Case report of a posttraumatic ankylosed right elbow treated with open capsule released, reconstruction of medial ulna colateral ligament (novel technique) and thermal arthroplasty of ulnahumeral articular surface

INTRODUCTION: Elbow ankylosis is a well-recognized but potentially difficult problem. Heterotopic ossification (HO) commonly occurs after elbow trauma leading to severe deformity. Thus, surgical release is imperative to restore elbow function. CASE REPORT: We report a 13 years old Malay girl was diagnosed with right neglected elbow dislocation. She was underwent open reduction with LCL reconstruction using Anconeus fascia 1 year ago and now complicated with stiffness due to ankylosis of the right elbow. There was terminal restriction of movement at elbow joint with fixed at 60’ flexion. Radiograph revealed fusion of the distal humerus with the adjacent radius ulna and heterotopic bone formations. A decision to perform open capsular release, reconstruction and direct diathermisation of ulnahumeral articular surface was made. Intraoperative, it was abundant heterotopic bone and no articular cartilage at the ulnahumeral joint. Anterior and posterior capsule released through medial approach with HO removal with reconstruction of medial ulna collateral ligament with palmaris longus was done. Articular surface of ulnahumeral was directly diathermised. RESULTS: Post-operatively, she when for regular physiotherapy. On the last follow up, there is no pain. ROM of the right elbow 5’-110’ with full supination and pronation. Radiograph shows no heterotopic bone and preserve of joint space. DISCUSSION:In elbow ankylosis, articular involvement has been associated with inferior clinical outcomes. Joint surface damage was associated with poorer elbow function. Clinically, patients complained of greater pain during mobilisation, which decreased their compliance with rehabilitation and thus affected the final ROM. Direct diathemisation to the bone surface desensitization of nerves surrounding the elbow joint and will help to reduce the pain. CONCLUSION:We concluded that direct diathermisation can be apply to reduce the pain post operatively and prevention from recurrence of HO formation

Primary hemiarthroplasty following severe proximal humerus fracture dislocations with irretrievable humeral head in young patients

Neer first popularised the use of primary hemiarthroplasty to treat complex proximal humerus fractures, especially when the humeral head is nonviable or not reconstructable with internal fixations, and with younger patients. A 16-year-old boy had a motor vehicle accident and sustained a closed right proximal humerus fracture dislocation without neurovascular injury. Intraoperatively, due to difficulty retrieving the humeral head which dislocated and positioned behind the clavicle, hemiarthroplasty was done to avoid injuring the brachial plexus, vessels and lung. Mr Y, a 34-year-old man similarly sustained closed left proximal humerus fracture dislocation with an irretrievable head. He too underwent hemiarthroplasty. Both patients were followed up for a year with no pain and fairly good range of movement and muscle power. In complex proximal humerus fractures, there is still debate regarding primary hemiarthroplasty. There are risks of secondary displacement of fracture fragments and head necrosis after internal fixation. Neer and Cofield reported over 90% patients had relief of pain and 66% patients had free range of movement post hemiarthroplasty. Other authors described primary malposition and subsequent migration or deficient osseous integration as a complication after prosthesis. In a thirteen-year observational cohort study of 163 patients with hemiarthroplasty, the overall rate of prosthetic survival was 96.9% at one year, 95.3% at five years, and 93.9% at ten years. Of the factors that were assessed, the age is most important due to factors such as degenerative changes in the rotator cuff, osteoporosis, and motivation to achieve a good range of motion. Successful treatment of acute proximal humerus fractures with prosthetic replacement is challenging to orthopaedic surgeons as it requires proper patient evaluation, good surgical technique, especially in soft-tissue tensioning and stability, and meticulous rehabilitation. In young patients with good bone quality and irretrievable head, hemiarthroplasty is a choice

Total elbow arthroplasty in a young post traumatic elbow arthritis. A case report

INTRODUCTION: Elbow arthroplasty is relatively uncommon type of arthroplasty and remains a difficult therapeutic option for young patient with post traumatic arthritis. Distortion of normal anatomy because of previous trauma with relatively higher rate of complication and mechanical failure in young patient make this procedure surgically demanding. CASE REPORT: A 37 years old gentleman, left hand dominant, presented with left elbow pain with restricted range of motion. He had previous history of open fracture left distal humerus and olecranon complicated with non union. Examination over left elbow range of motion is 20-90 degrees of flexion-extension with 20 degrees of supination and pronation. Sensory and motor function was intact with no evidence of infection. Radiologically revealed joint space narrowing with step deformity over the articular surface of left ulna and subluxation of left radial head. Since, uncemented elbow arthroplasty is not available in Malaysia, cemented semi constrained total elbow arthroplasty was done on January 2018 as patient willing to accept the future physical limitation and understood high rate of revision of this procedure in future. Post-operative his pain reduces, and range of motion improved to 0-130 degrees. DISCUSSIONS:Elbow arthroplasty in post-traumatic arthritis is challenging because of deformity, bone defect and change in joint congruency. Besides, variance of the radiological finding in relation to clinical presentation. The age at the surgery is a risk factor for complication, hence patient selection should carefully consider. CONCLUSION: Elbow arthroplasty has a potential to improve pain, function and quality of life of patient with post traumatic arthritis but on the same time associated with high rate of complication and mechanical failure. Therefore, elbow arthroplasty should be done in specialized center

Shoulder impingement syndrome: Outcome of arthroscopic subacromial decompression in Kuantan

INTRODUCTION: Shoulder impingement syndrome is one of the common problem which leads to shoulder disabilities. Neer (1972) first to describe this condition as impingement to the rotator cuff by anterior third of the acromion process. Treatment options varies depending on grade of the impingement and rotator cuff involvement. Arthroscopic subacromial decompression (ASAD) has become more popular in recent years and have shown to have good outcomes. MATERIALS & METHODS: Patients who underwent ASAD with or without rotator cuff repair in Hospital Tengku Ampuan Afzan, Kuantan and International Islamic University Medical Centre Kuantan from September 2016 until Dec 2017 were studied. The functional outcomes were evaluated using ASES, DASH and Constant scoring system. The patients were assessed at preoperative, 3months and 6 months post ASAD. RESULTS: 10 patients were collected. 2 patients also underwent ACJ resection, 2 patients with rotator cuff repair and another 1 converted to mini open cuff repair. All patients are satisfied with their current functions and have showed good functional outcome as early as 3 months. Mean constant score at 3 months is fair (25) but at 6 months is excellent (<11). Mean ASES and DASH score showed improvement by 72% and 56% respectively at 3 months compared to preoperative condition. While at 6 months improved by 86% and 74% respectively. DISCUSSIONS: Surgical treatment is always indicated if conservative treatment failed. Options of arthroscopic or mini open with or without rotator cuff repair remains debatable. Both have shown good outcome in terms of function and study showed there were no significant different [1]. In recent years, however, arthroscopic surgery became more popular compared to mini open as it is less invasive and proven to have good outcomes in short and long term [2][3]. Bidwai et al (2015) concluded that there is no significant benefit of cuff repair over decompression alone in partial cuff tear. Even though ASAD has proven good functional outcomes and has become more popular, it is still inconclusive whether is it the best treatment option in managing shoulder impingement syndrome. CONCLUSION: Arthroscopic subacromial decompression does give a good functional outcome in treating shoulder impingement syndrome with or without rotator cuff tear

Factors influencing functional outcome of philos plate fixation for proximal humerus fractures

INTRODUCTION: Displaced and unstable proximal humerus fractures are difficult to treat and they have high morbidity especially in elderly. The main goal is to achieve painless shoulder with full recovery in terms of range of movements of the shoulder joint [1]. It is a common occurrence, which accounts for 4 to 5% of all fractures incidence [2]. Impingement syndrome is one of the commonest postoperative complication is thought to be due to improper positioning of the plate [3]. This study aim is to appreciate the functional outcomes of Philos plate fixation for proximal humerus fractures and to establish association with high plate positioning with impingement syndrome of the shoulder after Philos plate fixation for proximal humerus fractures METHODS: This is a retrospective study, reviewing 26 patients who had proximal humeral fractures and underwent open reduction and Philos plate fixation between December 2010 and January 2015 in Hospital Tengku Ampuan Afzan, Kuantan, Pahang. Preoperative X-rays or CT scans were inspected, follow-up visits and Xray images were obtained at every follow up consultation to evaluate the plate position and bone union. A distance of 18 mm or less between the upper edge of the plate and the tuberosity was classified as a high plate position. Assessments of impingement syndrome and other complications were done and also functional outcome measured with Constant shoulder scoring system during final follow-up [4]. RESULTS: From 26 patients, 19 were male and 7 were female, mean age was 51.96 (21-78 years old), majority were Malays. All cases achieved union. None of the cases developed complication like malunion, infection, AVN, and loosening of implant while 2 cases complicated with shoulder impingement post operatively. DISCUSSIONS: Among all the factors, age more than 60 years, and high plate position found to be a significant factor in the outcome of the surgery. Neer 3 parts fractures have higher mean of Constant score compare to Neer 4 parts fractures. We also observed that high plate position is significantly associated with impingement syndrome postoperatively with a p value of 0.007. CONCLUSION: This study showed that age, fracture type and plate position were key factors affecting shoulder function after philos locking plate fixation surgery. We recommend that plate should be position at most 19mm from the greater tubercle to prevent impingement syndrome postoperatively and for better functional outcome

How to perform solah with upper limb injuries

Solah is one of the Five Pillars of Islam. The task of performing solah is of utmost importance for all Muslims. The order of performing solah was bestowed directly to Prophet Muhammad S.A.W during Israk Mikraj. This highlights the greatest priority of performing solah even in injurious conditions. In patients with upper limb injuries and limited function, solah is compulsory and must be performed with any remaining physical functions. A group of undergraduate medical students researched and discussed the correct method of performing ablution and solah in injured patients with a facilitator from Kulliyyah of Islamic Revealed Knowledge, IIUM. The issues discussed were the options available in performing ablution prior to solah which either was with water, tayammum (dust), or both. The method of performing solah in upper limb injuries was highlighted. We conclude that the tayammum is the most practical and feasible ablutions method for patients with upper limb injuries prior to perform solah

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

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