Biomechanics of intramedullary nail

Intramedullary nailing has undergone much extensive evolution to improve the biomechanical properties of the nail and its usage. It is design to be able to withstand loads acting on the nail. This lecture covers the factors affecting stiffness of the nail, nail entry point, length and working length, interlocking screws and effect of intramedullary reaming

A CASE OF PAEDIATRICS OSTEOMYELITIS : REVISITED

A CASE OF PAEDIATRICS OSTEOMYELITIS : REVISITED NAA N.Alyani1, S. Fudhlana1, AR Ardilla Hanim1, A M.Shukrimi1 1 Department of Orthopaedic, Traumatology and Rehabilitation, Kulliyyah of Medcine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia INTRODUCTION: Incidence of osteomyelitis is 8/100000 children reported3 with gradual increment that affecting children less than 5 year-old with higher incidence in males, and frequently involve the hip, knee and ankles. Morbidities such as growth arrest can lead to permanent disability2 METHODS: We reported a case of 16 months old girl who presented to us with painful limp of right hip for 2 days with history of fever and upper respiratory tract infection 2 weeks prior. Kocher criteria scored 3 but ultrasonograpy of the hip joint was negative for effusion. Pelvis radiograph showed lytic lesion of proximal femur. She was treated as subacute osteomyelitis with parenteral and oral cloxacillin for 4 weeks before she represented with recurrent right hip pain without fever. Repeated radiograph showed worsening lesion and ultrasound showed suspicious early abscess formation. She underwent surgical drainage of the collection and curettage of diseased bone and was put on hip spica as it involved about 60% of the cortical circumference for 6 weeks. Intravenous ampicillin and sulbactam is given in ward and discharge with oral amoxycillin and clavulanic acid as there is no syrup form of the above antibiotics. All blood and tissue cultures taken were negatives. RESULTS: At 4-month review, she obtained pain free full range of motion thou there was 1cm limb length discrepancy. Further review needed to assess any deformity in particular shortening or coxa valga. DISCUSSION & CONCLUSIONS: Staphylococcus aureus remains the commonest organism hence cloxacillin is the treatment of choice1,2. Streptococcal infection should be considered in child less than 5 years old1. New arising gram negative organism, Kingaella Kangae, commensal of oropharynx in children, affecting children of 6-month to 4-year1,2. Positive cultures revealed in 55% of cases, hence antibiotics type is a dilemma in case of unresponsiveness. FDA reported combination of ampicillin and sulbactam is effective against staphylococcus, gram negative and positive organisms. Involvement of greater trochanter physis arrest due to this disease may give rise to coxa valga

Outcome of arthroscopic vs mini open subacromial decompression in treating shoulder impingement syndrome

Introduction: Shoulder impingement syndrome is a common diagnosis leading to shoulder disabilities. Subacromial decompression surgery either arthroscopic or mini open is indicated in patients who failed conservative therapy. Arthroscopic surgery is introduced to reduce soft tissue dissection hence less soft tissue damage and fasten rehabilitation. This study is conducted to compare the outcome of mini open and arthroscopic surgery. Materials and Methods: A cross sectional study was conducted in patients who were diagnosed with shoulder impingement syndrome with or without rotator cuff tear who underwent subacromial decompression surgery, with mini open or arthroscopic surgery at Hospital Tengku Ampuan Afzan, Kuantan. Functional outcome was assessed using American Shoulder and Elbow Surgeon (ASES) score and Constant score. Results: Six patients were recruited in the mini open group while 11 in the arthroscopic group. Of these, all were female in mini open group, aged 56.7 ± 7.9 while seven female and four male in the arthroscopic group aged 55.1 ± 9.4 (p-value 0.733). They were evaluated at 3 to 5 years after surgery in the mini open, and at six months in the arthroscopic group. There was no significant different in the ASES score in the mini open group (89.8 ± 11.7) and arthroscopic group (89.8 ±17.9), with p-value of 0.998. Constant score in the mini open was 18.67 ± 7.61, while in the arthroscopic was 16.18 ± 15.03; and there was no significant difference in this two groups (p-value 0.712). Three patients each has good and fair outcome in the mini open surgery, while six patients has excellent, two each has good and fair; and one has poor outcome in the arthroscopic surgery. Conclusion: There were no significant differences in the functional outcomes between mini open and arthroscopic subacromial decompression surgery

Outcome of arthroscopic vs mini open subacromial decompression in treating shoulder impingement syndrome

Introduction: Shoulder impingement syndrome is a common diagnosis leading to shoulder disabilities. Subacromial decompression surgery either arthroscopic or mini open is indicated in patients who failed conservative therapy. Arthroscopic surgery is introduced to reduce soft tissue dissection hence less soft tissue damage and fasten rehabilitation. This study is conducted to compare the outcome of mini open and arthroscopic surgery. Materials and Methods: A cross sectional study was conducted in patients who were diagnosed with shoulder impingement syndrome with or without rotator cuff tear who underwent subacromial decompression surgery, with mini open or arthroscopic surgery at Hospital Tengku Ampuan Afzan, Kuantan. Functional outcome was assessed using American Shoulder and Elbow Surgeon (ASES) score and Constant score. Results: Six patients were recruited in the mini open group while 11 in the arthroscopic group. Of these, all were female in mini open group, aged 56.7 ± 7.9 while seven female and four male in the arthroscopic group aged 55.1 ± 9.4 (p-value 0.733). They were evaluated at 3 to 5 years after surgery in the mini open, and at six months in the arthroscopic group. There was no significant different in the ASES score in the mini open group (89.8 ± 11.7) and arthroscopic group (89.8 ±17.9), with p-value of 0.998. Constant score in the mini open was 18.67 ± 7.61, while in the arthroscopic was 16.18 ± 15.03; and there was no significant difference in this two groups (p-value 0.712). Three patients each has good and fair outcome in the mini open surgery, while six patients has excellent, two each has good and fair; and one has poor outcome in the arthroscopic surgery. Conclusion: There were no significant differences in the functional outcomes between mini open and arthroscopic subacromial decompression surgery

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