Wrecked calcaneum: ORIF with primary subtalar fusion; a case report

INTRODUCTION: The calcaneum is the most frequently fractured tarsal bone and comprises 2% of all fractures. Approximately three quarters of these calcaneal fractures are intra-articular and treatment of these fractures is difficult. Treatment modalities range from conservative management to open reduction and internal fixation (ORIF) and subtalar fusion. ORIF of intra-articular calcaneal fractures leads to good and excellent results in 60-80% of the patients. But 2-17% of patients require secondary subtalar fusions because of the development of a painful subtalar arthritis. This has a direct correlation with the degree of subtalar comminution. CASE REPORT We are reporting a case of a 46-year-old man who was involved in an alleged motor vehicle accident. He sustained open comminuted fracture of right calcaneum with subtalar subluxation and underwent urgent wound debridement with cross ankle external fixation. Two weeks later, open reduction, internal fixation with calcaneal locking plate and primary subtalar fusion with cannulated screws were done. Patient was discharged home after an uncomplicated post operative stay in the ward of 5 days DISCUSSION: The treatment of comminuted intra-articular calcaneal fractures is still very much debated. Although several authors have reported good results in these fractures that were managed operatively, prognosis remain poor for some cases especially those with severe comminution. In his case series, Sanders reported secondary fusions in 7 of 30 (23%) Sanders Type III fractures and in 8 of 11 (73%) Type IV fractures. However, the results of secondary subtalar fusion after an intra- articular calcaneal fracture are not always satisfying. Themann et al. found only 10/17 (59%) good and excellent results using the AOFAS Score. The 7 patients (41%) with fair and poor results had an impaired ROM of the ankle joint with a secondary painful arthritis in the adjacent joints. Hence, a primary fusion after open reduction and internal fixation of the calcaneum at the same setting is recommended in selected cases. CONCLUSION: Primary subtalar fusion with ORIF of the calcaneum is certainly an option in treatment of severely comminuted intra-articular calcaneal fractures

Tibial pilon fracture in a skeletally immature patient: mini open with intrafocal pinning and reduction technique; a case report

INTRODUCTION: Pilon fractures are intra-articular fractures of the distal tibia associated with variable talar injury, articular disruption, and comminution. These fractures were first described by Destot in 1911 and have been reported to represent 7% of all tibial fractures and <1% of all lower extremity fractures in adults. Despite the low incidence of these fractures, the resulting morbidity is considerable. The vast majority of reported cases have involved adults, with sporadic inclusion of children. Pilon fractures are the result of complex forces with axial compression, forced dorsiflexion, often associated with violent rotation resulting in severe, comminuted fractures. Several classification systems have been described; however, the most widely used system in the literature is that proposed by Ruedi and Allgower. They classified pilon fractures into three categories, based on the extent of articular surface fracturing. Type I fractures were nondisplaced, type II fractures were displaced with minimal comminution, and type III injuries were markedly comminuted CASE REPORT We are reporting a case of a 13-year-old boy who fell from rooftop of 2 metres height and landed on his right ankle. Having sustained closed comminuted fracture of distal end right tibia and right lateral malleolus, he was duly planned for surgical intervention. We performed a mini open approach with intrafocal pinning, reduction and further stabilized by conventional plating. Patient was discharged home on day 3 post operation with no complications. DISCUSSION: Preservation of the soft tissue is of particular importance in the care of pilon fractures. Traditional open reduction internal fixation of pilon fractures allows for direct visualization of the fracture(s) but is often criticized for the large exposure and periosteal stripping. External fixation has also been used but has not demonstrated much advantage to internal fixation and requires significant postoperative care. As such, mini open or minimally invasive approach has gained popularity and fast becoming an option in management of pilon fractures. The reduction technique in mini open surgeries are always difficult. In this case, we used an intrafocal pinning and reduction method to reduce the articular fragment. Kapandji described the use of intrafocal K-wires to buttress the dorsal and radial fragments in extra-articular distal radius fractures. We applied the same principles, albeit in this case for the articular fragments of tibial plafond ▲ Pre-operative and intra-operative images CONCLUSION: Mini open approach supplemented with intrafocal pinning and reduction technique offers a reliable option in treatment of pilon fractures, especially in the skeletally immature group

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

Pedobarography study among Malay population in Kuantan, Malaysia: A pilot study

Pedobarography has been widely used in developed countries for few decades. However, in Malaysia it is still in its infancy. Studies showed that the normal values of pedobarography vary between races. To the best our knowledge there is no standard value available for Malaysian or Southeast Asia. This study is designed to measure the pressure values in the normal foot of Malays in Pahang, Malaysia and its difference between different gender and body mass index (BMI). A total of 400 feet of adult Malay subjects with no existing diabetes mellitus, lower limb and spine pain or problem are measured using Emed-q100 pedobarography device. 226 (56.5%) were females. 44.5% were with normal BMI followed by overweight (31.5%), and obese (24%). The mean-maximum-peak pressure (MPP) is 509kPa (SD 167) with no significant difference among gender and BMI. Most (38.5%, n=154) of the peak pressure area (PPA) are observed in 1st metatarsal head and big toe region (1MH&T), followed by 2nd metatarsal head (2MH) (34.3%, n=137). In the normal BMI group, 48.3% were in 1MH&T region while in the overweight and obese groups, 42.1% and 43.8%, respectively were in 2MH. This difference is significant (x2(df=8)=36.963, p<0.001). There was no significant difference between PPA and gender. The MPP among Malays in this study was 509kPa(SD 167) and it is not affected by different genders or BMI. The PPA are most commonly fall on 1MH&T. There is a significant shift in the overweight and obese groups to the 2MHT. This finding can be used as initial reference for further studies, in Malaysia particularly

Implementation of the Islamic Input in Orthopaedics (Triple IO) undergraduate medical curricula & practice. IIUM’s experience (2002-2014)

The secularization of the modern fields of knowledge has lead to deprivation of religious and spiritual considerations, particularly in the current medical curriculum. In the past, the heavy medical curriculum has been blamed as a major contributing factor of production of ‘disease-oriented’ rather than ‘patient-oriented’ medical practitioners. Undergraduate students are very much unprepared to integrate the Islamic knowledge acquired during school-going years into the hectic life and specific conditions that they will encounter in the real clinical settings. There is a great need to reform the current education system to produce critical-minded medical practitioners, especially from the various aspects of the Islamic perspective. In IIUM, the teaching of medicine is augmented by series of relevant lectures and programs in line with the University’s Islamization of Human Knowledge agenda. The Department of Orthopaedics, Traumatology and Rehabilitation of IIUM has taken a step ahead by introducing the Islamic Input in Orthopaedics (Triple IO) Module since 2002. Since its implementation, various obstacles have been faced and many improvements have been made. After more than a decade, we would like to share our experience in conducting the program and how to improve it further to cope with future challenges

Clinical, biochemical and radiological factors affecting the prognosis of neurological deficit improvement in spinal tuberculosis patients at hospitals of Sabah

The incidence of spinal tuberculosis is highest in developing nations. We aimed to analyse the clinical, biochemical, and radiological parameters in spinal tuberculosis patients with significant neurological impairment in relation to their functional outcome. This cross-sectional study involved 224 patients who had been presented to three hospitals in Sabah from July 2017 to June 2018, with significant neurological impairment fulfilling the inclusion criteria were enrolled. Diagnosis of spinal tuberculosis was determined by clinical and radiological factors and confirmed with histopathology, micro bacteriology, and immunoassay. Patients with significant neurology received standard treatment protocol according to the middle pathway regime, anti-tuberculosis for the first three weeks, and were subjected to surgery if there was no improvement. Age, duration of symptoms, c-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white cell count (WCC), thoracolumbar spine involvement, and presence of soft tissue collection were evaluated. Modified Barthel Index (MBI) was used to assess the functional outcome. After a year, 146 patients (65.1%) had good functional outcomes and 78 patients had no significant improvement. On univariate analysis, there were no significant correlations between functional outcome and age (p>0.45); duration of symptoms (p>0.68); CRP (p>0.76); WCC (p>0.99); and presence of soft tissue collection (p>0.21).. High ESR (p<0.008) and thoracolumbar lesions were associated with poor functional outcomes (p<0.033). Higher ESR values and thoracolumbar lesions were associated with poor prognostic factors functional outcome in spinal tuberculosis patients

Primary ewing's sarcoma of the lumbosacral spine : a case report

Ewing's sarcoma is a rare tumor first discovered by James Ewing in 1921. It is more common in bone or skeletal component compared to soft tissue or extraosseous Ewing's sarcoma. Among soft tissue Ewing's, spinal cord involvement is rarer with only nine cases reported. We report a case of nine-year-old Malay girl who presented with low back pain for two months following a fall with progressive neurological deficits of bilateral lower limb. Magnetic resonance imaging was suggestive of a well-defined margin of intradural extramedullary tumor. With nerve sheath tumor in mind, surgical excision with laminectomy L2-S1 was performed. Intraoperative finding was an extradural mass from L3-L5 with extension to bilateral neuroforamen. Histopathology report defined a round cell tumour of Ewing's sarcoma from the mass

Islamic medical education revisited: conceptual and practical aspects

Even after more than two decades, the concept of Islamic Medicine is still widely debatable. While some intellectuals proclaimed that the treasury of medical knowledge was forfeited by the West from the Muslim Civilization, one could not deny that in the current modern civilization, Westerns are far ahead than Muslims in many aspects. The urge to revive the Muslim Civilization has lead towards the drive for Islamization of human knowledge. The call for Islamic Medicine, as part of the Islamization movement, has taken its course into two different directions: Islamic Medicine as an alternative to the Western Medicine, and a call towards integrating the Islamic values into the current accepted medical system. Further confusions were raised with the argument of which terminology is more practical and compliable, Islamization or Islamicisation, with the former may bring about the idea of conversion rather than integration. The term Islamic Medical Practice (IMP), widely used in various medical institutions, is a burden upon Muslim medical academicians, in which majority of them perceived as being incompetent to deliver the tasks. In Kulliyyah of Medicine IIUM, the term “Islamic input in Medical Practice” (IIMP) is preferred. It gives a broader approach in integrations of Islamic teachings in medical education, in line with the Islamization guidelines outlined by the University. This review discusses the concept and practical approach that can be offered by medical academicians of various backgrounds in contributing towards the vision and mission of the University