that the dislocation has successfully post-traumatic arthritis and recurrent reduced. dislocation (3). Patient was admitted to ward with skin References: traction applied over the left lower limb for 2 1. Thompson VP, Epstein HC Traumatic days till he was pain free. He was then dislocation of the hip; a survey of two discharged well with advice of non-weight hundred and four cases covering a period bearing. of twenty-one years. J Bone Joint Surg Am Other associated injury for this patient was 1951;33-A:746-78 closed fracture lateral border of the right 2. Aggarwal S, Kumar V, Bhagwat scapular, which was treated conservatively KR, Shashikanth VS, Ravikumar HS. with an arm sling. Inferior dislocation of the hip: a case series Discussions: and literature review. Chin J Traumatic hip dislocation is an orthopedic Traumatol. 2012;15(5):317-20. emergency. Gentle closed reduction under ABSTRACT TRUNCATED PT16A An Alternative Fixation Method For Tibia Plateau With Tibia Shaft Fractures

Shamsul, SA; Thevarajan, K; Hafifi, M Department Of Orthopaedics, Hospital Sultanah Aminah, Jalan Persiaran Abu Bakar, 80100 Johor Bahru, Johor, Malaysia

Introduction: Discussion: Tibia plateau fractures with metaphyseal The described technique provides a stable extension is a serious injury not only to the fixation for both the fractures and is also bone but also soft tissues. Fixation choices minimally invasive. Once the plateau fracture include plating of the proximal tibia or has united, the nail can be dynamised to allow external fixation systems. We describe a for better union of the shaft fracture. This viable alternative surgical technique for the technique also demonstrated an elastic fixation of this type of fractures. behaviour similar to lateral proximal tibia locking plates and rigid intra-articular stability Case Report: similar to double-buttress plating (Lasanianos, 23-year-old man presented post-road traffic Garnavos, Magnisalis, Kourkoulis, & Babis, accident with pain over the right leg and a 2013). This technique is a viable alternative in laceration wound measuring 3cm x 2cm on the plateau fractures without any evidence of anterior aspect of the leg at the mid-shin level. depression pre-operatively. Radiographs and a Computed Tomography (CT) scan (Figure 1) revealed a tibia plateau fracture extending to the metaphysis (Shatzker type VI) and a mid-shaft tibia fracture with a proximal third-shaft right fibula fracture. The patient underwent initial surgical debridement of the wound and definitive surgery was Figure 1 Pre-Op CT Scann Figure 2 Post-Operative performed day 7 post-trauma with screw X-rays fixation of the plateau and expert tibia interlocking nail. Intra-operatively, the plateau Conclusion: was stabilized initially with four size 2.0mm Intramedullary nailing is a viable option for Kirschner wires were inserted in four different undisplaced tibia plateau fracture with an directions (anteromedial to posterolateral, associated shaft fracture. anterolateral to posteromedial, posterolateral to anteromedial, posteromedial to References: anterolateral). A mid-line incision was then Lasanianos, N. G., Garnavos, C., Magnisalis, made through the patellar tendon and an awl E., Kourkoulis, S., & Babis, G. C. (2013). A was used to create the entry point for the nail. comparative biomechanical study for complex Guide wire and reaming was then performed tibial plateau fractures: Nailing and with insertion of the nail. The proximal screws compression bolts versus modern and of the nail were inserted with the help of the traditional plating. Injury, 44(10), 1333–1339. jig. Reduction of the plateau was maintained http://doi.org/10.1016/j.injury.2013.03.013 throughout the nailing procedure and the wires were replaced with half-threaded 4.0mm cancellous screws to maintain the reduction of the plateau. The post-operative radiograph (Figure 2) showed good reduction of the plateau and tibia shaft fracture. The patient was advised for non-weight-bearing ambulation with crutches post-operatively.

PT16B

Inferior Pole Patella Fracture: Simple And Easy Approach

1Muhamad Taufik ML; 1Farid F; 1Loke YH; 2Yusof Y 1Department Of Orthopaedic, Hospital Selayang, Lebuhraya Selayang-Kepong, 68100 Batu Caves, Selangor, Malaysia 2Department Of Orthopaedic, Universiti Teknologi Mara, Jalan Hospital, 47000 Sungai Buloh Selangor, Malaysia

Introduction Discussion Displaced inferior pole patella fracture are The surgical goal of reconstruction of patella difficult to treat in view of small fragment and fractures is to reestablish the extensor comminution and might end up with partial mechanism while simultaneously restoring patellectomy.. Surgical fixation is essential in articular congruency. Tension band wiring has this type of avulsion fracture for early been the most commonly used surgical mobilization and to restore extensor technique for displaced transverse patellar mechanism.There are various type of fixation fractures However, extra-articular fractures over the inferior pole of patella fracture; of the inferior pole of the patella are difficult intraosseous vertical wiring and cerclage of to fix and maintain reduction by tension band patella is one of technique. wiring because of small fragment and Materials and Methods comminution.There are various surgical We present a case of a 61 years old malay lady techniques including partial patellectomy and who had an alleged fall at home and sustained reattachment of patellar tendon using a displaced inferior pole of right patella transosseous suture or suture anchor and fracture whereby the extensor knee specific plate fixation for this difficult mechanism was still preserved.She was fracture. counselled for fixation but refused and she Inferior pole fracture of the patella is usually defaulted treatment.However she presented completely extraarticular type. Therefore, the back to our team 3 months later after another goal of surgical treatment of inferior pole fall which she sustained an old inferior pole fractures is restoration of extensor mechanism of right patella fracture.The xray showed that rather than anatomical articular reduction. the patella fracture appear to be more Separate vertical wiring technique for displaced and this results in loss of her right fractures of the inferior pole patella introduced knee extensor mechanism. This time she by Yang and Byun showed higher fixation agreed for fixation of the fracture. strength than tension-band wiring in the Result biomechanical study.Song et al. also reported The surgery of right intraosseous vertical the biomechanical and clinical study of wiring and cerclage of the right patella was separate vertical wiring augmented with successfully done without complications.The cerclage wire. The combined procedure radiological outcome postoperatively showed showed better fixation results compare to acceptable fixation. Patient was discharged separate vertical wiring alone well from our ward with application of We also believe that combined vertical wiring cylinder slab with cerclage wire for inferior pole fractures of the patella is a useful technique that is easy to perform and can provide stable fixation with excellent functional results. Conclusion Intraosseous vertical wiring with cerclage wire Figure 1: Preoperative X- of inferior pole patella fracture is one of the ray Figure 2: Postoperative best option of fixation which provide good X-ray radiological and clinical outcome. It has Figure 3: Vertical wiring technique. proven in term of biomechanical and clinical study and should be reestablish as one of the option of primary fixation method. ABSTRACT TRUNCATED PT16D Domestic Animal Bite Injury – A Retrospective Review And Case Series

1SD Balakrishnan; 2Hussin P 1Department of Orthopaedic Surgery, Hospital Serdang, 43000 Serdang, Selangor Malaysia, 2Department of Orthopaedic Surgery, Faculty of Medicine, University Putra Malaysia, 43400 Serdang, Selangor, Malaysia

Introduction: surgical intervention. All the patients were Domestic animals are common in our country. given intravenous antibiotics on admission. Among these, dogs and cats are the most Amoxicllin/Clavulanate was the antibiotic of popular. In the past, these animals were wild choice. animals that have been domesticated, thus they Discussion: retain their instincts, including behaviour that Several studies have found that the hands are may lead to human attacks 1 These animal the parts of the body most frequently injured bites in humans are a complex problem, in domestic animal bites3. Our study confirms embracing both public health and animal that patients with animal bite injuries to the welfare2. This is a case series of 7 patients hands are especially vulnerable to developing with such injuries that have been analyzed in secondary infectious complications after a dog Hospital Serdang. bite 3,4. According to Rothe et al., the hands— Method: with their close topographical relation to Our retrospective data analysis comprised of bradytrophic tissue such as tendons to the skin cases referred from our Emergency surface—are especially prone to develop Department to the Orthopaedic Department infectious complications4. Moreover, as there from 1st January 2014 to 31st December 2015, are no natural anatomical barriers, an infection in relation to domestic animal bite injury. The to the hand can easily spread along these patient database in the Hospital Serdang structures4. Information system was analyzed based on the Conclusion: referrals received during this period. From Although domestic animal bites are not very this, the patient’s details were categorized commonly seen in the hospital setting, they based on demography, type of pet, relationship can present with secondary infection that can to pet, localization of injury, depth of injury, be devastating if not treated in a timely treatment given in the hospital, presentation manner. timing and readmission rates. Secondary References: presentation was defined as presentation after 1. H. B. Weiss, D. I. Friedman, and J. H. 24 hours following a domestic animal bite Coben, “Incidence of dog bite injuries treated injury. Depth of injury were divided into in emergency departments,” Journal of the superficial if <1cm, and Deep if >1cm. American Medical Association, vol. 279, no. Readmission was defined as any repeat 1, pp. 51–53, 1998. admission required following the intial 2. B. Rosado, S. García-Belenguer, M. León, treatment given by the Orthopaedic team for and J. Palacio, “A comprehensive study of dog the same injury. bites in Spain, 1995–2004,” Veterinary Results: Journal, vol. 179, no. 3, pp. 383–391, 2009. Based on these data analysis, domestic animal 3. M. Morgan and J. Palmer, “Dog bites,” injuries commonly affect young male patients. British Medical Journal, vol. 334, no. 7590, The animals are usually known to the bite pp. 413–417, 2007. victims and have no recent change in 4. M. Rothe, T. Rudy, and P. Stankovic, behaviour. The upper limbs are most “Treatment of bites to the hand and wrist—is commonly involved. The hand injuries were the primary antibiotic prophylaxis necessary?” superficial, thus they present late (>24hrs) Handchirurgie, Mikrochirurgie, Plastische with signs of infection (eg: cellulitis, abscess). Chirurgie, vol. 34, no. 1, pp. 22–29, 2002 Those with injuries involving the lower limbs were deep, and they presented early for

PT17A Irreducible Traumatic Acute Anterior Dislocation Of The Shoudler: Candida Arthritis

CCH William; Suhaeb; A. Mahmod; Simmrat, S Department Of Orthopaedic Surgery, Faculty Of Medicine, University Of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia.

Introduction: medication. Eight months later, Failed reduction of acute anterior osteomyelitis of proximal humerus had dislocation of the shoulder is rare, and the eroded the entire humerus head (fig.3). She common cause is usually interposition of a was advised for shoulder joint replacement structure into the joint. We report a case of but she declined, as she is satisfied with the failed reduction due to candida arthritis of painless limited range of motion of her the shoulder. shoulder. Fig. 2: T2 MRI of shoulder; coronal, axial, sagittal

Fig.1 Fig.3 Case Report: A 69-year-old lady, who consumed Discussions: traditional medication for the past six There are two very rare aspects found in months, fell from bed and dislocated her this case. Firstly, failed closed reduction of right shoulder. Her radiographs confirmed an acute dislocated shoulder is uncommon. an anterior dislocation with suspicious soft The culprit for failure could be interposition tissue calcifications (Fig.1). Various of the tendon of rotator cuff muscles, techniques from traction-countertraction to fragments from the greater tuberosity, or Hippocrates method of closed reduction impaction of Hill-Sachs defect against the 1,2,3 were attempted for 3 times under sedation. glenoid . However, dislocation by However, the glenohumeral relationship interposition from multiloculated bursa has was abnormal and persistent anterior not been reported in literature. dislocation proven by radiographs. CT scan Next, shoulder candida arthritis is an and MRI were performed to identify source unusual invasive candidiasis, only 8% 4 of obstruction (fig.2). Imaging revealed a reported in shoulder . Majority of patients dislocated shoulder joint with has no overt presentation of infection e.g. multiloculated bursa collection, joint immune impairment; fever is uncommon effusion, large Hill-Sachs lesion and (13%); white blood cell count, ESR and proximal humerus osteomyelitic changes. CRP were only moderately elevated. 26% An arthroscopic shoulder joint of patients had no pre-existing invasive debridement was performed in which 20cc candidiasis, making it difficult to diagnose pus was aspirated and cultured Candida this disease. The success rate of treatment is albicans. The cause of the dislocation was only 78% through medical therapy with or found to be interposition of bursa. She without surgery. There is need for better completed antifungal (amphotericin and awareness and therapeutic approaches for fluconazole) for 3 months. Her this infection as early diagnosis and immunosuppression was attributed as the treatment prevent joint destruction and 4 cause from consumption of traditional preserve joint function .

ABSTRACT TRUNCATED PT17B Case Report Of A Traumatic Forequarter Amputation - Extreme Case Of Avulsion Injury

PX Hwang; SY Or; KA Wong; A. Aziz Department Of Orthopedic, Hospital Seberang Jaya, Pulau Pinang, 13700, Malaysia

Introduction: Results: Traumatic forequarter amputation is a rare and Postoperatively, he was discharged very devastating injury. The upper extremity uneventfully. On follow up, wound healed. could be severed from the trunk by a blunt Patient is currently on rehabilitation program. traction force. Left figure: clean amputated stump Materials & Methods: with avulsed soft We report a case of traumatic forequarter tissues. amputation due to industrial accident. A 35 Right figure: amputated years old farmer, had his upper limb entrapped extremity with into an operating fertilizer machine, resulting intact scapula his entire right upper limb pulled out from his and its attached trunk. He was immediately escorted to muscles, with hospital along with amputated limb. On part of shoulder girdle. presentation to hospital, wound had shown hemostasis, patient was at early phase of Discussions: hypovolemic shock which was reversed This case demonstrates an avulsion injury abruptly by aggressive resuscitation. Chest X- happened at forequarter level. The mechanism ray revealed lost of right humerus and scapula, of injury suggests a pulling and rotating force with retained clavicle associated with lateral exerted on upper extremity resulting third shaft fracture. The amputated limb had connection breakage of soft tissue from the the scapula intact, attached with its relative static body trunk. This is supported by surrounding muscles, with high grade open intraoperative findings that suggest indirect fracture of humerus. Despite warm ischemic trauma on amputated site causing soft tissue time of 1 hour and cold ischemic time of 1 avulsion. This level could represent weakest hour, replantation was not done due to severe physical connection over upper. Despite being trauma sustained to the amputated limb, a devastating injury, survival rate might be resulting poor outcome if replantation higher than expected. Major arterial performed. Wound exploration and vasculatures often sustain long segment debridement procedure were followed once endothelial injury due to avulsion injury stabilized. Intraoperatively, wound edge of the leading to thrombosis and hemostasis. amputated stump had minimum contusion. However, long segment neurovascular injury Scapula and rotator cuffs were avulsed away. poses major challenge to replantation Latissimus dorsi and pectoralis had their procedure resulting in low successful rate. humeral insertion detached. Axillary artery stump was found pulsatile with thrombosis, Conclusion: with axillary vein found next to it. They were Traumatic forequarter amputation is a rare ad ligated separately. Brachial plexus avulsed at devastating injury that at present has low cord level, they were pulled and divided. The replantation successful rate, probably due to lateral third clavicle was removed and fracture its nature of avulsion injury. edge smoothened. Rib cage remained intact. Thorough wound debridement done, wound References: edge was fashioned and stump closed 1. Z. Deng et al., Traumatic forequarter primarily. amputation associated acute lung injury (ALI): report of one case , Eur Rev Med Pharmacol Sci 2012; 16 (7): 974-976 PT17C Chronic Osteomyelitis Of Ulnar With Bone Loss Treated With Autologous Tricortical Iliac Bone Grafting And Titanium Locking Plate

M Fadzli; Abd Muttalib AW; Suhana SB; J Richford Department Of Orthopedic, Hospital Segamat, Jalan Genuang, 85000 Segamat, Malaysia

Introduction: forearm. Reconstruction of the forearm bone Chronic Osteomyelitis that arise from the in chronic osteomyelitis is essential to complication of internal fixation is one of the optimize the forearm rotation and its causes of bone loss during the surgical contribution to the rotational mobility of the intervention. To restore the length of the upper limbs. Titanium locking plate has been affected bone will be a challenge if a decision used to impart ulnar stability combined with to achieve union without shortening the autologous Tricortical Iliac bone grafting to adjacent bone has been made. achieve defect filling in fully treated chronic osteomyelitis of ulnar bone. Titanium plate Methods: has been chosen as it is a very biocompatible A case report of 17 years old, boy, alleged material. motorvehicle accident sustained Closed Fracture left Radius and Ulnar who underwent Conclusion: open reduction and internal fixation. A proper and effective management of Subsequently, he developed osteomyelitis of chronic osteomyelitis is crucial to salvage the ulnar bone. He underwent serial wound healthy bone by eradictae the infection and debridement and temporary fixation with K- remove all devitalised and necrotic tissue. A wire ,Gentabead insertion with a course of oral good timing for reconstruction of the affected antibiotic. It was complicated with 5cm ulnar bone with restoration of the bone loss by bone loss. Finally, his bone loss was treated plating with Titanium Locking Plate and with autologous Tricortical Iliac Bone autologous tricortical bone grafting may Grafting and Titanium Locking plate. optimize patient’s outcome and restore forearm function. This is one of the modalities Results: to achieve union of forearm bone loss. After 4 month follow up,wound over left forearm well healed. Radiography imaging of References: left forearm showed plate in situ without 1. Pernando Baldy dos Reis et al. Outcome of loosening of the scews, callous was seen. His diaphyseal forearm fracture-nonunions treated forearm range of motion is good including by autologous bone grafting and compression elbow and wrist joint. plate. Ann Surg Res. 2009; 3: 5.18.doi 10.1186 /1750 -1164-3-5. 2.Jain, Anil K MS et al. Infected Nonunion of the Long Bones. Clinical Orthopaedics & Related Research February 2005-Volume 431- Issue- pp 57-65.

Figure 1 :Radius Ulnar bone after 4 month plating withTitanium LCP with Autologous Tricortical Iliac Bone Grafting

Discussions: In this case, our surgical treatment aims to eradicate bone infection, restore anatomy reduction and good recovery function of PT17D Chronic Osteomyelitis Of The Femur: Concepts Approach

Kamarul A; Bajuri MY; Daun E; Hilmi N; Naim N; Yuen JC; Ali Noor I; Shukur MH Department Of Orthopaedics & Traumatology, Faculty Of Medicine, Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia

Introduction: culture showed no growth with the infective Chronic osteomyelitis of the femur following markers was normalized. During the PMMA intramedullary nailing is rather unusual, spacer removal, presence of a especially in closed fractures. Its incidence in pseudomembrane with healthy bone edges at closed fractures is between 1-2%1, and may go both ends. Later intraoperative tissue and bone up to 4-7% in open fractures2. Treatment cultures showed no growth. becomes more difficult when associated with Discussions: segmental bone loss. Insertion of PMMA spacer during the initial Case Report: stage for induced membrane formation and A 27 year old gentleman was involved in a then followed by the placement of bone graft motor vehicle accident in 2014. He sustained a within this membrane was popularized by closed ipsilateral intertrochanteric and Masquelet et al3. This membrane contains comminuted diaphyseal fracture of the right growth factors such as BMP, TGF-β, VEGF femur. A recon nail was used to stabilize the and IL-6 which ensures success of the bone fracture as well as cerclage wires for the graft. butterfly fragment on the shaft. He was otherwise well until mid of 2015 when he started discharging pus from a sinus on the lateral thigh. He underwent multiple debridements, removal of implant, and bone resection (10cm in length) with antibiotic cement spacer insertion in late 2015. A Limb Figure 2: Presence of the pseudomembrane Reconstruction System (LRS) was used for within the Critical Size Bone Defect (CSBD) distraction osteogenesis two months later after as shown. successfully eradicating the infection. Conclusion: Chronic osteomyelitis with segmental bone loss treatment requires careful planning and usually requires multiple procedures. Complete eradication of the infection remains the mainstay of treatment. References: 1. Duan X, Al-Qwbani M, Zeng Y, Zhang W, Xiang Z. Intramedullary nailing for tibial shaft fractures in adults. Cochrane Database Syst Rev. 2012;1:CD008241

(A) (B) 2. Young S, Lie SA, Hallan G, Zirkle LG, Figure 1: Note the involucrum, sclerotic Engesæter LB, Havelin LI. Risk Factors for fracture margins and periosteal reaction (A), Infection after 46,113 Intramedullary Nail following successful application of the Operations in Low- and Middle-income Monorail and bone transport from distal to Countries. World J Surg. 2013;37(2):349–55 proximal (B) 3. Masquelet AC, Fitoussi F, Begue T, Muller Results: GP. Reconstruction of the long bones by the The tissue culture initially showed induced membrane and spongy autograft Pseudomonas Aeruginosa with Enterococcus [Article in French]. Ann Chir Plast Esthet species and was treated with IV Ceftazidime 2000;45:346–353 plus Ampicillin for 6 weeks. Repeated tissue PT18A Tibia Fractures: A Singaporean Perspective

Decruz, Joshua; Antony Xavier, Rex Premchand; Khan, Sohail Ali Department Of Orthopaedic Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, S768828, Singapore

Introduction: Existing literature on epidemiology of tibia fractures tend to focus on specific fracture sites or mechanisms. This study aims to provide a general overview on the epidemiology of all tibia fractures in the unique urban population of Singapore.

Methods: Retrospective review of clinical and radiological records from 1st January 2012 to 31st December 2013 in a tertiary hospital in Singapore which covers a population of 700,000 and located closest to the northern land checkpoint which sees 130,000 vehicles passing through daily, one of the busiest in the Figure 1. Resident Figure 2. Causes of world. vs. Foreigner Cases Tibia Fractures

Results: Discussions: There were 141 cases of tibia fractures, of This study showed that the incidence of tibia which, 67.4% were from the Singapore fractures was 10.1/100000, four times lower resident population, while 32.6% were compared to previous epidemiological studies foreigners. This ratio closely resembled the done in Edinburgh, UK. Nevertheless, this population of Singapore, where 29.2% consist study reinforced the unimodal peak of tibial of foreigners. 75.9% of the patients were fractures in older females and young males, males, with a mean age of 40.2 years old, which were shown in the mentioned study. while the mean age of females were 62.4 years. The average age of patients with proximal and 66% of cases were managed operatively, and distal tibia fractures were on average 9 to 15 the 3 most common causes of fractures were years more than tibial shaft fractures and this road traffic accidents at 40%, followed by showed an ageing trend to such fractures. simple falls and falls from height at 26.2% and 12.1% respectively. Open fractures made up Conclusion: 17.7% of all cases, most of which were The incidence of tibia fractures in males was Gustillo-Anderson Class III. Tibial shaft 15.5/100,000 while in females it was fractures were the most common and made up 4.7/100,000. Despite the incidence of tibia almost half of all tibia fractures. The most fractures in Singapore being considerably low, common AO Fracture Class was however, 41- epidemiology is constantly evolving and B1. should be regularly revisited.

References: 1. Cowie J, et. al. The Journal of Bone & Joint Surgery 2012 2. Court-Brown, et. al. Injury 2006; 37: 691- 697 PT18B A Review On Lower Limb Necrotizing Fasciitis Mortality In Hospital Segamat

Elaine SZF; Cheong KW; Richford J; Suhana SB; A Muttalib Department Of Orthopaedic, Hospital Segamat, Jalan Genuang, 85000 Segamat, Malaysia . Introduction: creatinine level , poor WBC response, high Necrotising fascitis is an extensive, rapidly serum urea and low hemoglobin level 1,2 progressive and life threatening disease Delay in surgical debridement >24 hours from involving the necrosis of fascia and hospital admission were linked to increase in subcutaneous tissue. Local data showed mortality rate .3 A scoring system (Laboratory mortality rate for necrotizing fascitis of the socring system for predilection of NF) has lower limb ranging from 19.5% to 36% 1,2. been developed to help in diagnose early necrotizing fasciitis, and to distinguish Methods: necrotizing fasciitis from other soft tissue This is a retrospective study on variables infections. 4 affecting mortality of lower limb necrotizing fascitis cases in Hospital Segamat, Johor from Conclusion: June 2014 to August 2015. Recognizing the factors associated with mortality, early diagnosis and prompt Results: treatment are essential to reduce the mortality Total of 21 lower limb necrotizing fasciitis of lower limb necrotizing fasciitis. cases were admitted during the study period, 6 were mortality cases and included in this References: study. Subjects’s age group ranging from 31 1. Chee EK et al :Necrotising fascitis of the to 80 years old with 83.3% were male. All lower limb – A Prospective study of patients have comorbidities with the most prognostic factors affecting mortality. common being diabetes mellitus (66.7%) . Malaysian Ortho J 2009;3(1):32-35. Commonest presenting symptom is leg 2. Kwan MK et al: Necrotising fascitis of the swelling . 83.3% of them have short duration lower limb: an outcome study of surgical of symptoms (2 to 4 days). Most common treatment. Med J Malaysia 2006 Feb;61Suppl signs were swollen limb, tender, warmth, A:17-20. erythematous .4 out of 6 cases presented with 3. Wong CH et al.:Necrotising fascitis: clinical blisters over limb. Only 1 out of 6 cases has presentation, microbiology, and determinants crepitus on examination . 2 out of 6 cases of mortality. J Bone Joint Surg Am.2003; noted to have gas shadow over limb on 85(8): 1454-1460. radiographs. All patients have raised white 4. Wong CH et al: The LRINEC ( Laboratory blood cell count and lactate value .Only 1 out Risk Indicator for Necrotising Fasciitis) score: of 6 cases was diagnosed as necrotizing A tool for distinguishing necrotizing fasciitis fasciitis on first impression.4 out of 6 cases from other soft tissue infections.Crit Care Med had above knee amputation done with 2 of 2004; 32(7):1535-1541 them being done as first operation. Duration till the first operation was carried out from admission ranges from 15 to 50 hours. Duration till major amputation was performed from admission ranges from 16 hours to 8 days. Common organisms cultured from the affected limbs include Klebsiella pneumonia and Streptococcus algalactiae Group B.

Discussions: Factors associated with mortality that had been identified by local study includes advanced age, initial high pre-operative PT18C Limb Salvage In Necrotizing Fascitis: A Case Report

Elaine SZF; Richford J; Suhana SB; A Muttalib Department Of Orthopaedic, Hospital Segamat, Jalan Genuang, 85000 Segamat, Malaysia

INTRODUCTION: considered to be the most important treatment Necrotising fasciitis is an extensive and in necrotizing fasciitis.2 Limb amputation was rapidly progressive condition involving the not found to correlate with survival. However, necrosis of fascia and subcutaneous tissue. It amputation is usually a shorter procedure is associated with high mortality rate. 1 associated with less blood loss than a radical debridement of the skin and fascia. Patients in METHODS: profound shock requiring inotropes and those A case report of successful limb salvage in with severe concurrent medical diseases may lower limb necrotizing fasciitis. not tolerate a protracted operation and amputation was often performed.2 A radical RESULTS: debridement of infected and necrotic tissue Mr S is a 43 years old gentleman, with could be beneficial in some patients because it premorbid history of Type II Diabetes has less post-operative complications and the Mellitus, was alleged pricked by palm oil patient will be more likely to mobilize early thorn. He presented with left lower limb after debridement when compared to swelling, pain and pus discharge from the postamputation.2,3However, when compared to popliteal fossa. He undergone emergency an amputation, a radical debridement will not wound debridement and intraoperatively noted be able to control the septic focus as quickly findings of necrotizing fasciitis up to the thigh as its alternative, and multiple debridement level. Thorough debridement done and he was attempts would often have to be done.2 treated with antibiotic based on sensitivity of culture result. Sequential debridements were CONCLUSION: performed and the wound showed good Early debridement with aggressive treatment clinical improvement. Secondary suturing was is beneficial in treating limb necrotizing performed and he was then started with honey fasciitis. based dressing. Split thickness skin graft was performed later. Currently, the wound has REFERENCES: healed and patient is back to his routine work. 1.Chee EK et al :Necrotising fascitis of the lower limb – A Prospective study of prognostic factors affecting mortality. Malaysian Ortho J 2009;3(1):32-35. 2.Tang W, Ho P, Fung K, Yuen K, Leong J. Necrotising fasciitis of a limb. J Bone Joint Surg Br. 2001;83(5):709-14 3.Aulivola B, Hile CN, Hamdan AD, et al. Major lower extremity amputation: outcome of a modern series. Arch Surg. 2004;139 (4):395-9.

Fig 1 : Wound post Fig 2: Split fasciotomy and thickness skin debridements grafting was performed.

DISCUSSIONS: Early and aggressive debridement of the involved skin, subcutaneous fat and fascia is PT18D Open Reduction And Internal Fixation (ORIF) Of Clavicle Fracture: 3 Years Serdang Hospital Experience

1YJ Wong; 2Hussin P 1Department Of Orthopaedic Surgery, Hospital Serdang, Kajang, 43000, Selangor, Malaysia. 2Department Of Orthopaedic Surgery, Faculty Of Medicine&Health Science, University Putra Malaysia, Kajang, 43000, Selangor, Malaysia.

INTRODUCTION: DISCUSSIONS: Clavicle fractures are very common and In recent times, fixation of clavicle has comprise approximately 35% of all fractures become popular due to its fracture union rate in the shoulder region. In the majority of were comparable to those treated cases, they can be managed non-operatively conservatively. Our study shows union rate with the expectation of the patient achieving a was high (94%) and mean time to union was 2 good outcome. Previously, indication of month. The mean Constant-Murley score for surgery is very limited because fixation of all patients was 86.8 shows that most patients clavicle has a worse outcome as compared to obtain an excellent outcome after open conservative management. reduction and internal fixation (ORIF) of clavicle fracture. Study done by J.C. van der METHODS: Ven Denise et al shows superior outcome A retrospective study was conducted on scores were seen at six weeks for the operative patients with clavicle fracture who were group compare to conservative group. Beside operated between year 2013 and 2015 in that, patient who underwent ORIF were able Serdang Hospital. Data regarding age, to undergo early rehabilitation after the indication of surgery, implant used, duration surgery. Limitation in our study was the small of hospital stay, injury-to-surgery time, time to sample size. Future study should aim to union, infection and complication due to the include patient’s satisfaction level and also surgery were analyzed. Radiographic other associated injury of clavicle fracture. examinations were taken to assess the adequacy of implant fixation and degree of CONCLUSION: bony union. Clinical results for pain, shoulder Open reduction and internal fixation of function and range of motion were evaluated clavicle fracture is beneficial and has a good using Constant-Murley scores. outcome in certain cases with specific  indication.

RESULTS: REFERENCES: A total of 16 patients with clavicle fracture 1. Daniel W. Good, Darren F. Lui, Michael were managed surgically in this study. The Leonard.Clavicle hook plate fixation for mean age was 36.4 years (range, 20-52 years). displaced lateral-third clavicle fractures (Neer Indication of surgical intervention of clavicle type II): a functional outcome Study. J fracture were unstable lateral third clavicle Shoulder Elbow Surg (2012)21, 1045-1048. fracture (38%), followed by floating shoulder

(25%), then non union (19%), skin tenting 2. Tsai-Hsueh Leu, Wei-Pin Ho.Clavicular (12%) and open fracture (6%). The mean Hook Plate: A Better Implant Choice for length of hospital stay was 4 days. The median Fixation of Unstable Distal Clavicle injury-to-surgery time was 14 days. The mean Fractures? J Exp Clin Med 2012;4(5):270-274. time to union was 2 month and the union rate was 94%. In total, 38% of plates were removed. The median time to removal was 6 months. There were no complications or infection reported. The mean Constant-Murley scores were 86.8.

PT19A Soft Tissue Cysticercosis Of The Left Leg

Low, Weng Kong; Suhaeb AR; Simmrat S Department Of Orthopaedic Surgery, Faculty Of Medicine, University Of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia

INTRODUCTION: DISCUSSIONS: Cysticercosis is a type of parasitic infestation Cysticercosis can occur anywhere in the caused by Taenia solium in its larva form. human body, but has a known predilection for Common tissues affected include neural tissue the nervous tissue, eyes, skeletal muscles and (brain), skeletal muscle, subcutaneous tissue subcutaneous tissues(1). The basis of this and eyes. We report a case of cysticercosis selected tropism is still unknown. It has been involving the left leg skeletal muscle, reported that in 87% of the cases of presented with cellulitis changes over the cysticercosis presents as a solitary lesion(2). infected area. We are reporting a case of cysticercosis of the calf muscle, which to our best knowledge was CASE REPORT: not reported before. Moreover, our patient A 49 year old Bhutanese, presented with the presented with cellulitis like presentation with complaint of left leg swelling, redness and intense sign of inflammation over underlying pain for one week duration with no history of infested muscles, unlike the usual presentation trauma or insect bite to the affected region. of cysticercosis. In a calcified cyst, routine Examination his leg revealed an area of plain radiograph is adequate to confirm the swollen and erythematous skin overlying the diagnosis. It typically appears as isolated or anterolateral aspect of his distal left leg, multiple oblong calcified specks in the skeletal mildly tender on palpation. A plain radiograph muscles parallel to the muscle fibers, hence (Figure 1) of his right leg showed 3 rice-grin giving the characteristic “puffed-rice” shaped calcifications in the soft tissue appearance(1) corresponding to the area of complaint, while 2 more seen more proximally at the posterior CONCLUSION: and lateral aspect of the leg. On further Cysticercosis is relatively rare parasitic questioning, patient revealed the history of infestation. The treating physician or surgeon wild boar meat ingestion. He was treated with should have a high index of suspicion for this oral Albendazole. The swelling and redness condition if patient presented with isolated regressed and patient become asymptomatic intramuscular painful swelling with variable during clinic review 2 months later. degree of inflammation, or when patient presented with cellulitic changes over the extremities which does not respond to the usual empirical antimicrobial.

REFERENCES: 1. Agrawal R. Soft Tissue Cysticercosis: Study of 21 cases. Journal of Clinical and Diagnostic Research. 2012;6(10):3. 2. SD PCP. Lingual Cysticercosis. Indian Journal of Plastic Surgery. 2005;Vol 38(2):2. Figure 1: Plain radiograph showing the calcified specks of cysticerci in the proximal and distal part of the left tibia fibula

PT19B Orthopaedic Related Trauma In Industrial Injury: A Serdang Experience

YJ Wong; SK Liew; RDK Yeak Department Of Orthopaedic Surgery, Hospital Serdang, Kajang, 43000, Selangor, Malaysia

INTRODUCTION: than 10 years have the least incidence (7%) of Industrial injury is one of the most common injury. Most of the injuries (60%) occurred injuries after road traffic accident in after 6 hours of work. orthopaedic practice. The objective of this study is to analyze the demographic data as DISCUSSIONS: well as other relevant data pertaining to Our study showed that the majority of the orthopaedic trauma in industrial injury at patients were foreigners and the highest injury Serdang Hospital. area was the hand. The most common industry was the manufacturing industry which MATERIALS AND METHODS: involved handling of heavy machineries. The This is a prospective cross-sectional study highest incidence of injury happened after 6 involving all industrial injury patients hours of work. Most of the trauma happened presented to the Emergency Department at towards the end of their working hours which Serdang Hospital during the period June 2015 included over-time hours. Future study should to December 2015. Data regarding gender, aim to include patient’s socioeconomic status, age, nationality, site of injury, time of injury, injury management and also other associated type of industry, hours of work before injury non-orthopaedic injury. and years of experience in the occupation were analyzed. Data were collected using a pre- CONCLUSION: designed questionnaire during first Hand injury was the most common injury consultation and diagnoses were updated after found among industrial trauma. Our surgery. All patients consented prior to demographic data suggested that most of the participation. Our exclusion criteria included injuries involved manual labourers who were patients who refused treatment. foreigners. The incidence of industrial injury was found to be proportionate to the working RESULTS: hours. Safety education and preventive A total of 116 patients with occupational strategies in the work place will help to trauma were included in this study. There decrease the incidence of orthopaedic related were 97% of male and only 3% of female. The trauma. patients’ age ranged from 19 to 61years, with the median age of 31 years. The predominant REFERENCES: age group was between 21-30 years (49 %). 1. Mathur N, Sharma KK, Thivari VK, Bangladeshis (34%) sustained the highest Orthopaedic Industrial Injury, Journal of incidence, followed by Burmese (22%), Indian Medical Association, 1990 Indonesian (16%), Malaysian (14%) and Jun;88(6):153-4. others (Indian & Vietnamese, 4%). Upon analysis of the injury pattern, hand had the 2. Roslan A. Rahman, Haizal M. Hussaini, highest number (57%), followed by foot Normastura A.Rahman, Siti R.A.Rahman, (19%), arm and forearm (12%), spine (6%) Ghazali M.Nor, Sharifah M.AI Idrus, and thigh and leg (5%). The manufacturing Roszalina Ramli. Facial Fractures in Kajang industry had the highest trauma which was Hospital, Malaysia: A 5-Year Review. Eur J 67% followed by construction (19%), services Trauma Emerg Surgery 2007 .No. 1. (12%), transportation (3%) and others (2%). 78% of the patients sustained open fracture while 22% sustained closed fracture. Majority of them had working experience less than 5 years (76%), while those who worked more PT19C Luxatio Erecta: Report On 4 Cases

1YJ Wong; 1IP Faris; 2Hussin P 1Department Of Orthopaedic Surgery, Hospital Serdang, Kajang, 43000, Selangor, Malaysia. 2Department Of Orthopaedic Surgery, Faculty Of Medicine&Health Science, University Putra Malaysia, Kajang, 43000, Selangor, Malaysia

INTRODUCTION: DISCUSSIONS: Inferior shoulder dislocation, which is also Our small study shows that the common known as luxactio erecta, is a rare lesion that presentation of luxatio erecta was comparable affects approximately 0.5% (1 in 200) of to other literature. Due to it rarity, it may be shoulder joint dislocation cases. Although misdiagnosed, resulting in inappropriate luxatio erecta is rare, its clinical presentations manoeuvres trying to reduce the dislocation. are very distinct. Patient’s affected shoulder will be hyperabducted, with the elbow flexed CONCLUSION: and forearm resting on top of or behind the Early recognition and prompt treatment are head. Due to its rare nature, literature show essential factors to prevent neurovascular very limited review about its treatment and compromise. Outcomes may vary depending complication. We report 4 cases of luxatio on severity of injury and also patient erecta presented to Serdang Hospital from the compliance on rehabilitation. year 2010 to 2015. REFERENCES: METHODS: 1. Gordon I. Groh, Michael A. Wirth, Charles Cases were retrospectively evaluated on its A. Rockwood Jr. Results of treatment of nature of injury, clinical presentation, luxatio erecta (inferior shoulder dislocation). J treatment as well as complication from the Shoulder Elbow Surg (2010) 19, 423-426. year 2010 to 2015 in Serdang Hospital. 2. Sedat Yanturali, Ersin Aksay, James RESULTS: Holliman, Ozge Duman, Yahya Kemal Ozen. A total of 4 cases were evaluated Luxatio Erecta: Clinical Presentation and retrospectively. Two of the patients had the Management In The Emergency Department. distinct clinical presentation as mentioned The Journal of Emergency Medicine, Vol. 29, above, of which, the affected shoulder No. 1, pp.85– 89, 2005. hyperabducted, with the elbow flexed and forearm resting on top or behind the head. The others two presented with deformed shoulder. Treatment was closed manipulation and reduction either under sedation or general anaesthesia. Three of the patients were reduced under sedation and one patient under general anaesthesia due to unsuccessful reduction under sedation. Most common complications associated with luxatio erecta were rotator cuff injury, fracture of humerus and stiffness of shoulder joint. 3 of them develop rotator cuff injury post trauma. One patient had developed stiffness of the shoulder joint while another one patient develops avascular necrosis of the humerus head which is a rare complication. Generally the Constant- Murley score post rehabilitation was satisfactory. PT19D Recontruction Of Coronoid Process Using Autologous Tricortical Iliac Bone Graft After Persistant Traumatic Elbow Dislocation - Case Report

Khairul NS; Ardilla AR; Shukrimi A; Amin CA Department of Orthopaedic Surgery, Faculty of Medicine, International Islamic University of Malaysia, 25200 Kuantan, Pahang, Malaysia.

INTRODUCTION: buttress. Two cannulated screws size 4.0-mm Coronoid fractures are challenging to manage used to fix the graft. and rarely isolated. Its always associated with The Medial Collateral Ligament (MCL) was three instability patterns of the elbow which is primarily reconstructed and supplement with the terrible triads, varus posteromedial anchor suture. The ulna nerve transposed rotatory instability and transolecranon subcutenously. Intraoperatively, these fracture- dislocation.[1] procedures provided sufficient elbow stability We have performed an open reduction and with ROM 10-120 degree. Postoperatively the reconstruction of the coronoid process using elbow was protected with hinged elbow brace autologous tricortical iliac bone graft for one for 6 weeks. patient after persistent elbow dislocation in Follow-up at 6 months, the patient had malunited type III coronoid fracture. flexion-extension ROM 30-120 degree (Figure CASE REPORT: 1). Valgus and varus test of the elbow was A 29-year-old gentleman, right hand dominant, stable. The function and pain markedly had motor vehicle accident in 2015. reduced and improved. Radiograph of the Radiograph reveals dislocated right elbow elbow shows union of the autograft after 6 with grade 3-coronoid fracture. The patient weeks (Figure 2). underwent open reduction and plating of the coronoid process. One month post-injury, the radiograph demonstrated mal-united coronoid fracture with posteriorly subluxated elbow joint. Figure 1: Range of motion right elbow after Computerized tomography (CT) scan revealed 6 months displaced comminuted fracture of coronoid fracture. Contralateral CT scan of the left elbow done as a guidance of native coronoid process for reconstruction. Figure 2: Radiograph of the right elbow; The patient was under general anaesthesia. He anteriorposterior and lateral view shows was in supine position. The affected elbow solid union of autograft and congruent and contralateral iliac crest (left) were draped ulnarhumeral joint to allow access for tri-cortical grafting. The medial approach of the elbow was utilized. The ulna nerve identified and isolated. Previous anterior band of medial collateral ligament reconstruction noted and had healed. The MCL tagged and detached to expose the Figure 3; Schematic drawing of tricortical elbow joint. bone graft placement; A: Anterior view B; The malunited fragment of coronoid process Lateral view was removed. The foot print of the fragment DISCUSSIONS: prepared and cleared. The tri-cortical iliac Operative management of elbow dislocation bone graft harvested and trimmed according to after malunited of the coronoid process the preoperative templating of the contralateral fracture is challenging task. When persistent native process. The graft was inserted so that dislocation and instability occur, coronoid the smooth inner table of the graft congruent process reconstructions with autografts need to with the ulnahumeral joint and act as anterior be considered.[2]

ABSTRACT TRUNCATED PT20A Pattern Of Emergency Orthopedic Cases Delayed During Long Weekends In Hospital Temerloh

Hasni, MH; Khairunjauhari, NM; Han CS; Aziz, MY Department Of Orthopaedic, Hospital Sultan Haji Ahmad Shah, Jalan Maran 28000 Temerloh, Pahang, Malaysia

INTRODUCTION: Weakness to do so will increase patient's Malaysia is known to have many celebrations morbidity, length of hospital stay. throughout the year. Unfortunately we have high rates of motor vehicle accidents during Table 1. The distribution of cases delayed in the festive seasons.1 This translates into Hospital Temerloh during long weekends. Delayed Total Percen increase in the number of visits to the hospital Holidays needing care.2 cases cases tage New Year, 1 14 7.14% METHODS: Prophet's birthday The long weekends during 2015 were Chinese New Year 5 26 19.23% identified. These include any public holiday Labour Day 1 17 5.88% that fall on Monday, Thursday or Friday. The Hari Hol 3 18 16.67% number of orthopaedic emergency cases Vesak Day 5 25 20.00% posted during these time were collected and Eidul Fitr 5 31 16.13% any cases with waiting period more than 24 National Day 6 23 26.09% hours were identified. Eidul Adha 10 30 33.33% RESULTS: Awal Muharram 4 26 15.38% There are 10 long weekends during year 2015 Christmas 22 47 46.81% which included the major festive seasons. The Total 62 257 24.12% total cases with waiting period more than 24 hours are 62 out of 257 cases (24.12%). CONCLUSION: Percentage of cases being delayed ranges from The significant numbers of delayed emergency 5.88% during Labour Day long weekend to orthopaedic cases has draw attention to our 46.81% during Christmas long weekend which ability in delivering satisfactory health care. coincides with the pulic school holiday. This study will be groundwork for us to look further into consequences of delayed DISCUSSIONS: orthopaedic emergency cases. Reasons for delayed surgery is multi-factorial which ranges from not having enough REFERENCES: operating time, patient's pre-operative 1. Op Selamat during festive season sees 39% condition, consent and operation room spike in road fatalities, say police. (2015, technical issues. The most common cause August 15). The Malaysian Insider. found is due to not having enough operating 2. Ismail, N., Karim, Z. I. A., Jaaman, S. H., & time. Majid, N. (2009). Frequency of admittance Measures taken to improve timing of delayed and probability of inpatient treatment: operations are postponing semi-emergency Experience of Emergency Department, cases and having extra operating time after Hospital Universiti Kebangsaan long weekends. These steps taken have helped Malaysia. European Journal of Social to improve our delay however it is still Sciences, 8(1), 76-87. beneath our desired standard. Modifiable factors within the hospital resources should be better utilized and adaptable to occurring situation as needed. PT20B Meliodotic Osteomyelitis Of Right Femur – A Case Report

Ram KR; CH Foo; Jaffar MSA; Maris SW Department Of Orthopaedic Surgery, Queen Elizabeth Hospital, Lorong Bersatu, Jalan Damai Luyang, Kota Kinabalu, 88300, Sabah, Malaysia

INTRODUCTION: focal/multiple organ abscesses, Meliodosis is an infectious disease caused by a musculoskeletal infection and lethal Gram Negative bacterium, Burkholderia septicemia. However, osteomyelitis due to pseudomallei. It’s commonly seen in tropical Burkholderia pseudomallei even though a climate areas predominantly Southeast Asia recognized presentation is rarely encountered3. and northern Australia1. Burkholderia The initial presentation of our patient was pseudomallei has been known to cause confusing as the clinic findings and multiorgan infection, however isolated investigations were pointing towards either osteomyelitis is quite rarely encountered malignancy or infection

CASE: Figure 1: Showing MRI findings of the We are reporting a 40yr old diabetic man, a Right Femur Police Officer who presented to us with complaints of sudden onset of pain over distal part of right thigh for 2 weeks duration. The pain was sudden in onset and was not preceded by trauma. There was history of contact with water in a forest area during training. He also complained of fever, chills, rigor with loss of appetite and significant loss of weight. On examination, mild vague swelling with localized erythema was observed over the lateral aspect of right thigh, about 5cm above CONCLUSION: the knee joint. Mild tenderness on deep Since the Clinical findings and investigative palpation was elicited. results were mimicking that of a malignancy, a Xray of right femur showed an ill-defined lytic bone biopsy was certainly of great assistance lesion at femoral metaphysis. in diagnosing Osteomyelitis for this Patient. MRI right femur reported a suspicious lesion Thus we would recommend a bone biopsy for at distal right femur with region of hyperactive such cases and also vigilance during initial red marrow and adjacent periosteal thickening assessment in regards with co-morbids and (figure.1). Inflammatory markers, ESR and occupational hazard is of great importance. CRP were markedly raised. The bone biopsy results was reported as osteomyelitis, and the REFERENCES: organism isolated was Burkholderia 1. Popoff I, Nagamori J, Currie B. pseudomallei. Melioidotic osteomyelitis in Northen Australia. Aust N Z J Surg 1997; DISCUSSION: 67:692-5. Meliodosis caused by Burkholderia 2. Leelarasamee A, Bovornkitti S. Pseudomallei is predominant in south East Melioidosis: review and update. Rev Asia and commonly affects individuals with Infect Dis 1989; 11:413-25 diabetes mellitus, renal failure and 3. Subhadrabandhu T, Prichasuk S, immunocompromised state. Its causal Sathpatayavongs B. Localised organism, a gram negative soil saprophyte is melioidotic osteomyelitis. J Bone Joint mostly found in soil and contaminated water2. Surg Br 1995; 77:445-9 The common presentation for Meliodosis includes local cutaneous lesions, pneumonia, PT20C Common Microorganisms In Diabetic Patients In Kota Kinabalu. A Tertiary Hospital Experience

Harkeerat Singh; Babar Bilal; Asrul YHN; Ibrahim N; Siti Zulaifah CS; Chan SK; Paul AG Department Of Orthopaedics, Hospital Queen Elizabeth, Lorong Bersatu, Off Jalan Damai Luyang 88300, Kota Kinabalu

INTRODUCTION: antibiotic is used, it may not be able to act on Diabetes mellitus is a common systemic patients with polymicrobial infections. illness in our developing nation today. It Therefore we recommend the usage of manifests in the triad of neuropathy, Amoxicillin + Clavulanic Acid, Cefuroxime or vasculopathy, and immunopathy thus Ampicillin + Sulbactam as first line therapy to complicating the care of wounds in these treat infected wounds in diabetic patients. This patients. The purpose of this study is to look is due to the broad spectrum of organism into the common microorganisms that infect coverage offered by these antibiotics. Stronger diabetic wounds and their sensitivity to antibiotics should be reserved for ill patients antibiotics or when resistant strains of infections are METHODS: suspected. All diabetic patients admitted to Hospital Queen Elizabeth for infected wounds from the 1st of June 2015 till the 31st December 2015 were included into this study. Their first debridement cultures were traced and documented. Their respective sensitivity panels were compiled to pick out the associated sensitive antibiotics. RESULTS: A total of 196 patients were enrolled in this study, presenting with an array of soft tissue Table 1: infections such as necrotizing fasciits, Organisms Vs Antibiotics abscesses, and diabetic foot ulcers. Out of the 196 patients 27 patients had to be excluded Legend: from the study as their cultures were found to S: Sensitive yield no growth. The microorganisms and I: Intermidiate their associated sensitivity are as per the table R: Resistant below. REFERENCES: DISCUSSIONS: 1. Cunha BA. Antibiotic selection for diabetic Based on our study we have found that foot infections: a review. J Foot Ankle Surg. patients with diabetic wounds often present 2000;39(4):253–257 with polymicrobial infections. Furthermore 2. Citron DM et al. Bacteriology of moderate- close to 20% percent of wounds were infected to-severe diabetic foot infections and in vitro with resistant microorganisms with sensitivity activity of antimicrobial agents. J Clin to stronger antibiotics. A pictorial Microbiol. 2007;45(9):2819–2828. representation of the data collected would be presented on the poster. CONCLUSION: The treatment of diabetic wounds still remains a challenge; if a stronger antibiotic is routinely used to treat it usually promotes resistance within that bacterial colony. If a weaker PT21A Floating Shoulder: Ipsilateral Clavicle,Scapular Body,Glenoid Fracture And Superior Shoulder Suspensory Complex Disruption

Mithun Vijay; Thinesh VS; Ramesh NA; Abdul Rauf Department Of Orthopaedics, Hospital Tuanku Ja’afar Seremban, Jalan Rasah, 70300 Seremban, Negeri Sembilan, Malaysia

INTRODUCTION: Patient was positioned supine under general Floating shoulder is an uncommon but severe anaesthesia to approach the clavicle .A non injury pattern to the shoulder.Determining the locking recon plate size 3.5mm was used to fix specific injury pattern will aid in diagnosis and the clavicle. management. The scapula and glenoid was approach with It is known as a shoulder instability where it the patient in prone position.A mini locking involves mid-clavicle fracture,scapula neck titanium plate size 2.4mm was used to reduce and glenoid fracture.Recent studies also the scapula body and glenoid suggested that the superior shoulder fracture.Articular surface of the glenoid was suspensory complex disruption must be taken restored. into consideration . Wound healed well post operatively.The left However the degree of ligamentous injury is shoulder was immobilized with arm sling for unpredictable the outcome of non surgical 2/52.Pendulum exercise was initieated once treatment is uncertain. pain subsided.The patient was discharged and The most important factor to determine the physiotherapy was initiated . need for fixation or non surgical treatment is During follow up at 2/12 post operatively,on the glenoid displacement.Studies show that examination the left shoulder abduction was caudally displaced glenoid showed good 90 degrees.Forward extension and flexion was functional outcome only with internal fixation. full. CASE REPORT: DISCUSSION: A 23 year old male,presented to us following a Floating shoulder is usually associated with road traffic accident .After stabilization of high energy trauma.Injuries to the structures vital signs he was referred to the orthopaedic surrounding the shoulder is equally important unit for further expert management.On our besides managing the fracture.Associated examination his left shoulder was swollen injuries such as neurovascular and respiratory minimal bruises .Left shoulder range of organs need to be identified because of their motion was reduced.Neurovascular was intact. life threatening nature. From his radiological examination we noted Acording to the latest studies and that he had sustained clavicle,glenoid and discussion,ipsilateral clavicle ,scapula and scapula fracture. glenoid fracture alone is inadequate to The clavicle fracture accoding to Allman diagnose floating shoulder.Another very classification is Type ii(middle third).The important element is needed it’s the glenoid and scapula according to Ideberg is ligamentous shoulder injury to come up with type Vc. the floating shoulder diagnosis. CT showed clavicle fracture and scapula neck Direct AP and Y scapula view radiograhs is fracture extending through the glenoid needed.A reconstructed 3d CT of the shoulder articular surface and scapula body.The glenoid is important to see the fracture pattern. was also caudally dislocated. 1)Preoperative xray 2)Preoperative CT image This rare and unusual injury pattern was treating with surgical intervention .We had used the modified judet approach.The main advantage of this approach is the limited muscular dissection which eventually improves the rehabilitation and limit the morbidity of the surgery.

ABSTRACT TRUNCATED PT21B Case Report - Luxatio Erecta: A Rare Shoulder Dislocation Within 10 Days Opening Of A New Hospital!

M Afiq MA; A Zubair AA; M Afiq MF Department Of Orthopedic, Hospital Shah Alam, Persiaran Kayangan, Seksyen 7, 40000 Selangor, Malaysia

INTRODUCTION was reduced with traction and counter-traction Luxatio erecta is a rare type of shoulder method and the head of humerus pushed back dislocation. It accounts about less than 1% of into the glenoid fossa using the examiner’s shoulder dislocation(1). A number of cases foot. have been reported in western countries, OUTCOME however rarely reported in Malaysia. After the reduction , the stability of the SUMMARY shoulder was examined. Apprehension test A 45 years old gentleman who was involved was negative. Patient was pun arm sling. in a motor-vehicle accident presented to ED with right upper limb in hyper-abduction at the shoulder , flexed elbow and upper limb ‘locked’ at the overhead position. This happened in Shah Alam Hospital (HSAS) which was just opened about less than 2 weeks! BACKGROUND Luxatio erecta usually occurs due to an axial loading force with the arm abducted (2). It also can occur when the shoulder is forced to hyper-abducted and the proximal humerus being levered over the acromion process (3). DISCUSSION Typical presentation is hyper-abduction and Luxatio erecta usually comes with its typical external rotation of arm at shoulder, flexed presentation as described above. It is elbow and hand at overhead position (4). associated with rotator cuff injury, humeral CLINICAL PRESENTATION fracture and neurovascular complication. A 48 years old gentleman, was riding a Nerve injury is more commonly reported motorbike involved in an MVA. He was compared to vascular injury. thrown forward from the bike. Exact CONCLUSION mechanism and position of the upper limb Luxatio erecta is rare type of shoulder during the incident was not really remembered dislocation. However its pathognomonic by the patient. He was brought to ED with clinical presentation made it easier to identify deformity noted over his right upper limb. when it present to ED. INVESTIGATION REFERENCE The position of the right upper limb is typical 1. J.R. Goldstein,WP Eilbert. Locked of a luxatio erecta as described above. Any anterio-inferior shoulder subluxation attempt to bring arm adducted will cause presenting as luxation erecta. J Emerg Med,27 severe pain. Humeral head was palpable under (2004) pp 245-248 the axilla. Neurovascular status was 2. Kahn ML, Bade HA III, Stein I (1987). uneventful. Plain radiograph (AP and axial Body surfing as a cause of luxatio erecta view) revealed right inferior shoulder report of 4 cases. Orthop Rev Oct 16(10):729– dislocation associated with greater tubercle 733. fracture. 3. Mallon WJ, Basset PH, Goldner RD TREATMENT (1990). Luxatio erecta; the inferior A closed manual reduction was attempted glenohumeral dislocation. J Orthop Trauma under propofol sedation in ED. The shoulder 4:19

ABSTRACT TRUNCATED PT21C Cost Assesment Of Dynamic Hip Screw(DHS) Versus Proximal Femoral Nail(PFN) In Treating Intertrocheneric Fractures

Azwan ZB; A. Wafiy MP; M. Faiz HK; M. Shafiq Department Of Orthopaedic, Hospital Tengku Ampuan Rahimah, Taman Chi Lung,, Jalan Langat, 41200 Klang, Selangor, Malaysia

INTRODUCTION: the analysis,patient that been treated with PFN Intramedullary device has been top of the had lesser blood loss (estimated blood loss choice for the treatment of unstable <200cc, p= 0.05) and shorter operative intertrochanteric fracture since its introduction time( ( less than 60minutes, p = 0.04) . In the in the early of millennium. Even though DHS mean time, time of mobilization and time of is an acceptable option in treating union show no clinical significant between intertrochanteric fracture, the option has been those two. However, patient that was treated kept for stable fracture due to its post- with DHS had more morbidity as incidence of operative complication and morbidity1. Even post -operative transfusion (n;24) and screw said so, intramedullary device is expensive, cut-out ( n: 11) was higher. and most of the time patient unable to afford the implant. Thus this study was carried out in DISCUSSIONS: order to evaluate cost-effectiveness of treating PFN is a minimally invasive procedure which unstable intertrochanteric fracture using not only minimized the soft tissue dissection proximal femoral nail versus dynamic hip and blood loss but also speed up patient compression plate. recovery and allowing early mobilization. Furthermore, it also reduces operative time METHODS: and has low post-operative complication rate. This study was a retrospective study whereby As compared to DHS, even though it is data from January 2012 till June 2015 was cheaper but in needs higher surgical skill to collected. All patients with intertrochenteric ensure better outcome in treating unstable fracture that was admitted to Hospital Tengku intertrochanteric fracture. Ampuan Rahimah, Klang was identified. Subsequently, patients with only unstable CONCLUSION: intertrochanteric fracture were included into Eventhough time of mobilization and time of this study. From that group, patients with other union shows no significant difference, PFN is long bone fracture, head injury, intra- much more cost effective as it has lesser abdominal injury, premorbidly unable to walk morbidity as compare to DHS. and patient with pathological fracture were excluded from this study. Apart from REFERENCES: demographic data, information on operative 1. Gupta SV, Valisetti VS. Comparative study time, intra-operative blood loss, surgical site between dynamic hip screw vs proximal infection, time of mobilization, time of union femoral nailing in inter-trochanteric fractures and quality of life was recorded. These data of the femur in adults. International Journal of were statistically analyze to compare the cost Orthopaedics Sciences. 2015;1(1):07-11. effectiveness of treating unstable 2. Zhang S, Zhang K, Jia Y, Yu B, Feng W. intertrochenteric fracture with proximal InterTan nail versus Proximal Femoral Nail femoral nail versus dynamic hip screw. Antirotation-Asia in the treatment of unstable trochanteric fractures. Orthopedics. 2013 Mar RESULTS: 1;36(3):182-e292. 198 samples that follows the inclusion and exclusion criteria was retrieved. Out of 198 samples, 95 patients was treated with DHS and 103 patient was treated with PFN. From PT21D Open Subtalar Dislocation With Infection 6 Months Clinical Outcome

Sim SE; Randhawa SS; Adnan YK; Sankara Kumar C Department Of Orthopaedic Surgery, Faculty Of Medicine, University Of Malaya, Lembah Pantai, Kuala Lumpur, 50603, Malaysia

INTRODUCTION: Subtalar joint dislocations are uncommon injuries which involves disruptions of the talocalcaneal and talonavicular joints. Open dislocations are even rarer which are associated with a high rate of infection and Figure 1: Open dislocation of right talus poor clinical outcomes. head

MATERIALS & METHODS: We report a case of 24 years old male who presented with an open wound and deformity of his right ankle following a motor vehicle Figure 2: Plain radiograph of right subtalar accident. He sustained an open right subtalar medial dislocation joint dislocation. Immediate wound wash out and closed reduction was performed at Infection is common and is usually casualty followed by wound debridement, associated with poor outcomes. The wash out and across ankle external fixation mechanism of open subtalar dislocation in within 10 hours. Pus discharge was noted this case was due to direct impact to the within the joint at 48 hours during 2nd look lateral foot, forcing the foot into a supination wound debridement. Two more wound position. The anterolateral aspect of skin was debridements and arthrotomy wash out were sheared off resulting in the talar head being undertaken over the next three weeks due to exposed. Timing of wound debridement persistant wound infection. He received a should be as soon as possible, and ideally total of 6 weeks of intravenous antibiotics should be within 6 hours to reduce the risk and his external fixation was removed after 6 of infection. The external fixation was used weeks. With a well healed surgical wound, for optimum wound management due to patella tendon bearing cast was applied for a severe soft tissue injury as well as to reduce further 6 weeks followed by limb the risk of avascular necrosis of talus by strengthening and range of motion exercises. reducing the load over the talus (2). In this case, despite severe infection, we were able RESULTS: to achieve good short term clinical outcome. Six months after injury, he had no complains of pain or instability of his ankle and his gait CONCLUSION: was normal. His wound well healed and was Open subtalar dislocations complicated with able to achieve full range of motion of his infection but treated with adequate wound right ankle. The American Orthopaedic Foot debridement and antibiotic can still achieve and Ankle Society (AOFAS) Ankle good clinical outcome. Hindfoot score was 100. REFERENCES: DISCUSSIONS: 1. Merchan EC. Subtalar dislocations: long- The medial subtalar joint dislocation is the term follow-up of 39 cases. Injury most common type of subtalar dislocation 1992;23:97—100. with an incidence of about 85%. Open 2.Milenkovic, S., Mitkovic, M., & subtalar joint dislocations account for about Bumbasirevic, M. (2006). External fixation 10-40% of these cases (1). of open subtalar dislocation. Injury, 37(9), 909-913 PT22A Antibiotic Impregnated Cement Spacer As Definitive Treatment For Shoulder With Infected Implant: A Case Report

Ng MG; Lam AWC; Dian DL; Ang HL Hospital Tengku Ampuan Rahimah, Taman Chi Lung, Jalan Langat, 41200 Klang, Selangor, Malaysia

INTRODUCTION: DISCUSSION: Three and four part fractures of proximal The management of an infected implant has humerus are usually treated surgically and always been a challenge, especially if ORIF is the treatment of choice for younger involving a joint. A 2 staged approach is one patients. Management can be complex in the of the recommended methods. This involves event when patients develop surgical site insertion of an antibiotic cement spacer and infection. The following report addresses the subsequently a definitive implant once management of such complication with the infection is eradicated. In this case, we did not use of an antibiotic impregnated cement proceed with the second stage procedure as spacer to resolve the infection, pain, restore of our patient had satisfactory outcome with the function and provide patient satisfaction. antibiotic spacer as the definitive treatment in CASE REPORT: terms of pain and function for the past 3 years. A 21 year old lady was involved in a road The recent radiological controls show no signs traffic accident and sustained closed fracture of spacer loosening or joint osteolysis. of proximal humerus (Neer 4). Open reduction Infective markers are also within the normal and proximal humerus locking plate was done range. Literature review found that the within 3 days. Four weeks later, she developed duration of antibiotic spacer as a temporary pain, swelling and purulent discharge from her prosthesis was debatable. Ranging from 6 surgical wound. Infective markers WBC, ESR months till 5 years, without adverse effects and CRP were raised. She was treated with IV reported. However, the cement-bone antibiotics for 6 weeks and wound articulating surface and its long term effects debridement/arthrotomy wash-out. After 12 are still not well described. months of follow up, there were no signs of CONCLUSION: fracture union, there was destruction of the Antibiotic cement spacer can be considered as humeral head with raised infective markers. an alternative definitive treatment for infected The implant was removed and a manually shoulder implants in selected cases as molded antibiotic impregnated cement spacer proceeding with joint arthroplasty in a attached to a rush rod was used as first stage previously infected region is not without risks. treatment for her giving her the option of a In this case, our patient achieved reasonable second stage shoulder arthroplasty in the outcome in terms of functionality, pain control, future. During follow up, she was pain free satisfaction and cost effectiveness. with gradual improvement of function with REFERENCES: physiotherapy. Option of second stage 1) Haddad S et al. Antibiotic-impregnated shoulder arthroplasty was discussed but she cement spacer as a definitive treatment for refused as she was very satisfied with her post-arthroscopy shoulder destructive current condition. 5 years after initial injury osteomyelitis: case report and review of and 3 years post spacer insertion, she has literature. Strategies in Trauma and Limb minimal functional disability and is able to Reconstruction. 2013;8(3):199-205. carry out her daily activities. Her shoulder 2) Levy J et al. Use of a Functional Antibiotic range of motion was forward flexion (0-60O), Spacer in Treating Infected Shoulder abduction (0-75O), extension (0-30O), internal Arthroplasty. Orthopaedics. 2015; 38: rotation (60O), and external rotation (30O). She e512-e519. is also pain free and satisfied with her current 3) Leone J et al. Management of infection at condition. Her American Shoulder and Elbow the site of a total knee arthroplasty. Instr Surgeons (ASES) shoulder score was 63.3. Course Lect. 2006;55:449–461. PT22B Review Of Autogenous Morcelized Fibula Bone Graft In Illizarof External Fixator Patients With Delayed & Non-Union Tibia

Choong Jin. N; Ganaisan. P; Rabin.V; Manickam T; Vincent.J; Selvan. D Department Of Orthopaedics and Traumatology, Hospital Tengku Ampuan Rahimah Klang, Taman Chi Lung, Jalan Langat, 41200 Klang, Selangor, Malaysia

INTRODUCTION: DISCUSSIONS: Non union tibia in patients treated with IEF We find this technique advantageous in terms for complex open tibial fractures are common of a shorter duration of surgery with minimal in which can be treated with bone grafting , blood lost, lesser donor site morbidity and chipping osteotomy or partial fibulectomy complication as well as a shorter duration of .Our series of patients with non union tibia on hospital stay. Furthermore with morcelized IEF shows promising results and advantages fibula graft, we were able to produce with the use of ipsilateral morcelized fibula significant amount of fine cortical bone graft cortical bone graft. that would increase the surface area of tibia METHODS: bone contact with graft, thus accelerating We retrospectively analysed 4 patients that callus formation by 6 weeks post operatively.. was treated with IEF for complex open tibial CONCLUSION: fractures in our centre from Jan 2015 to Jan Morcelized fibula bone graft is advantageous 2016 who eventually developed delayed or in non union or delayed union tibia on IEF as non union An above knee tourniquet was it produces significant callus formation by 6 applied and 1-2 cm of cortical bone was weeks and possibly reduces external fixator harvested from ipsilateral fibula through a 2 index with reduction in intraoperative and cm lateral skin incision over the fibula shaft. postoperative morbidity and post op pain thus The graft is then placed into a bone miller and shorten duration of hospital stay. shredded into fine pieces and packed into the REFERENCES: large tibial defect. Post operatively, pain was 1. Jo DUJARDYN , Johan LAMMENS. assessed with visual analogue score and Treatment of delayed union or non-union of followed up at our clinic every six weeks to the tibial shaft with partial fibulectomy and an denote radiographic callus formation and Ilizarov frame: Acta Orthop. Belg., 2007, 73, union. 630-634 RESULTS: 2.. Pieter H. J. Bullens MD, H. W. Bart We noted minimal blood lost of less than Schreuder MD, PhD, Maarten C. de Waal 50ml from a small incision and significant Malefijt MD, Nico Verdonschot PhD, Pieter reduction in operative time. Post-op pain Buma PhD: Is an Impacted Morselized Graft averaged at VAS score of 3-4/10 and patients in a Cage an Alternative for Reconstructing were able to immediately ambulate and Segmental Diaphyseal Defects?- Clin Orthop discharge on post-op day 2. All patients Relat Res (2009) 467:783–791 showed significant radiographic callus formation by 6 weeks post operatively.

Figure 1: showing X- Figure 2: showing X- ray (AP view) non ray(AP view) at post union tibia on IEF op 6 weeks. PT22C Coronal Shear Fracture Of Distal End Of Humerus Treated With Headless Screw Fixation Via Antero-Lateral Approach – A Case Report

Ram KR; Maria SW; CH Foo; Jaffar MSA Department Of Orthopaedic Surgery, Queen Elizabeth Hospital, Jalan Penampang, Penampang, 88200 Kota Kinabalu, Sabah, Malaysia

INTRODUCTION: headless screws from anterior to posterior. The Coronal shear fractures of distal end of the left elbow was immobilised for 3 weeks. He Humerus comprises 1% of elbow fractures. was prescribed Indomethacin and This fracture was first described by McKee et rehabilitation programme. On follow up, the al in 1996(1). An Open reduction and Headless fracture healed well and his active range of screw fixation is the preferred mode of movement was from 20º to 130º. treatment (2,3). We like to share our experience DISCUSSION: in managing this rare fracture. The mechanism of injury is vertical shear CASE: force on the distal humerus. As this is a rare A 15 year old boy presented to us with a fracture, it’s easily missed. A lateral elbow history of fall on outstretched left hand during radiograph and CT scan is very helpful in a football game. He couldn't move his left diagnosing, classifying and managing this injured elbow. On examination, the left elbow fracture. 4 types were described by McKee et was kept in flexed position. His left elbow was al (1). Type 1(Hahn-Steinthal fracture), which swollen and tender on palpation. Distal involves large fragment of the capitellum, with neurovascular status was intact. A lateral left minimal or no involvement of lateral part of elbow radiograph demonstrate the the trochlea. Type 2 (Kocher-Lorenz fracture), characteristic “Double Arc Sign” (1, 4). An open which involves anterior articular surface of reduction and screw fixation was performed. capitellum with minimal underlying bone. SURGICAL TECHNIQUE: Type 3 (Broberg and Morrey), which is An Anterolateral approach of the elbow was comminuted fracture of the capitellum. Type 4 used. An incision was made over the lateral is coronal shear fracture of the capitellum. border of the left biceps muscle 5 cm above Lateral or an extended Kocher approach is the the flexion crease of the elbow and curved recommended approach to this fracture, but it laterally as it approaching the flexion crease does not provide an adequate surgical view for and curved medially after the flexion crease anatomical fixation of the trochlear fragment (3, along the medial border of the brachioradialis 4). In this case, Antero-lateral approach was muscle. Lateral cutaneous nerve of forearm used in order to solve this issue. was secured .Deep fascia was incised, CONCLUSION: brachioradialis muscle and brachialis muscle The Antero-lateral approach provides an were identified proximal to the elbow joint. excellent intraoperative view and hence allows Internervous plane of these two muscles was a good anatomic reduction as compared to an developed and retracted accordingly. Radial extended lateral approach in our experience. nerve was identified and secured. Distally We thus recommend the Antero-lateral brachioradialis muscle and pronator teres approach in this elbow injury. muscle were identified and retracted according REFERENCES: to the internervous plane. The elbow capsule 1. Michael D. McKee, Jesse B. Jupiter and H. was incised. The fracture comprised of 3 Brent Bamberger, Coronal Shear Fractures major fragments. A major capitellar fragment, of the Distal End of the Humerus. J Bone a fragment consisted of medial border of Joint Surg Am. 1996; 78:49-54. capitellum and lateral half of trochlear and a fragment of medial half of trochlear. 2. Junya Imatani, Yoshiaki Morito, Hiroyuki Fragments were reduced anatomically and Hashizume and Hajime Inoue, Internal held with Kirschner wires temporarily. The fixation for coronal shear fracture of the definitive fixation was performed with 3 distal end of the humerus by the

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Open Reduction And Internal Fixation Mason Type IV Radial Head Fracture: Case Report

Mohd FR; Amir FZ Department Of Orthopaedic, Hospital Sultanah Nur Zahirah, Jalan Sultan Mahmud, 20400 Kuala Terengganu, Terengganu, Malaysia

Introduction: only case we did ORIF using mini plate with Eventhough radial head fracture accounts good outcome. about 4% of all fractures it is a challenging injury to treat as its complications can be catastrophic. Complications rate was as high as about 47% in a randomised controlled study comparing group of patients underwent radial head arthroplasty to that of those underwent ORIF of radial head1. Figure 1.0 Case report: A 26 year-old female had involved in a motor vehicle accident and presented with left elbow pain, swelling and deformity. Plain radiographs showed she had left radial head fracture with elbow dislocation, Mason's classification type IV. A successful close manual reduction was done without neurovascular compromise. She was then offered for operative management. Uneventful open reduction and internal fixation (ORIF) mini plate of left radial head Figure 2.0 were commenced. She developed left wrist drop postoperatively. The wrist drop resolved Conclusion: after 2 months and 7 months later she had full Patients with Mason's type IV radial head left elbow range of motion with good wrist fracture could be offered ORIF (mini plate) and forearm functions on her last follow up but with optimum intra and post operative care session. to ensure good prognosis.

Discussion: References: Management of radial head injury depends on 1. Salah AB et al. (2015) Open reduction and internal fixation versus radial head the fracture configurations which are arthroplasty in the treatment of adult close described in Mason classification. Type 4 communited radial head fracture. involves radial head fracture with elbow 2. Xiao Chen et al. (2010) Comparison dislocation. In this case, surgical option might between radial head replacement and open benefit her in terms of satisfactorily stabilising reduction and internal fixation in clinical the fractures with early mobilisation which treatment of unstable, multi-fragmented radial head fractures. eventually yields a good elbow function ( Nalbantoglu U, et al. in 2007). In our setting, we have several radial head fracture cases since 2012 until recent, but this patient was the PT23A Establishing Standard Operating Procedure For Femoral Head Procurement And Preparation As Allograft

Eva Mahirah Zulkifli; Abdul Wafiy Mohd Padzil; Lim How Keat; Ristiman Idris; Tiew Sei Kern; Rifa Aquidag Subhan Hospital Tengku Ampuan Rahimah, Taman Chi Lung, Jalan Langat, 41200 Klang, Selangor, Malaysia

INTRODUCTION: Hospital Tengku Ampuan Rahimah (HTAR), Klang is a centre for advanced trauma cases. Our orthopaedic department deals with a high number of non-union cases which require bone grafting. Autologous bone grafts, however, are limited in supply and are associated with donor site morbidity while synthetic bone graft substitutes are expensive with questionable results. Allografts are an attractive alternative as they are cheap and available in large quantities. However, a standard operating procedure needs to be established and followed in order to ensure safety without compromising their quality as bone grafts.

METHODS: Literature review was done in order to Figure 1: Standard Operative Procedure Of establish a standard operating procedure in all femoral head procurement and allograft aspects of allograft bone banking including preparation. donor screening and harvesting, sterilization, transport, and storage of the allografts. Questionnaires, consent forms and a checklist DISCUSSIONS: were constructed and their validity was The availability of this standard operating ensured before being used for the study. procedure for all hospitals will ensure the The standard operating procedure was then safety and efficacy of using allografts in cases used and audited by our internal auditor. of non-unions requiring large amounts of bone graft. RESULTS: From June 2015 till December 2015, 20 REFERENCES: patients going for hemiarthroplasty or total hip 1. Patzakis MJ et. al. Clin Orthop 1989; replacement were approached for femoral 243:36–40 head bone banking. 18 patients agreed out of 2. Adams CI et. al. Injury 2001; 32: 61-65. which 16 patients passed the screening tests and their bones were harvested. However, only 12 femoral heads were kept as these follow our standard operating procedure and were sent for sterilization. The whole process was audited.

Up till December 2015, only 1 allogaft was used and the recipient was well without any complication. PT23B Primary Soft Tissue Reconstruction Versus Delayed Soft Tissue Reconstruction In Grade IIIb Open Tibia Fractures. A District Hospital Experience

1Harkeerat Singh; 1Ariffin M.A; 1K.Hariharan; 2Fauzlie.Y, 1VS.Naveen 1Department of Orthopaedic Surgery Hospital Tawau, 67, Peti Surat, 91007 Tawau, Sabah, Malaysia 2Department of Orthopaedic Surgery Hospital Melaka, Jalan Mufti Haji Khalil, 75400 Melaka, Malaysia

INTRODUCTION: hemisoleus flap patients one had sea water Open fractures of the lower limb pose an array contamination and developed wound infection of complexity in the soft tissue reconstruction post reconstruction.One patient who of these patients. Special interest is taken for underwent the reverse sural flap had Grade IIIb open fractures of the tibia where developed partial flap necrosis.For the second soft tissue and blood supply is scarce. We group,all patients had good wound healing conducted a prospective study to look into the except for 3 patients who developed chronic viability of soft tissue reconstruction with wound sinuses primary closure with flaps on the same sitting as the debridement versus a vaccum dressing DISCUSSIONS: post debridement and soft tissue The number one obstacle that we faced in reconstruction on a further scheduled date. All treating our tibial open fractures was infection. operations were performed Hospital Tawau by Contused soft tissue and muscles that appears the Orthopaedic Surgeon in charge. normal intraoperatively pose a threat post manipulation for organisms to colonize. METHODS: Partially attached fragments that pass the tug All patients with open tibia fracture Grade IIIb test in comminuted fractures also threaten to were recruited for this study. The patients harbour colonies. Therefore we recommended were then randomly assigned into two a multiple inspection of tissue viability and management groups, the first group had 15 copious irrigation umpteen times patients where primary soft tissue intraoperatively. reconstruction was performed on the same sitting as the debridement. The second group CONCLUSION: had 28 patients who underwent debridement Primary soft tissue coverage with muscle flaps and vaccum dressing followed by soft tissue is a viable option in the management of Open reconstruction on a planned elective date. Grade IIIb Tibia fractures.the debridement Reconstruction comprised of flaps based on should be meticulous and carried out by the the site of fracture, proximal tibia fractures surgeon.We note that cases where open underwent gastrocnemius flaps, midshaft fractures were a result of barn yard injuries fractures underwent either a split tibialis and injuries resulted at rivers and ponds were anterior flap or hemisoleus flap, and distal not good candidates for primary soft tissue fractures were subjected to sural flaps. coverage.

RESULTS: REFERENCES: A total of 43 cases were recruited in this 1. Jeffrey L, Gum MD, David Seligson. study, Out of the 15 in the primary flap group Update on The Management of Open 6 of them had a gastrocnemius flap, 5 of them Fractures. AAOS 2012; Vol 10: No 9 with a split tibialis anterior flap and 2. Raman M et al. Open Tibial Fracutres: hemisoleus flaps and 4 reverse sural flaps. Out Updated Guideline for Management. JBJS of the 6 gastrocnemius flap patients one of Reviews, 2015 Feb; 3 (2): e1 them developed fulminant sepsis due to severe 3. Simon K et al. Standards for the comminution of the fracture fragments and management of open fractures of the lower violation of the soft tissue. Out of the 4 limb. BAPRAS 2009 September PT23C Ipsilateral Traumatic Fracture Proximal And Distal Humerus (Floating Arm): A Case Report

Lloyd S Department Of Orthopaedic, Hospital Selayang, Lebuhraya Selayang-Kepong, 68100 Batu Caves, Selangor

The combination of supracondylar humerus fracture with an ipsilateral fracture of the proximal humerus is known as “Floating arm “ injury . This is a high velocity injury which is rare and the technique is very challenging for the treating surgeons. This surgery also carries a poor prognosis. There are a lot of queries among surgeons regarding the method of reduction for these type of fracture. Apart from that, deciding which fracture to be reduce first has always been a problem to many surgeons. It is also depends on the fracture configuration. In our case, initially we approach the proximal humerus fracture through deltoid splitting method since it was a simple transverse fracture. This was done in a supine position. The patient was then repositioned to left lateral to approach the communited supracondylar fracture through a chevrons osteotomy . The proximal fixation made the fixation more stable and it was easier to approach the second fracture which was more communited . The intraoperative image intensifier became more easier to performed and aid in the reduction. The main aim of this treatment is for the patient return to functional state. In conclusion, we propose reduction of simple fracture should be given priority before addressing a communited fracture in a floating arm injury. After reduction and fixation, these patients need early rehabilitation to avoid stiffness PT23D An Alternative In Managing Open Grade IIIb Tibia Fracture. Is 8 months Enough?

TJ Teoh; Thirumurugan K; Prashant Narhari Department of Orthopedics, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia

Introduction: Vacuum-Assisted Closure(VAC) system has been successfully used in the management of Fig 1: Patient initial various complex and large wounds. Open wound tibial fractures are severe injuries, largely affecting young men of working age, and take on average 11 months to unite, with 13% developing non-union in the best centres.1 Therefore, decision making is crucial when Fig 2: Patient wound deciding in method of soft tissue post 3 times reconstruction. With a combined treatment of both the soft-tissue and skeletal components in vaccuum dressing severe open tibial fractures, outcomes can be improved and mortality reduced. We report a case of an elderly patient who sustained an open tibia fracture with extensive soft tissue Fig 3: AP view left injury who was treated with standard early tibia fibula Xray 8 care followed by VAC dressing for soft tissue months following coverage and Bone Morphogenic Protein injury (BMP) to achieve bone union.

Case report : 68 year old gentlemen presented to us Discussion following a motor vehicle accident in January Open tibial fractures imposes significant risk 2015. He sustained an open fracture of his left of morbidity as well as socioeconomical tibia and fibula, grade IIIB. Wound was problem for society. The treating surgeon contaminated with extensive soft tissue loss faces challenges incontrolling infection, over the left leg. Standard care using wound getting good soft tissue coverage and finally debribment with external fixation was done as getting the bone to unite. VAC is an the early management. Due to severe soft alternative to standard dressings in a number tissue involvement, postoperatively the patient of orthopaedic trauma related wounds. In was left with a 7X4 cm exposed tibia.(Fig 1) recent years it has been exploited to achieve Patient underwent serial wound debridements, "soft tissue" cover in cases which classically with Vacuum Assisted Closure (VAC) and required flaps. cortical drilling. After 6 weeks, the bone was In our highlighted case, the "soft tissue" covered with healthy granulation tissue and coverage proved to be durable enough in split skin grafting(SSG) performed.(Fig 2) The withstanding infection and supporting the wound healed well. The patient subsequently underlying bone to achieve union. With the underwent plating of left tibia with BMP and assistance of bone grafting and BMP, the autologous bone grafting. 8 months following union of the bone was obtained faster than injury, his fracture completely united and was standard therapy. able to fully weight bear(Fig 3) We believe the combination of standard early care with VAC and bone grafting combined with BMP gives excellent control in managing infection, soft tissue loss and bone union.

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