Segmental Tibial bone defect is challenging because of its poor soft tissue coverage. Reconstruct... more Segmental Tibial bone defect is challenging because of its poor soft tissue coverage. Reconstruction using internal fixation carry a risk of infection. Furthermore, large segmental defect often require large amount of autologous bone graft. However, ilizarov bone transport is a complex reconstruction procedure that is associated with a lot of complications and treatment failures. The aim of this study is to review the outcome of patients treated for segmental tibial defect in Advanced Trauma and Limb Reconstruction Unit in our hospital. Methodology This is a retrospective study of 36 patients who have underwent bone transport from January 2006 to December 2018. There were 32 males and 4 females with a mean age of 33.2 years old (range 15 to 65). Fifteen defect in the distal, 13 midshaft and 8 proximal tibia. Nineteen cases due to open fractures, 9 implant related infection, 3 atrophic non-union, 3 septic non-union and 2 osteomyelitis. Four patients have underlying diabetes mellitus, 1 HIV and 1 hepatitis B infection. Fifteen patients had a local flap and 1 had a free flap surgery to cover the soft tissue defect. The mean size of bone defect is 4.8 cm (range 2- 10 cm). The clinical and functional status was assessed using the ASAMI criteria. Results Two patients were not able to complete the treatment because cannot tolerate the ilizarov external fixation. Thirty (88%) patients achieve union with a meant time of 12 months (range 5 to 30 month). Four patients develop non-union. Two underwent amputation, 1 free fibular transfer and 1 underwent bone transport with the Monorail external fixation. Twenty three achieve excellent, 4 good and 3 fair bone results. Eleven achieve excellent, 17 good and 1 each fair and poor functional results. Conclusions Ilizarov bone transport able to salvage nearly 90% of segmental tibial defect with more than 90% excellence and good functional results. Patients’ selection and close monitoring are important to achieve successful treatment
INTRODUCTION: Perforators flap has gained popularity recently in lower limb trauma as reliable me... more INTRODUCTION: Perforators flap has gained popularity recently in lower limb trauma as reliable methods soft tissue coverage in the distal tibia. It is based on the concept of angiosome that was introduced by Taylor in 1987 to describe the territory of skin supply by perforators. The aim of this study is to describe the surgical technique and the outcome using this flap in orthopaedic patients. MATERIALS & METHODS: We reported 6 cases of the use of perforator base flap for the wound coverage of the distal tibia. All were males with mean age of 36 years old (range 8-69). 2 cases were due to open fracture dislocation of ankle, 2 open fracture grade IIIB distal tibia and 2 infected open fracture. RESULTS: All flaps survive with no congestion or necrosis. Figure1: Location of the perforator (red arrow) that will become the pivot point of the flap Figure 2: The leg after raising of the perforator flap. the donor site can be partially sutured and skin grafted. DISCUSSIONS: Exposed bone, jo...
Background Literature review on diabetic foot problem in Malaysia so far has mainly report on epi... more Background Literature review on diabetic foot problem in Malaysia so far has mainly report on epidemiology and complication related to diabetic foot problems. To date, there were no local study that investigates the psychological aspect and the quality of life among patients with diabetic foot problems. . Objectives The aims of this study were to analyze the short and long term psychological impact and health related quality of life (HrQOL) among diabetic patients who had underwent amputation. Methods Ninety four diabetic patients who underwent amputations at TengkuAmpuanAfzan General Hospital Kuantan were recruited in this prospective study from January 2012 to July 2013. There were 58 (61%) major amputation and 36 (38%) minor amputation. The level of depression and anxiety was assessed by the Depression Anxiety Stress Scales (DASS) and the assessment of quality of life was done by using SF-36. Results The study showed major amputation patients, unemployment, patientswho stayed in ...
Soft tissue coverage in the distal tibia, heel and ankle remain a challenging issue in orthopaedi... more Soft tissue coverage in the distal tibia, heel and ankle remain a challenging issue in orthopaedic surgery. Free flap is considered the best option, however, distally based reverse sural flap seems effective in relatively small wounds or in unfit patients. The ischaemic complications for sural flap could reach 36%, therefore, a two stage procedure was introduced. Improved outcome has been attributed to the choke vessels opening up, in which they form communicating vessels between the adjacent perforators and the angiosome territory. Following a review of our practice, we began performing a delayed (2 stage) procedure for patients with comorbidities or large wounds distal to the ankle with no ischaemic complications.
Replantation services are a highly specialized field and are usually rendered by a tertiary centr... more Replantation services are a highly specialized field and are usually rendered by a tertiary centre in most hospitals around the world. Usuallv these centres would have an existing established plastic surgery unit or dedicated hand depaftment. In a developing country like Malaysia, replantation services also do exist and are mainly taken care by few centres with established hand units. This service is offered by our hospital, which is a public hospital with no established plastic surgery or hand surgery unit. This service was started in early 2005 and we would like to share our experiences. Majority of the cases are from industrial injuries and most of these cases are from remote areas. We have about 11 cases of partial amputation injuries and 7 total amputations. For the revascularization cases, we obtained 100% success rate. and about 80% of replantation cases. We would like to share our experience of success and failures in building up a highly specialized field of orthopaedic sub...
Ankylosing spondylitis is a systemic inflammatory disease which may predispose the cervical spine... more Ankylosing spondylitis is a systemic inflammatory disease which may predispose the cervical spine to fracture, subluxation or dislocation. High mortality and morbidity has been reported mainly due to neurological deficit, respiratory failure and sepsis. We report two patients with ankylosing spondylitis presenting with cervical fracture after motor vehicle accident who succumbed to respiratory failure.
We report four cases of gram negative infection following plating of the tibia that resulted in e... more We report four cases of gram negative infection following plating of the tibia that resulted in expose bone and metal implant which were treated in our center from March 2003 till December 2008. The incidence of Gram negative implant related infection is increasing and probably has poorer outcome. Treatment of this condition requires both bone and soft tissue reconstruction technique that is done in three stages (debridement, soft tissue reconstruction and bone reconstruction). All patient achieved union at the end of follow up.The mean union time is 9.25 months (ranges from 6 to 12 months) after the injury. At the end of follow up, only one patient had persistent infection but able to ambulate normally following fracture union).
This paper is to report on the work that has been performed, in conjunction with a multi-institut... more This paper is to report on the work that has been performed, in conjunction with a multi-institution research project, toward achieving the production of a locally made bone graft substitute. Hydroxyapatite (HA) granules made from local raw materials have been fabricated using a novel method (Patent pending No. PI 2004 0748). The granules were characterized both chemically and physically and found to abide by the ASTM F1185-88 (1998) specification that cover the materials requirements for HA intended for use as surgical implants. Biocompatibility studies, involving various cytotoxicity and genotoxicity studies: in vivo animal studies, comprising of acute systemic toxicity, dermal sensitization and primary skin irritation assays and also implantation studies: and a phase 1 clinical trials involving the use of the granules for root socket obliteration in young healthy adults following tooth extraction was performed. Based on the result of these studies, the material was approved for a phase 2 clinical trial. Young adult patients with fractures of the distal end of the radius requiring bone graft usage is voluntarily recruited into this study after fulfilling a set of inclusion and exclusion criteria. An informed consent is acquired prior surgery. Clinical and radiologically observations were made and recorded. Measurements are made and the results were analysed. This presentation represents the preliminary results of patients that have been operated on in 2005.
This is a prospective study on infection following fixation of closed fractures done in Hospital ... more This is a prospective study on infection following fixation of closed fractures done in Hospital Tengku Ampuan Afzan ,Kuantan from May 2003 to May 2005. There were 23 cases in this study. The mean age of patient was 32.9 years (range 15 to 77). Twenty one were males and 2 females. Twenty (87%) infections occurred in the lower limb and only 3(13%) occurred in the upper limbs. Twenty two patients (91%) had plating done for the fracture. Infection following internal fixation is commonly a deep seated (96%) and florid (78%) infection in which 70% occur after the surgical wound has healed. Staphylococcus aureus is the commonest organism isolated in which 43% are Methicillin resistant (MRSA). Overall infection caused by gram negative organisms is more common than gram positive organisms
Religion plays an imperial role in the ever-changing healthcare system of Malaysia. The Malaysian... more Religion plays an imperial role in the ever-changing healthcare system of Malaysia. The Malaysian, being a multi-racial society, has to adapt and accommodate various practices of religion from different cultural and religious backgrounds. It is this diversity that demands the understanding of the different ideology of faith a necessity to the healthcare giver such as doctors, nurses and the paramedics. This article aims to compare the principles and practices of the official religion of Malaysia, Islam, as compared to the mainstream religion of the Chinese race, which is Buddhism. The discussions focus mainly on the general beliefs and practices of these two religions, the approach towards health and disease and dealing with the issues of death and dying.
Blount’s disease produce varus, procurvatum and rotational deformity. We reported 2 cases of Blou... more Blount’s disease produce varus, procurvatum and rotational deformity. We reported 2 cases of Blount’s disease who presented late during their adolescent. Both presented at early adolescent with severe deformity of more than 20 degrees angulation. The first case was a boy presented early at of 3 years with genu varus of both knee. At the age of 5 corrective osteotomy and fixation of K wire was done. However he come again at the age of 9 with recurrence. At the age of 10 we did bilateral open wedge osteotomy, fibula graft and plating. He return to us again at the age of 15 with recurrence. This time, the right side we treat him with Truelok circular fixator 11 month. The left side we treat him with hexapod (TL Hex) for 11 month. The second case is a 14 year old boy who had genu varus at both knee. We perform gradual correction using TL Hex for 4 month of his left tibia. Currently he is waiting for correction his right knee during the next school holiday. Hexapod allows correction of s...
INTRODUCTION: Anterior border of the tibia is covered only by a thin layer of protective tissue. ... more INTRODUCTION: Anterior border of the tibia is covered only by a thin layer of protective tissue. Plating of the tibia often results in wound complication and infection if the injury to this area is not recognized. We review our results of managing infection following plating of the tibia using a protocol base on the status of bone healing and the presence of bone or soft-tissue defect. Methods: Eight cases of infection following plating of the tibia were managed according to stage procedures protocols and classification, which is based on the state of bony union and the defect following wound debridement. The soft-tissue defects were managed with local flaps, and the bone defects were managed with Illizarov bone transport. Results: Three patients had more than one bacterium isolated. Gram negative organisms were isolated from seven patients. Methicillineresistant Staphylococcus aureus was isolated in two patients. All patients achieved union with a mean union time of seven months. T...
INTRODUCTION: Bone defect following resection of unhealthy bone often become contracted and fill ... more INTRODUCTION: Bone defect following resection of unhealthy bone often become contracted and fill with fibrous tissue. This will lead to resistance during bone transport, fibrous tissue interposition and skin invagination at the docking site. We report a case where synthetic bone constructs (SBC) was used as a temporary spacer to prevent valley formation and soft tissue interposition during bone transport. The SBC dissolved slowly and thus allowing the bone to be transported with minimal resistance and preventing fibrous tissue formation in the bone gap. METHODS: A 30 year-old lady had a 4 cm bone gap following resection of unhealthy bone for nonunion following open grade IIIB distal tibia fracture. The gap was filled with SBC and ilizarov circular frame was assembled for bone transport. SBC is a biodegradable osteoconductive material made from calcium phosphate based materials. It is manufactured by Granulab (M) Sdn Bhd in a GMP accredited factory and certified by British Standard I...
Segmental Tibial bone defect is challenging because of its poor soft tissue coverage. Reconstruct... more Segmental Tibial bone defect is challenging because of its poor soft tissue coverage. Reconstruction using internal fixation carry a risk of infection. Furthermore, large segmental defect often require large amount of autologous bone graft. However, ilizarov bone transport is a complex reconstruction procedure that is associated with a lot of complications and treatment failures. The aim of this study is to review the outcome of patients treated for segmental tibial defect in Advanced Trauma and Limb Reconstruction Unit in our hospital. Methodology This is a retrospective study of 36 patients who have underwent bone transport from January 2006 to December 2018. There were 32 males and 4 females with a mean age of 33.2 years old (range 15 to 65). Fifteen defect in the distal, 13 midshaft and 8 proximal tibia. Nineteen cases due to open fractures, 9 implant related infection, 3 atrophic non-union, 3 septic non-union and 2 osteomyelitis. Four patients have underlying diabetes mellitus, 1 HIV and 1 hepatitis B infection. Fifteen patients had a local flap and 1 had a free flap surgery to cover the soft tissue defect. The mean size of bone defect is 4.8 cm (range 2- 10 cm). The clinical and functional status was assessed using the ASAMI criteria. Results Two patients were not able to complete the treatment because cannot tolerate the ilizarov external fixation. Thirty (88%) patients achieve union with a meant time of 12 months (range 5 to 30 month). Four patients develop non-union. Two underwent amputation, 1 free fibular transfer and 1 underwent bone transport with the Monorail external fixation. Twenty three achieve excellent, 4 good and 3 fair bone results. Eleven achieve excellent, 17 good and 1 each fair and poor functional results. Conclusions Ilizarov bone transport able to salvage nearly 90% of segmental tibial defect with more than 90% excellence and good functional results. Patients’ selection and close monitoring are important to achieve successful treatment
INTRODUCTION: Perforators flap has gained popularity recently in lower limb trauma as reliable me... more INTRODUCTION: Perforators flap has gained popularity recently in lower limb trauma as reliable methods soft tissue coverage in the distal tibia. It is based on the concept of angiosome that was introduced by Taylor in 1987 to describe the territory of skin supply by perforators. The aim of this study is to describe the surgical technique and the outcome using this flap in orthopaedic patients. MATERIALS & METHODS: We reported 6 cases of the use of perforator base flap for the wound coverage of the distal tibia. All were males with mean age of 36 years old (range 8-69). 2 cases were due to open fracture dislocation of ankle, 2 open fracture grade IIIB distal tibia and 2 infected open fracture. RESULTS: All flaps survive with no congestion or necrosis. Figure1: Location of the perforator (red arrow) that will become the pivot point of the flap Figure 2: The leg after raising of the perforator flap. the donor site can be partially sutured and skin grafted. DISCUSSIONS: Exposed bone, jo...
Background Literature review on diabetic foot problem in Malaysia so far has mainly report on epi... more Background Literature review on diabetic foot problem in Malaysia so far has mainly report on epidemiology and complication related to diabetic foot problems. To date, there were no local study that investigates the psychological aspect and the quality of life among patients with diabetic foot problems. . Objectives The aims of this study were to analyze the short and long term psychological impact and health related quality of life (HrQOL) among diabetic patients who had underwent amputation. Methods Ninety four diabetic patients who underwent amputations at TengkuAmpuanAfzan General Hospital Kuantan were recruited in this prospective study from January 2012 to July 2013. There were 58 (61%) major amputation and 36 (38%) minor amputation. The level of depression and anxiety was assessed by the Depression Anxiety Stress Scales (DASS) and the assessment of quality of life was done by using SF-36. Results The study showed major amputation patients, unemployment, patientswho stayed in ...
Soft tissue coverage in the distal tibia, heel and ankle remain a challenging issue in orthopaedi... more Soft tissue coverage in the distal tibia, heel and ankle remain a challenging issue in orthopaedic surgery. Free flap is considered the best option, however, distally based reverse sural flap seems effective in relatively small wounds or in unfit patients. The ischaemic complications for sural flap could reach 36%, therefore, a two stage procedure was introduced. Improved outcome has been attributed to the choke vessels opening up, in which they form communicating vessels between the adjacent perforators and the angiosome territory. Following a review of our practice, we began performing a delayed (2 stage) procedure for patients with comorbidities or large wounds distal to the ankle with no ischaemic complications.
Replantation services are a highly specialized field and are usually rendered by a tertiary centr... more Replantation services are a highly specialized field and are usually rendered by a tertiary centre in most hospitals around the world. Usuallv these centres would have an existing established plastic surgery unit or dedicated hand depaftment. In a developing country like Malaysia, replantation services also do exist and are mainly taken care by few centres with established hand units. This service is offered by our hospital, which is a public hospital with no established plastic surgery or hand surgery unit. This service was started in early 2005 and we would like to share our experiences. Majority of the cases are from industrial injuries and most of these cases are from remote areas. We have about 11 cases of partial amputation injuries and 7 total amputations. For the revascularization cases, we obtained 100% success rate. and about 80% of replantation cases. We would like to share our experience of success and failures in building up a highly specialized field of orthopaedic sub...
Ankylosing spondylitis is a systemic inflammatory disease which may predispose the cervical spine... more Ankylosing spondylitis is a systemic inflammatory disease which may predispose the cervical spine to fracture, subluxation or dislocation. High mortality and morbidity has been reported mainly due to neurological deficit, respiratory failure and sepsis. We report two patients with ankylosing spondylitis presenting with cervical fracture after motor vehicle accident who succumbed to respiratory failure.
We report four cases of gram negative infection following plating of the tibia that resulted in e... more We report four cases of gram negative infection following plating of the tibia that resulted in expose bone and metal implant which were treated in our center from March 2003 till December 2008. The incidence of Gram negative implant related infection is increasing and probably has poorer outcome. Treatment of this condition requires both bone and soft tissue reconstruction technique that is done in three stages (debridement, soft tissue reconstruction and bone reconstruction). All patient achieved union at the end of follow up.The mean union time is 9.25 months (ranges from 6 to 12 months) after the injury. At the end of follow up, only one patient had persistent infection but able to ambulate normally following fracture union).
This paper is to report on the work that has been performed, in conjunction with a multi-institut... more This paper is to report on the work that has been performed, in conjunction with a multi-institution research project, toward achieving the production of a locally made bone graft substitute. Hydroxyapatite (HA) granules made from local raw materials have been fabricated using a novel method (Patent pending No. PI 2004 0748). The granules were characterized both chemically and physically and found to abide by the ASTM F1185-88 (1998) specification that cover the materials requirements for HA intended for use as surgical implants. Biocompatibility studies, involving various cytotoxicity and genotoxicity studies: in vivo animal studies, comprising of acute systemic toxicity, dermal sensitization and primary skin irritation assays and also implantation studies: and a phase 1 clinical trials involving the use of the granules for root socket obliteration in young healthy adults following tooth extraction was performed. Based on the result of these studies, the material was approved for a phase 2 clinical trial. Young adult patients with fractures of the distal end of the radius requiring bone graft usage is voluntarily recruited into this study after fulfilling a set of inclusion and exclusion criteria. An informed consent is acquired prior surgery. Clinical and radiologically observations were made and recorded. Measurements are made and the results were analysed. This presentation represents the preliminary results of patients that have been operated on in 2005.
This is a prospective study on infection following fixation of closed fractures done in Hospital ... more This is a prospective study on infection following fixation of closed fractures done in Hospital Tengku Ampuan Afzan ,Kuantan from May 2003 to May 2005. There were 23 cases in this study. The mean age of patient was 32.9 years (range 15 to 77). Twenty one were males and 2 females. Twenty (87%) infections occurred in the lower limb and only 3(13%) occurred in the upper limbs. Twenty two patients (91%) had plating done for the fracture. Infection following internal fixation is commonly a deep seated (96%) and florid (78%) infection in which 70% occur after the surgical wound has healed. Staphylococcus aureus is the commonest organism isolated in which 43% are Methicillin resistant (MRSA). Overall infection caused by gram negative organisms is more common than gram positive organisms
Religion plays an imperial role in the ever-changing healthcare system of Malaysia. The Malaysian... more Religion plays an imperial role in the ever-changing healthcare system of Malaysia. The Malaysian, being a multi-racial society, has to adapt and accommodate various practices of religion from different cultural and religious backgrounds. It is this diversity that demands the understanding of the different ideology of faith a necessity to the healthcare giver such as doctors, nurses and the paramedics. This article aims to compare the principles and practices of the official religion of Malaysia, Islam, as compared to the mainstream religion of the Chinese race, which is Buddhism. The discussions focus mainly on the general beliefs and practices of these two religions, the approach towards health and disease and dealing with the issues of death and dying.
Blount’s disease produce varus, procurvatum and rotational deformity. We reported 2 cases of Blou... more Blount’s disease produce varus, procurvatum and rotational deformity. We reported 2 cases of Blount’s disease who presented late during their adolescent. Both presented at early adolescent with severe deformity of more than 20 degrees angulation. The first case was a boy presented early at of 3 years with genu varus of both knee. At the age of 5 corrective osteotomy and fixation of K wire was done. However he come again at the age of 9 with recurrence. At the age of 10 we did bilateral open wedge osteotomy, fibula graft and plating. He return to us again at the age of 15 with recurrence. This time, the right side we treat him with Truelok circular fixator 11 month. The left side we treat him with hexapod (TL Hex) for 11 month. The second case is a 14 year old boy who had genu varus at both knee. We perform gradual correction using TL Hex for 4 month of his left tibia. Currently he is waiting for correction his right knee during the next school holiday. Hexapod allows correction of s...
INTRODUCTION: Anterior border of the tibia is covered only by a thin layer of protective tissue. ... more INTRODUCTION: Anterior border of the tibia is covered only by a thin layer of protective tissue. Plating of the tibia often results in wound complication and infection if the injury to this area is not recognized. We review our results of managing infection following plating of the tibia using a protocol base on the status of bone healing and the presence of bone or soft-tissue defect. Methods: Eight cases of infection following plating of the tibia were managed according to stage procedures protocols and classification, which is based on the state of bony union and the defect following wound debridement. The soft-tissue defects were managed with local flaps, and the bone defects were managed with Illizarov bone transport. Results: Three patients had more than one bacterium isolated. Gram negative organisms were isolated from seven patients. Methicillineresistant Staphylococcus aureus was isolated in two patients. All patients achieved union with a mean union time of seven months. T...
INTRODUCTION: Bone defect following resection of unhealthy bone often become contracted and fill ... more INTRODUCTION: Bone defect following resection of unhealthy bone often become contracted and fill with fibrous tissue. This will lead to resistance during bone transport, fibrous tissue interposition and skin invagination at the docking site. We report a case where synthetic bone constructs (SBC) was used as a temporary spacer to prevent valley formation and soft tissue interposition during bone transport. The SBC dissolved slowly and thus allowing the bone to be transported with minimal resistance and preventing fibrous tissue formation in the bone gap. METHODS: A 30 year-old lady had a 4 cm bone gap following resection of unhealthy bone for nonunion following open grade IIIB distal tibia fracture. The gap was filled with SBC and ilizarov circular frame was assembled for bone transport. SBC is a biodegradable osteoconductive material made from calcium phosphate based materials. It is manufactured by Granulab (M) Sdn Bhd in a GMP accredited factory and certified by British Standard I...
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