Chronic tibial osteomyelitis in children. A case review at Hospital Tengku Ampuan Afzan, Kuantan

Osteomyelitis in children has various clinical manifestations causing diagnostic and therapeutic difficulties. Inappropriate treatment of acute osteomyelitis may lead to chronic, serious and complicated condition. Chronic osteomyelitis continues to be a major cause of morbidity and disability in children living in developing countries. We present three cases of tibial osteomyelitis that have different presentations and sequalae. Our intention is to alert our colleagues, particularly primary physicians, regarding the variety of presentation and the important of early diagnosis and treatment to reduce the risk of morbidity following osteomyelitis

Early functional and radiological outcomes between plaster cast and fiberlass cast in stable thoracolumbar burst fracture

Introduction: Burst fracture results from compression failure of both the anterior and middle columns under substantial axial loads. Conservative treatment was a method of treatment for fractures without neurological deficit. This cross sectional study was designed to evaluate the functional and radiological outcome of patient with thoracolumbar burst fracture treated conservatively. Methods: 40 cases were recruited from January 2013 till December 2015. They were followed-up with minimum period of 1 year and evaluated for the functional (Oswetry Disbility Index) and radiological outcomes (kyphotic angle deformity and anterior body compression). Results: 20 patients were treated with body cast made form plaster of Paris and remaining 20 patients with fiberglass cast. In plaster of Paris group, mean kyphotic angle deformity at last follow up was 16.60 ± 2.95 with a mean improvement 4.45 degree and anterior body compression at last follow up was 30.35% ± 10.2 with mean improvement of 9.30%. In fiberglass group, mean kyphotic angle deformity at last follow up was 15.55 ± 3.38 with a mean improvement 7.25 degree and anterior body compression at last follow up was 25.90% ± 7.81 with mean improvement of 3.45%. The functional outcome showed Oswetry Disability Index (ODI) score in plaster of Paris group was 23.70 (SD = 7.82) and in fiberglass group was 18.50 (SD = 5.94). Conclusions: Application of body cast using a fiberglass material give better radiological outcome hence less pain, more functional and higher patient’s satisfaction as compared to plaster of Paris

Neglected DDH in older children: A report of two cases

INTRODUCTION: Multiple studies reported on different types of approaches and acetabuloplasty for management of neglected developmental dysplasia of the hip (DDH) in older children. REPORT: Here, we report 2 cases of sisters aged 9 and 10-year-old presented with painless limp since childhood. They walked with short limb gait with shortening of 5 and 6cm each. Younger sister has right neglected DDH. They underwent open reduction, capsulorraphy, femoral shortening and shelf acetabuloplasty. Hip ilioinguinal approach was used with separate lateral approach to proximal femur. Concentric and stable reduction of the hip were achieved after the acetabuloplasty and 2 and 2.5cm femoral shortening. The graft used was from femoral osteotomy and held with 2 K-wires and another K-wire for maintaining the concentric reduction. Femoral osteotomy fixed with small DCP with 4 screws. They were immobilised with hip spica for total 12 weeks. Review at 18-month post-operative revealed both patients walked with short limb gait and the radiograph showed good remodeling. CONCLUSION: A stable painless mobile hip should be the aim of management. Regardless of any surgical methods and surgical approaches, excellent to good McKay criteria reported up to 85-100%. Similar principles were applied in DDH surgical reconstruction at any age, but in patients aged more than 8-year-old, acetabular development should not be expected hence effort should be made to reconstruct. No evidence in the literature to support the deterioration of hips due to any osteoarthritic changes up to 6 years of follow up. If this is happened in future, hip replacement will be made much easier

Infant with Multifocal Osteomyelitis

INTRODUCTION: Multifocal osteomyelitis is rare but potentially cause morbidity and mortality. Higher risk in infants and older children with risk. Incidence reported 20-50% in all neonates with osteomyelitis. REPORT: 3-month-old boy, born premature at 35 weeks, had reduced left upper limb movement for 1 week without history of trauma. 2 weeks prior, he had vaccination to right thigh and fever secondary to tonsilitis where he was prescribed with amoxycillin. Examination revealed left shoulder reduced motion with swelling and erythema. Radiograph showed callus over clavicular fracture and ultrasound showed subcutaneous edema. Infective parameters were raised. Initial diagnosis were cellulitis with healing clavicle fracture and parenteral cloxacillin was started. Clinical condition not improving despite 7 days antibiotics and repeated radiographs showed lytic lesion with extensive periosteal reaction, hence raised the suspicious of osteomyelitis where it was confirmed with MRI. MRI revealed ostemomyelitic foci at left clavicle and scapula, T1 to T7 ribs and left humeral head. Parenteral ceftazidime was added. He responded well with improved clinical condition and blood parameters. At 3 weeks of admission, noted reduced motion and swelling over right forearm. Radiographs of the right radius and ulna showed similar changes as left clavicle. Radionuclide imaging detected high uptake at bilateral radius and ulna, left clavicle and left ankle. Due to multiple bones involvement, syrup rifampicin was added for 2 weeks. Patients responded well to the antibiotics regime clinically and biochemically and was discharged well. Review at 6 Review at 6weeks from the first diagnosis, he was active and well. CONCLUSION: Whole body MRI or radionuclide imaging are suggested for suspected cases. Antibiotics should cover for staphylococcus, gram negative and positive. Short duration of rifampicin may be considered in case of unresponsiveness

The siblings' problem

THE SIBLINGS’ PROBLEMS: REPORT OF TWO NEGLECTED DDH NAA N.Alyani1, AR Ardilla Hanim1, A M.Shukrimi1 1 Department of Orthopaedic, Traumatology and Rehabilitation, Kulliyyah of Medcine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia INTRODUCTION: The surgical management of neglected developmental dysplasia of the hip (DDH) in walking children has always been a challenge to orthopaedic surgeons. Multiple studies reported on different types of approaches and acetabuloplasty methods. METHODS: Here, we report 2 cases of sisters aged 9 and 10 years old who presented with unilateral painless limp since childhood. Clinically, they walked with short limb gait with shortening of 5 and 6 cm each. The younger sister has right neglected DDH (Fig 1) while the elder has left sided (Fig 2). They underwent open reduction, capsulorraphy, varus derotation osteotomy of proximal femur and shelf acetabuloplasty. Hip ilioinguinal approach were used with separate lateral approach to proximal femur. We were able to get concentric reduction of the hip and stable after the acetabuloplasty and femoral shortening about 2 to 2.5cm. The graft used was from femoral osteotomy and held with 2 K-wires and another K-wire for maintaining the concentric reduction. Femoral osteotomy was fixed with small dynamic compression plate with 4 screws. They were immobilised with hip spica for initial 6 weeks where removal of wire and change of spica were done; then continued to another 6 weeks before it was removed and partial weight bearing was allowed. RESULTS: They developed early complication of pressure sore and superficial SSI at 3-6weeks post operatively that resolved with dressing. At latest review about 10 months post operatively, patient were active but with some abductors weakness which has been improving the previous review. The reduction is maintain and shelf bone graft were well incorporated (Figure 3). DISCUSSION & CONCLUSIONS: A stable painless mobile hip is the aim of the management1,2. Regardless of any surgical methods and surgical approaches, excellent to good McKay criteria reported up to 85-100%2,3,4 of cases. Similar principles are applied in DDH surgical reconstruction at any age, but in patients aged more than 8 year-old, acetabular development should not be expected hence effort should be made to reconstruct. No evidence in the literature to support the deterioration of hips due to any osteoarthritic changes up to 6 years of follow up. If this is happen in the future, hip replacement will be made much easier1. REFERENCES: 1 M.El-Sayed et al, (2012), The effect of Dega acetabuloplasty and Salter innominate osteotomy on acetabular remodeling monitored by the acetabular index in walking DDH patients between 2 and 6 years of age: short- to middle-term follow-up, J Child Orthop 6:471–47. 2 HE El-Tayeby, (2009) One-stage hip reconstruction in late neglected developmental dysplasia of the hip presenting in children above 8 years of age, J Child Orthop 3:11–20. 3 I Qadir et. al. (2018) One-stage Hip Reconstruction for Developmental Hip Dysplasia in Children over 8 Years of Age, Korean Medical Journal. 4 Vallamshetla VRP et al. (2006), Congenital dislocation of the hip a re-appraisal of the upper age limit for treatment, J Bone Joint Surg Br. Aug;88(8):1076-8

Fracture prediction on patient-specific tibia model with osteogenesis Imperfecta under various loading direction

This study aims to predict the fracture of bone with osteogenesis imperfecta (OI) by considering the homogenization properties of real patient. A Type-III of osteotomy in OI femur was used as bone specimen. Nine representative volume element (RVE) models were developed based on μCT-images of bone specimen. Homogenized properties particularly the Young's moduli of the RVEs was obtained based on homogenization theory in Voxelcon software. The obtained homogenized properties were then assigned to the OI patient-specific model that was developed from CT-images of real patient. The fracture of OI bone was predicted based on linear static analysis and finite element method under loadings of activity daily living (ADL). The results found that the fracture might be happen to the patient under jumping load case, whereas the subject is expected to be safe under standing still and walking load case

Bilateral olecranon fracture in adult. A case report.

We report a case of a 14 - year - old Malay male who fell at school and sustained bilateral olecranon fractures. He had undergone an open redu ction and tension band wiring to stabilize the fracture. Three months after the surgery, the movement of both his elbows was satisfactor

Modelling of patient-specific femur with osteogenesis imperfecta to determine the fracture risk under various loads

Osteogenesis imperfecta (OI) is a fragile bone disease characterized by easy fractures. The femur consists of cortical and cancellous bone, each with different mechanical properties. Bone fractures often occur throughout patients’ lifetime. However, doctors still have no quantitative method to predict fractures. Therefore, this project’s purpose is to investigate the OI femoral fracture risk to help prevent fractures. The project consists of three sections; cortical and cancellous segmentation, reconstruction of 3D OI femoral model and finite element analysis (FEA) of the OI femur to obtain fracture risk. The fracture risk in daily activities and the fracture load were examined. All the stress values were judged by the fracture criteria, assumed as 115 MPa. The exercises that exerted force more than 6 times of body weight can cause fractures. In addition, the optimal compressive force and tensile force were 919.7 N and 912.1 N, respectively, while medial and lateral impact were 230.8 N. Cancellous bone was not affected even a fracture happen. Based on these findings, we can conclude that when the OI femur is subjected to lateral or medial forces, the femur breaks easily. The bone can be reconstructed into a solid body without having to separate bone into cortical and cancellous