Surgical reconstruction of an open medial malleolus fracture using a novel technique: a case report

Case: A 17-year-old male sustained an open fracture of the right medial malleolus (MM) with significant bone and soft tissue loss following a motor-vehicle accident. Following serial wound debridement, his ankle was effectively reconstructed with MM antiglide plate stabilization, iliac autogenous bone graft, and a free radial forearm soft tissue flap. Conclusions: Open MM fracture with bone and soft tissue loss is rare. It is feasible to treat this injury with a novel surgical reconstruction technique involving autogenous bicortical iliac bone graft and radial forearm free flap

A rare cause of dyspepsia: a case report of gastric diverticulum

A gastric diverticulum is an outpouching from the gastric mucosa. It is extremely rare. It is normally asymptomatic, but some may present with non-specific abdominal pain. A combination of upper gastrointestinal endoscopy and radiological contrast study such as oral barium study and computed tomography are needed to make a definite diagnosis and to rule out other associated pathology. Although treatment with medical therapy has been reported to be effective, the use of open and laparoscopic resection also yields a good outcome in the management of complicated gastric diverticulum. We present a case of symptomatic gastric diverticulum which has been successfully treated with medical therapy

Heterotopic ossification of the hip post reamed intramedullary femoral nail: a case report

Hetorotopic Ossification (HO) is abnormal formation of bone in the soft tissue. Heterotopic ossification of the hip following reamed interlocking medullary nail is uncommon and it has received little attention from the clinician. We take this opportunity to report a young man who presented with symptomatic heterotopic ossification of the hip eight months post antegrade reamed interlocking medullary nail which failed conservative treatment. Reamed intramedullary nailing and delayed mobilization are the contributing factors in this patient. The pathophysiology of this condition is not fully understood. As a result, there is no consensus in the prevention of heterotopic ossification in such patients. Similarly, the management of this condition also is lacking but resection is the treatment of choice for symptomatic patient

Factors associated with deep surgical site infection in spinal surgery

Introduction: Surgical site infection (SSI) rate in spinal surgery ranges from 1% to 9%, depending on the type of procedure and institution. SSI gives rise to increased morbidity, poorer outcomes and increased healthcare costs. Various risk factors have been reported in the literature but there is no such related report from Malaysia. This pilot study aimed to determine the incidence and risk factors of deep surgical site infections which require surgical debridement in patients who had undergone spinal surgeries. Materials and Methods: Patients who had undergone spinal surgery at Hospital Tengku Ampuan Afzan, Kuantan from the 1st January 2016 to the 31st December 2017 were included in this study. Associations between SSI and risk factors were analysed with IBM SPSS version 21. Age, body mass index, number of vertebral level involvement, hemoglobin reduction and white blood cell count were analysed by the student t-test while gender, smoking status, spinal cord involvement, fracture dislocation at thoraco-lumbar junction and history of pre-operative blood product transfusion were analysed by Fisher’s exact test. Results: Four (17%) out of 24 patients developed deep SSI which required surgical debridement. Fracture dislocation at the thoraco-lumbar junction (p=0.008) and history of pre-operative blood product transfusion (p=0.003) were associated with deep SSI. Conclusions: This study highlighted different risk factors associated with deep SSI in spinal surgeries. A larger study is needed to further confirm these findings

Arthroscopic subacromial decompression in the treatment of shoulder impingement syndrome: a prospective study in Malaysia

Introduction Shoulder impingement syndrome (SIS) is one of the common problems which lead to shoulder disabilities. This condition has been described as impingement to the rotator cuff by the anterior third of the acromion process and has been classified into three stages. Treatment option varies depending on the grade of the disease. Arthroscopic subacromial decompression (ASAD) has become more popular in recent years and has shown to have a good outcome. The purpose of this study is to evaluate the outcomes following ASAD in terms of the functional, clinical, and radiological parameters in treating SIS in the ageing population in Kuantan, Pahang, Malaysia. Materials and methods This was an observational study looking at the outcomes of patients with stage 2 and stage 3 (partial cuff tear) impingement syndrome who underwent ASAD in Hospital Tengku Ampuan Afzan and International Islamic University Malaysia Medical Centre from May 2018 to June 2019. The functional outcomes were evaluated using American Shoulder and Elbow Surgeons (ASES) score taken at pre-operative, six weeks, three months, and six months post-operation. Clinical outcomes were evaluated using Constant score (CS) taken at six months post-operation. Radiological outcomes were measured by comparing acromiohumeral distance pre- and post-operation on anteroposterior (AP) view radiograph of the affected shoulder. Results A total of 28 patients were selected for the study. On functional outcome, there was a significant effect of time on the ASES scoring system (p-value <0.05) from pre-operative to six months post-operation. On clinical outcome, the CS at six months showed 13 patients have excellent scores, 10 have good, and five have fair scores. There was a statistically significant difference in mean values of all categories (p-value <0.05). In terms of the radiological outcome, this study observed a significant increase in patients’ subacromial space on X-ray from the pre-operative and post-operative treatment stages. In this study, we also observed that there was no significant difference in outcomes between partial and intact rotator cuff (RC) tears at six- month post-operation. Conclusion In this study, ASAD was found to be a beneficial intervention in the treatment of patients with shoulder impingement evidenced by the significant outcomes in terms of functional, clinical, and radiological parameters

MRI evaluation of anterolateral ligament of the knee: a cross-sectional study in Malaysia

Introduction After detailed anatomical delineation of the anterolateral ligament (ALL) of the knee, there is a surge in research on this anatomical structure. Owing to the anatomical variation and lack of experience in the identification of this structure, magnetic resonance (MR) evaluation of the ALL produces mixed results. It was aimed to evaluate the ALL using the routinely performed MR imaging of the knee and to determine any associated factors with ALL injuries. Materials and methods Thirty-six MR images of the knee from 31 patients from January 1, 2017, to June 30, 2017, are evaluated. MR sequences performed include TI-weighted, T2-weighted, proton density (PD), and PD fat saturation (FS). All MR images were double-read by two authors and approved by a consultant radiologist with more than 20 years of radiological experience. The ALL was divided into three portions: femoral, meniscal, and tibial, and the ALL was considered fully visualized when all three portions were seen on MR images. Results At least a portion of the ALL was visualized in 27 scans (75%), and it was fully visualized in 20 scans (55.6%). The femoral portion was the most commonly identified (75%), followed by the meniscal portion (69.4%) and the tibial portion (58.3%). ALLs were best visualized on corona! view in PD FS with the lateral inferior genicular artery as a guide to locate the bifurcation of the meniscal and tihial components. Conclusion The ALL can be visualized in routine 1.5-T MR imaging, either full delineation (55.6%) or partially visualized (75%). It is best characterized via a PD-weighted sequence with fat saturation on the coronal plane. The ALL injury was associated with an anterior cruciate ligament (ACL) injury

Characteristics and microbiological profile of patients with diabetic foot infections in Kuantan, Pahang

Introduction: The number of people suffering from diabetic foot infection (DFI) has increased precipitously over the years in Malaysia, owing to increased population, urbanisation, the surge of number of people with obesity and physical inactivity. As one of the most dreaded complications of diabetes mellitus, DFI is associated with high morbidity and mortality. We aim to study the microbiological profile of patients with DFI at a university hospital in Kuantan, Pahang. Materials and methods: This retrospective study was carried out at at Sultan Ahmad Shah Medical Centre @IIUM (SASMEC @IIUM) from 1 January 2018 to 30 April 2019. Patients’ demographic data, types of infection and surgical intervention, and the microbiological profile were obtained from the medical records. Results: A total of 142 causative pathogens were cultured from 130 tissue samples, with an average of 1.09 pathogens per lesion. Majority of the pathogens were gram-negative pathogens (52.8%). Staphylococcus sp. was the most common pathogen isolated (22.5%). This was followed by Streptococcus sp. (10.6%), Pseudomonas sp. (9.2%), Morganella sp. (5.6%), Klebsiella sp. (4.9%), Enterobacter sp. (4.9%), and others. Among the 142 pathogens, there were 9 multidrug-resistant strains observed. Most of the antibiotics were effective against the gram-positive pathogens except benzylpenicillin, tetracyclin, fusidic acid and ciprofloxacin. Meanwhile, cefotaxime, amoxicillin and ampicillin-sulbactam were also not suitable against gramnegative pathogens. Oxacillin and sulfamethoxazole/trimethoprim can be used as empirical antibiotics against gram-positive pathogens, while vancomycin should be reserved for patients with septic shock or suspected multidrug resistant strain infection. Piperacillin/tazobactam and ceftazidime can be used as empirical antibiotics against gram-negative pathogens. Conclusion: Early initiation of empirical antibiotic(s) is paramount to stymie the infection from getting worse while waiting for the identification of causative pathogens in the management of DFI. This study provides a guide for treating physicians to initiate the most appropriate empirical antibiotic in DFI

Extracorporeal reconstruction of the radial head

Radial head fractures are common in adults. The radial head acts as an important stabilizer of the radius, especially during the forearm pronation and supination. Surgical treatment of Mason type III fracture of the radial head includes radial head excision, radial head replacement and open reduction and internal fixation. For patients treated with radial head excision, the radius might migrate proximally, causing complications such as chronic pain at the wrist, forearm, and elbow. On the other hand, radial head arthroplasty is associated with a high revision and removal rate. Hence, open reduction and internal fixation are preferred when feasible. This is technically demanding due to the severe displacement of the radial head fragments and limited surgical space. Mr K, a 30-year-old manual worker sustained a closed right radial head fracture Mason type III after an alleged fall. The radial head was displaced anteriorly. Intra-operatively, the radial headpieces were retrieved and were reconstructed extracorporeal and fixed with a miniplate. The patient subsequently recovered with good function. The new technique of extracorporeal reconstruction of the radial head offers a viable option to the surgeon with similar, or even better, outcomes in terms of elbow function

Factors associated with deep surgical site Infection following Spinal surgery: a pilot study

Introduction: Surgical site infection (SSI) is the most common healthcare-related infection in surgical patients. Patients who have undergone spinal surgeries and have contracted postoperative SSI face increased morbidity and mortality, which invariably leads to additional burden on the healthcare system and higher costs. The risk factors for the increase in SSI in patients who have undergone spinal surgery have been investigated in numerous studies but no studies have been performed in Malaysia. The aim of this pilot study is to determine the incidence and factors associated with deep SSIs in patients that have undergone spinal surgeries. Methods : This retrospective study includes all patients who underwent spinal surgeries at Tengku Ampuan Afzan Hospital, Kuantan, from 1 January 2016 to 31 December 2017. Patients with an active spinal infection, polytrauma, and open fractures were excluded from this study. Patient characteristics and laboratory investigations were extracted to determine the risk factors for deep SSI events. Associations between SSI and risk factors were analyzed with SPSS V21.0 (IBM, Armonk, NY). Results: The univariate analysis indicated that fracture dislocation at the thoraco-lumbar junction (p=0.008) and a history of preoperative blood product transfusion (p=0.003) were associated with deep SSI. Other factors such as age (p=0.162), gender (p=0.262), body mass index (p=0.215), smoking status (0.272), number of vertebrae involved in the surgery (p=0.837), spinal cord involvement (p=0.259), postoperative hemoglobin reduction (p=0.816), and preoperative white blood cell count (p=0.278) were not associated with deep SSI. Conclusions: This pilot study highlights the factors associated with deep SSI in spinal surgeries. A larger study is needed to further confirm these findings

Evaluation of feasibility of medial plantar artery flap with computed tomography angiography in diabetic patients: a pilot radioanatomic study

Background: A soft tissue defect resulting from a diabetic heel ulcer can be difficult to address due to limited reconstructive options and unique local area demand. The medial plantar artery flap is ideal for heel defect coverage as it provides a thick glabrous skin with good sensory feedback. The prerequisite of medial plantar artery flap surgery is a patent medial plantar artery, which is a branch of the posterior tibial artery (PTA). Nevertheless, no feasibility study of the medial plantar artery flap in diabetic patients with vascular insufficiency has been reported so far. We conducted a pilot study with the aim of investigating the patency of the medial plantar artery in diabetic patients with suspected peripheral artery disease to determine the vascular feasibility of the medial plantar artery flap in these patients. Material and methods: A pilot study was performed at Sultan Ahmad Shah Medical Centre at International Islamic University Malaysia (IIUM). A total of 15 diabetic patients with suspected vascular insufficiency who had undergone lower limb computed tomography angiography (CTA) from January 2022 to June 2023 were included in this study. All patients were identified via the electronic record system. Lower limb CTA images were retrieved from the Radiology Information System (RIS) and Picture Archiving and Communication System (PACS) and were double-reviewed. Both the posterior tibial artery (PTA) and medial plantar artery (MPA) were assessed for their patency, and the diameter of the lumens was measured if they were patent. Bedside clinical assessments such as palpation of pulses and portable Doppler assessment were evaluated to determine whether they could serve as substitutes for computed tomography angiography (CTA) in assessing the feasibility of medial plantar artery flap using the McNemar test. Results: In this study cohort, the medial plantar artery was present in 16 legs and absent in another 14 legs. The largest diameter of the medial plantar artery was 2.5mm (range 0-2.5mm). Palpation of the posterior tibial artery was not optimal for predicting the patency of the medial plantar artery, with a false positive of 21.4% and a false negative of 68.7%. Similarly, a hand-held Doppler assessment of the posterior tibial artery was also ineffective, with a false positive of 64.3% and a false negative of 18.8%. While the medial plantar artery is a continuation of the posterior tibial artery (PTA), PTA patency did not necessarily correlate with medial plantar artery patency. This was demonstrated on CTA assessment, where two legs with absent PTA still have reconstitution, resulting in patency of the medial plantar artery. Additionally, one leg with patent PTA did not have a patent medial plantar artery distally due to calcified vessels. Conclusion: This is a first-of-its-kind pilot study attempting to determine the feasibility of medial plantar artery in diabetic patients with vascular insufficiency. The medial plantar artery was present in more than 50% of the investigated lower limbs, paving the way for using the medial plantar artery flap in these patients. Nevertheless, a computed tomography angiogram is essential to determine the patency of the medial plantar artery prior to the flap procedure, as palpation and hand-held Doppler were inadequate to predict the patency of the medial plantar artery in these high-risk patients