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SINGAPORE ORTHOPAEDIC ASSOCIATION P1

Table of Contents

Chairman’s Message P2

Organising Committee P3

Invited Overseas and Singapore Faculty P4

Meeting Information P5

Acknowledgements P7

Note for Speakers P8

Programme At a Glance P10

Opening Ceremony P19

Programme Details P23

Compilation of Abstracts P59- SOA Lecture P93- Donald Gunn Lecture P97- N Balachandran Memorial Lecture P101- Free Papers Session 1a P113 Session 1b P125 Session 2a P139 Session 2b P151 Session 3a P165 Session 3b P179- Young Orthopaedic Investigator’s Award P203- Other abstracts

List of Exhibitors P213

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Welcome to the 30th Annual Scientifi c Meeting of the Singapore Orthopaedic Association. The highlight of this year’s meeting will be the 1st SOA – Mayo Clinic Hip & Knee

Instructional Course. This is an intensive course spanning 1½ days on Hip Surgery and another 1½ days on Knee Surgery.

The “Why” “When”, & “How” of the latest technique will be presented and discussed together with the “What (are the results)”.

There will be 2 pre-congress meetings. The fi rst is the Asian Meeting of International Federation of Foot & Ankle Surgery which will have a symposium on ankle arthroplasty and free paper presentations.

The other is a hands-on workshop on hip and knee navigation involving Stryker, Depuy, Aesculap & Zimmer-Medtronics equipment including hip resurfacing navigation, in revision surgery, ACL, HTO navigation.

I am sure you will fi nd the scientifi c programme and workshops challenging and enriching.

Dr Lai Choon HinOrganising ChairmanPresident, Singapore Orthopaedic Association

Chairman’sWelcome Message


Chairman : Dr Lai Choon Hin

Vice-Chairman : Dr Lo Ngai Nung

IFFAS Pre-congress Meeting, Director : A/Prof Inderjeet Singh

Hip & Knee Navigation Workshop, Director : Dr Yang Kuang Ying

Scientifi c Programme : Dr Yeo Seng Jin

: Dr Wilson Wang

Secretary : Dr S S Sathappan

Asst Secretary & Facilities : Dr Ooi Lai Hock

Publication & Publicity : Dr Leslie Leong

Treasurer : Dr James Loh

Trade & Exhibition : Dr Chin Thaim Wai

Social : Dr Derrick Oh

Secretariat : Ms Nora Owyong

Meeting Secretariat

Blk 6 Level 7 Room A56Singapore General HospitalSingapore 169608Tel: (65) 6321-4041 Fax: (65) 6227-7114 Email: [email protected]: www.soa.org.sg

OrganisingCommittee

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Prof David Lewallen, Mayo Clinic, USA

Prof Robert Trousdale, Mayo Clinic, USA

Dr Alfred Jacques Tria, New Jersey, USA

Dr Zhou Yixin, Beijing China

Dr Tetsuya Tomita, Osaka Japan

Dr Yasuyuki Ishibashi, Hirosaki Japan

Dr Tria Vaughan – Lane, UK

Dr Ameet P. Pispati, Mumbai India

Dr Shekhar Agarwal, India

Dr Richard John Beaver, Perth, Australia

Dr Arun Mullaji, Mumbai India

Dr Aree Tanavalee, Bangkok Thailand

Dr Mark Blackney, Melbourne Australia

Singapore Faculty

Dr Lai Choon Hin

Prof Lee Eng Hin

Dr P. Thiagarajan

Dr Andrew Tang

Dr Lo Ngai Nung

Dr Yeo Seng Jin

Invited Overseas and SingaporeFaculty


MeetingInformation

The organizing committee cordially welcomes all participants to the 30th Annual Scientifi c Meeting Singapore Orthopaedic Association.

Meeting Venue Sheraton Towers Singapore39 Scotts Road, Singapore 228230Tel : 65-6737-6888 Fax : 65-6737-1073Email : [email protected] : www.sheratonsingapore.com

LanguageThe language of the meeting will be English.

Registration1) Registration for the Asian-IFFAS Pre-congress meeting & Hip & Knee Navigation Workshop will commence on Tuesday, 13 November 2007 from 7.30am – 5pm at Level 2, Ballroom Foyer, Sheraton Towers.

2) Registration for main meeting from Wednesday, 14 November 2007 from 7.30am – 5pm at Level 2, Ballroom Foyer, Sheraton Towers.Admission to all scientifi c and social functions of the meeting is limited to registrants only. Please wear your name badge to all functions.

Opening CeremonyThe meeting will be declared open by Dr Lai Choon Hin on Tuesday, 13 November 2007 onwards at 7.00pm at Level 2, Ballroom 1 & 2, Sheraton Towers. This will be followed by SOA Lecture. All registered participants are invited to attend.

Offi cial BanquetThe dinner will be held on Thursday, 15 November 2007 at Level 2, Ballroom 1 & 2 registered participants are required to RSVP with the staff at the registration counter.

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Scientifi c SessionsAll scientifi c sessions will be held in the Ballroom 1 & 2 unless otherwise stated. Con-current free paper sessions will be held in the break-out rooms

Lunches and Coffee BreaksCoffee and lunches will be served only to registered participants along the ballroom foyer.

Trade ExhibitionIn conjunction with the meeting, a trade exhibition will be held in the Ballroom 3 & 4 on Level 2. Leading pharmaceutical and medical instrument manufacturers will display recent innovations and products in their respective fi elds.

CME Accreditation PointsThe meeting has been accredited with ( _ ) points for the whole duration.

Kindly ensure that you sign in the daily CME attendance record during each session which is available from the Registration desk from 13 – 17 November 2007.

Certifi cate of AttendanceA Certifi cate of Attendance will be issued to all registered participants.

LiabilityThe Organising Committee is not liable for personal accidents, loss or damage of private properties of registered participants during the Meeting. Participants should make their own arrangements with regards to personal insurance.

DisclaimerWhilst every attempt shall be made to ensure that all scheduled programmes and events take place as planned, the Organising Committee reserves the right to make changes should the need arise.

MeetingInformation


The Chairman and Organising Committee of the 30th Singapore Orthopaedic Association would like to graciously thank the following organizations for their

support of the 30th Annual Meeting of Singapore Orthopaedic Association:

Platinum Sponsors

Stryker Singapore Pte LtdZimmer Pte Ltd

Gold Sponsor

DePuy Johnson & JohnsonMerck Sharp & Dohme (I.A) Corp

Silver Sponsor

B Braun Singapore Pte LtdBrainLab

KCI Medical Asia Pte LtdRottapharm Singapore

Sanofi -Aventis Singapore Pte LtdServier (S) Pte Ltd

Synthes Singapore Pte Ltd

Bronze Sponsors

Genzyme Singapore Pte LtdHeraeus Medical GMBH

Opto Systems (S) Pte LtdP.T Medindo Inovasi

Pfi zer Pte LtdSmith & Nephew Pte Ltd

Trufi t Limbs Centre

Nominal Sponsors

Australian Wine IndexMedtronic Int Ltd

Acknowledgements

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Kindly store your presentation in a CD or thumb drive. Other storage devices will not be accepted. You may self-load your talk onto laptops which will be located (at Level 2, Outside the ballroom foyer near the registration counter) to the respective allocated folder of FP session or pass the CD (with your name written on the CD) or thumb drive to the AV personnel 1 day or at least 3 hours before your presentation during the conference. All presentations should be in Powerpoint only.

All power-point presentation must be clearly marked or labelled CD or thumb drive to the staff in charge.

You may collect your cd and thumb drive only after the entire session is over.

1) Young Orthopaedic Investigator’s Presentation, the time allowed is 6 minutes followed by 2 minutes of question time.

2) Free Paper presentation, the time allowed is 6 minutes followed by 2 minutes of discussion.

3) N Balachandran Memorial Lecture – 20 minutes.

All presenters are advised to strictly adhere to the time allocated to them.

Notes on Slide/Power Point Presentation for Speakers

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Tuesday, November 13, 2007

PRE-CONGRESS HIP & KNEE NAVIGATION WORKSHOP

0800 – 1700 hrs

VENUE : Ballroom 1 & 2, Level 2, Sheraton Towers

B Braun : 0800 - 1700 hrs

Stryker : 0900 - 1600 hrs

Zimmer : 0900 – 1230 hrs

Depuy : 0800 – 1230 hrs



AESCULAP TKA, ACL & HTO NAVIGATION

0800 – 1230 hrs

VENUE : Ballroom1 & 2, Level 2, Sheraton Towers

NAVIGATED TKA Speaker : Dr Timothy Vaughan Lane Clinical Director in Tauma & Orthopaedics, Hinchingbrooke Hospital, Huntingdon, UK

Welcome and Registration

0800 hrs Introduction to Computer Assisted TKA with OrthoPilot

Principles of knee navigation

Surgical procedures of Navigated TKA with OrthoPilot

0925 hrs Surgical planning & soft tissue balancing with OrthoPilot 0925 – 0940 hrs DISCUSSION

0940 hrs BREAK

1000 - 1230 hrs Saw bone workshop

1230 - 1330 hrs LUNCH

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1330 – 1700 hrs


NAVIGATED ACL & HTOSpeaker : Prof Yasuyuki IshibashiAssociate Director, Department of Orthopaedic Surgery, Hirosaki University School of Medicine Aomori, Japan

1330 hrs Introduction to Computer Assisted ACL Reconstruction Computer assisted evaluation of rotational stability of single bundle ACL reconstruction with OrthoPilot

Validation of computer-assisted double bundle ACL reconstruction

1415 hrs Introduction to Computer Assister HTO and Clinical Results 1415 - 1430 hrs DISCUSSION

1430 – 1450 hrs BREAK

1450 – 1700 hrs Saw Bone Workshop

1700 hrs END OF WORKSHOP



DEPUY - COMPUTER ASSISTED SURGERY FOR ARTICULAR SURFACE REPLACEMENT

0800 – 1230 hrs


Speaker: Dr. Ameet Pispati, Jaslok Hospital, Mumbai India & Prof Wilson Wang – National University Hospital , Singapore 0800 hrs Patient selection & indication

0810 hrs Total Hip Replacement or Resurfacing – Which When & Why

0820 hrs Operative Steps -Life made easy

0830 hrs Computer Navigated Hip Resurfacing – When, Why and How ?

0840 hrs How to overcome complication, & pitfalls in resurfacing ?

0900 hrs Questions & Answers

0910 hrs Hands-on sawbone workshop

1000 hrs Tea

COMPUTER ASSISTED SURGERY FOR OPEN, LESS AND MINIMALLY-INVASIVE TOTAL KNEE REPLACEMENT

Speaker: Mr. Yeo Seng Jin, Singapore General Hospital, Singapore

1030 hrs Computer Navigation for Primary TKA

1040 hrs Challenges of MiTKR Surgery


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1050 hrs Can CAS enhance accuracy through MI approach?

1100 hrs Surgical techniques, pearls with CAS

1110 hrs Questions & Answers

1120 hrs Hands-on sawbone workshop

1230 hrs End



STRYKER NAVIGATION PROGRAM

0800 – 1600 hrs


Speaker : Dr Andrew Tang, Senior Consultant Orthopaedic Surgeon, Dept of Orthopaedic Surgery, Singapore General Hospital

NAVIGATION TKA

0900 – 0920 hrs Surgical Pearls for Navigation – Equipment & placement of trackers

0920 – 1040 hrs Navigated TKA : Demonstration followed by hands-on- practice

1040 – 1100 hrs Q & A

NAVIGATION UKA

1100 – 1115 hrs Familiarization with UNIX prosthesis

1115 – 1135 hrs Demonstration of Navigated UKA

1135 – 1145 hrs Q & A

1200 – 1400 hrs LUNCH

NAVIGATION THA

1400 – 1420 hrs Pitfalls in Conventional THA

1420 – 1540 hrs Navigated THA : Demonstration followed by hands-on practice

1540 – 1600 hrs Q & A

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ZIMMER NAVIGATION PROGRAM

0800 – 1230 hrs


0900 – 0915 hrs History Of Navigation Lo NN • Navigation Technology through the years

0915 – 0930 hrs To Navigate Or Not To Navigate Lo NN • Pros & Cons Of Navigation • When to use Navigation

0930 – 0945 hrs Electro Magnetic Technology Lo NN

0945 – 1015 hrs EM on NexGen Surgical Technique Aree Tanavalee

1015 – 1030 hrs TEA BREAK

1030 – 1100 hrs EM Navigation Demonstration Lo NN

1100 – 1120 hrs Hands On by Participant on EM All

1120 – 1145 hrs Gender – Key Design Features Aree Tanavalee & Application 1145 – 1215 hrs Early Results on Clinical Lo NN / Relevance of Gender Aree Tanavalee

1215 – 1230 hrs DISCUSSION All

1230 hrs LUNCH


OpeningCeremonyOpeningOpeningOpeningCeremony



1830 hrs PRE-OPENING REFRESHMENT Venue : Ballroom 3 & 4, Level 2, Sheraton Towers

1850 hrs Guests to be seated

1900 hrs OPENING CEREMONY President’s Welcome address by Dr Lai Choon Hin Chairman, Organising Committee President, Singapore Orthopaedic Association

1910 hrs Citation and Introduction of 2007 SOA Lecturer, Prof David Lewallen by Dr S S Sathappan

1915 hrs 2007 SOA Lecture “New Technology In Orthopaedics : Mission, Marketing & Mayhem” by Prof David Lewallen

1945 hrs Cocktail Reception


ProgrammeDetailsProgramProgramProgrammeDetails


ProgrammeDetailsProgramProgramWednesday14 November 2007


Wednesday, November 14, 2007

0730 – 1700 hrs REGISTRATION Venue : Ballroom 1 & 2, Level 2

HIP SYMPOSIUM – MIS THAChairman : Yang Kuang YingTime : 0800 – 0900 hrsVenue : Ballroom 1 & 2, Level 2, Sheraton Towers

0745 – 0800 hrs Welcome & Annoucements Lai Choon Hin

0800 – 0815 hrs Minimally Invasive THA - approach options Robert Trousdale

0815 – 0825 hrs Modifi ed Watson-Jones Approach Aree Tanavalee

0825 – 0835 hrs 2 Incision THA Aree Tanavalee

0835 - 0850 hrs Complications of MIS THA Robert Trousdale

0850 - 0900 hrs DISCUSSION

NEW INNOVATIONS IN THAChairmen : Brian Lee, Chin Thaim WaiTime : 0900 – 1000 hrsVenue : Ballroom 1 & 2, Level 2, Sheraton Towers

0900 – 0912 hrs Highly porous metals in adult David Lewallen reconstruction surgery What we have, What is coming and Where we may be going

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NEW INNOVATIONS IN THA ( continued)

0912 – 0924 hrs Metal on Metal articulations – Robert Trousdale what we know today

0924 – 0936 hrs Ceramic on Ceramic Richard Beaver

0936 – 0948 hrs Navigation in THA Richard Beaver

0948 – 1000 hrs DISCUSSION


DIFFICULT THASChairmen : Lo Ngai Nung, Shamal Das DeTime : 1030 – 1130 hrsVenue : Ballroom 1 & 2, Level 2, Sheraton Towers

1030 – 1045 hrs Dealing with a high riding hip Zhou Yixin

1045 – 1100 hrs Acetabular fractures/Fusion takedowns Robert Trousdale

1100 – 1130 hrs Panel Discussion Moderator : Lai Choon Hin Panel : David Lewallen Robert Trousdale Zhou Yixin Aree Tanavalee Richard Beaver Ameet P. Pispati



1130 – 1210 hrs DONALD GUNN LECTURE Chairman: Lai Choon Hin Citation on Donald Gunn Lecturer, Prof K. Satku by Prof VP Kumar

Donald Gunn Lecture “ Unfi nished Business” Prof K. Satku

1210 – 1230 hrs N. Balachandran Memorial Lecture Ernest Kwek Chairman: Howe Tet Sen “ Sun Tzu and the Arts of Orthopaedics”

1230 – 1330 hrs LUNCH

COMPLICATIONS IN THAChairman : Ong Leong BoonTime : 1330 – 1500 hrsVenue : Ballroom 1 & 2, Level 2, Sheraton Towers

1330 – 1345 hrs Dislocation following THA David Lewallen – Causes, Prevention & Treatment

1345 – 1400 hrs Neurovascular complication of THA David Lewallen

1400 – 1415 hrs Ceramic Liner Fracture Richard Beaver

1415 – 1430 hrs Infection after THA –The Royal Perth Richard Beaver Hospital Hip Spacer for infected THR

1430 – 1445 hrs Management of Periprosthetic Fractures David Lewallen following THA



P30


PELVIC OSTEOTOMY - PLENARY LECTUREChairman : David ChuaTime : 1530 – 1600 hrsVenue : Ballroom 1 & 2, Level 2, Sheraton Towers

1530 – 1600 hrs Pelvic Osteotomies in Adults – Robert Trousdale Indication, Techniques, Results & Complications

HIP RESURFACINGChairmen : Wilson Wang, Leslie LeongTime : 1600 – 1700 hrsVenue : Ballroom 1 & 2, Level 2, Sheraton Towers

1600 – 1615 hrs Hip resurfacing in India Ameet P. Pispati

1615 – 1630 hrs Hip resurfacing in Mayo Clinic Robert Trousdale

1630 – 1645 hrs Computer Assisted Hip Resurfacing Ameet P. Pispati – Technique & Results

1645 – 1700 hrs Failure in Hip Resurfacing Ameet P. Pispati + Revision Options - causes of failure and how to avoid them



ProgrammeDetailsProgramProgramThursday15 November 2007


Thursday, November 15, 2007

HIP IMPINGEMENT SYNDROMEChairman : Howe Tet SenTime : 0800 – 0900 hrsVenue : Ballroom 1 & 2, Level 2, Sheraton Towers

0800 – 0815 hrs Hip Arthroscopy + Treatment of P Thiagarajan Impingement Syndrome

0815 – 0845 hrs Open Hip Surgery for Hip Impingement Robert Trousdale + Labral tears - Technique & Results


REVISION THA – SYMPOSIUM 1Chairmen : Low Ying Peng, Francisco P. AltarejosTime : 0900 – 1000 hrsVenue : Ballroom 1 & 2, Level 2, Sheraton Towers

0900 – 0915 hrs Keys to success in revision THR Robert Trousdale

0915 – 0930 hrs Exposures in Revision THA Aree Tanavalee

0930 – 0945 hrs Revision THA – Management Issues Shekhar Agrawal

0945 – 1000 hrs Planning + Management of Revision THA Ameet P. Pispati


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REVISION THA – SYMPOSIUM 2Chairmen : Yang Kuang Ying, S S SathappanTime : 1030 – 1230 hrsVenue : Ballroom 1 & 2, Level 2, Sheraton Towers

1030 – 1045 hrs The Jumbo Cup – the 95% solution Robert Trousdale

1045 – 1100 hrs Management of bone defects during David Lewallen revision THA

1100 – 1115 hrs Use of a porous ingrowth cup-cage David Lewallen construct for massive acetabular bone defi ciency

1115 – 1130 hrs Role of impaction grafting. Indication Robert Trousdale & technical tips

1130 – 1145 hrs Use of Modular Stems in Revision THA Robert Trousdale

1145 – 1230 hrs Panel Discussion Moderator : Lai Choon Hin Panel : David Lewallen Robert Trousdale Aree Tanavalee Shekhar Agarwal Ameet P. Pispati

1230 – 1330 hrs LUNCH SYMPOSIUM “Intergrated Treatment Approach For Osteoporosis to achieve optimal bone health By Prof Peter Ebeling” (Sponsored by MSD)



INAUGURAL MEETING OF ASEAN ARTHROPLASTY ASSOCIATIONChairman : Lai Choon HinTime : 1330 – 1530 hrsVenue : Ballroom 1 & 2, Level 2, Sheraton Towers

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FREE PAPER SESSION 1A (Adult Reconstruction)Chairmen : (1330 – 1410 hrs) Shamal Das De / Chin Pak Lin (1410 – 1450 hrs) Chin Pak Lin / S S SathappanTime : 1330 – 1450 hrsVenue : Sapphire Room, Lower Lobby Level

1330 – 1336 hrs Patellar Recontruction Using Distal Femoral Autograft in a Patellectomized Patient Undergoing Total Knee Arthroplasty, Pang Hee-Nee

1336 – 1342 hrs A Prospective, Randomised Comparison of Multimodal Analgesic Regime After Unicondylar Knee Arthroplasty, Pang Hee-Nee

1342 – 1348 hrs Early Results of a Novel Hydroxyapatite-Coated Total Knee Replacament, Alan Cheung

1348 – 1354 hrs A Novel Selective Multiple Injection Technique for Interscalene Block in Shoulder Surgery, Alan Cheung

1354 – 1400 hrs Clinical and Radiological Results of a Porous Tantalum Acetabular System in Revison Hip Surgery, Teo Yee Hong


1410 – 1416 hrs Pain in the Assessment of Oxford Phase 3 Unicompartmental Knee Arthroplasty (UKA), Andrzej Lisowski

1416 – 1422 hrs Complications in 223 Cases of the Oxford Phase 3 Unicondylar Arthroplasty (UCA) in a Country Hospital, Andrzej Lisowski

1422 – 1428 hrs Independent Study of the Oxford Phase 3 Unicompartmental Arthroplasty (UCA) for Treatment of Anteromedial Osteoarthritis of the Knee : 8 Years Results, Andrzej Lisowski



1428 – 1434 hrs Cementing Technique in Total Knee Replacement : A Randomized Control Trial Comparison Between Standard and Mnimally Invasive Approaches at 2 Years, Loo Wee Lim

1434 - 1440 hrs Deep Infection Following Hemiarthroplasty of The Hip, Tan Zhi Peng


P38


FREE PAPER SESSION 1B (Adult Reconstruction)Chairmen : (1450 – 1530 hrs) Ooi Lai Hock (1530 – 1610 hrs) Leslie Leong / Seow Kang HongTime : 1450 – 1610 hrs

1450 – 1456 hrs Evolution of Total Hip Arthroplasty in Singapore Over The Past Decade, Gurpal Singh

1456 – 1502 hrs Metal on Metal Total Hip Arthroplasty in Young Patients with Neck of Femur Fracture - A report of 2 cases, Kenneth Chung

1502 – 1508 hrs Does Computer-Assisted Surgical Navigation Total Knee Arthroplasty Reduce Venous Thromboembolism Compared with Conventional Total Knee Arthroplasty? A Pilot Study, Ooi Lai Hock

1508 – 1514 hrs A Case of Recurrent Anterior Hip Dislocation, Tan Sok Chuen

1514 – 1520 hrs Vascular Injuries in Total Hip Replacement Arthroplasty, Amarjit Singh


1530 – 1536 hrs The Aetiology and Surgical Outcomes of Patients Undergoing Revision Total Hip Replacement in a Tertiary Institution in Singapore, Tan Sok Chuen

1536 – 1542 hrs Clinical Outcomes Following Total Knee Arthroplasty - A Case Series, Soh Chee Cheong, Reuben

1542 – 1548 hrs Thirty-Day Mortality and Morbidity After Total Knee Arthroplasty, Seah Wee Teck, Victor



1548 – 1554 hrs Total Knee Arthroplasty Complicated By Symptomatic Venous Thromboembolism : An Objective Outcome Measurement, Lin Kuo Hung, Bernard

1554 – 1600 hrs Effect of Combined Isotonic Exercises Protocol on Unilateral Symptomatic Osteoarthritis Knee, Suraj Kumar


1610 hrs End of Session

P40


FREE PAPER SESSION 2A (Sports & Spine)Chairmen : (1330 – 1402 hrs) Chang Haw Chong (1402 – 1442 hrs) Yegappan M / Andrew TangTime : 1330 – 1442 hrsVenue : Ruby Room, Lower Lobby Level

1330 – 1336 hrs Consent for Medical Photography in Orthopaedic Surgery and the Emergency Department, Alan Cheung

1336 – 1342 hrs Traumatic Knee Dislocations :Distinct Subset of Multiligamentous Injury, Ong Kee Leong

1342 – 1348 hrs Anterior Cruciate Ligament Reconstructions with Hamstring Grafts - Our 5 Year Follow-Up, Lee Yee Han, Dave

1348 – 1354 hrs Patient Reported Outcomes and Health Related Quality of Life Following Microsugical Decompression for Symptomatic Lumbar Spinal Stenosis on Octogenarians, Tan Yu-Heng, Gamaliel


1402 – 1408 hrs A Rare Case of Lumbar Facet Joint Septic Arthritis After Acupuncture Treatment in a Tertiary Hospital Setting, Gurpal Singh

1408 – 1414 hrs Association Between Long Distance Running and Lower Limb Injuries : A Retrospective Study, Ng Yau Hong

1414 – 1420 hrs Epidemiology and Clinical Outcomes of Patients Undergoing Anterior Cruciate Ligament Reconstruction : An Asian Perspective, Saiful Nizam



1420 – 1426 hrs Analysis of the Effects of Percutaneos Vertebroplasty in Osteoporotic Compression Fractures, Bryan Tan

1426 – 1432 hrs Accuracy of Pedicle Screw Placement on Human- Cadaver Vetebra using Subroto-Salim Scoliometry Device (S3D) as a Guidance, Rahyus Salim


P42


FREE PAPER SESSION 2B (Trauma)Chairmen : (1444 – 1522 hrs) Wong Merng Koon (1522 – 1602 hrs) David Chua / Howe Tet SenTime : 1444 – 1602 hrs

Venue : Ruby Room, Lower Lobby Level

1442 – 1448 hrs The Orthopaedic Surgeon and Fragility Fractures : Beyond Fixing The Bone; An Australian Perspective, Shyan Lii Goh

1448 – 1454 hrs The Changing Face of Fracture Clinics : Not Just Broken Bones, Shyan Lii Goh

1454 – 1500 hrs Loose Body Formation Within The Knee Joint Following Retrograde Intramedullary Nail Fixation of a Femoral Shaft Fracture, Yong Chern Chet

1500 – 1506 hrs Traumatic Retrosternal Dislocation of the Sternoclavicular Joint in a Young Adult with Generalised Ligamentous Laxity, Lim Kean Seng, Andrew

1506 – 1512 hrs Operative Fixation of a Subtrochanteric Fracture in a Patient with Previous Spontaneous Hip Fusion, Tan Guoping, Kelvin

1512 – 1522 hrs DISCUSSION 1522 – 1528 hrs Severe Lower Extremity Injuries - Early Flap Versus Delay Flap, Lau Leok Lim

1528 – 1534 hrs Management and Outcome of Severe Open Lower Extremity Injuries, Lau Leok Lim



1534 – 1540 hrs Management of Hoffa Fractures - Review of 2 Cases with a Literature Review, Eileen Tay

1540 – 1546 hrs Management of Extensor Mechanism Disruption Following Total Knee Arthroplasty Using a “Railroad” Technique with a Patella Tendon Allograft : A Case Report and Literature Review, Wee Liang Hao, James

1546 – 1552 hrs A Review of Management of Open Tibial Fractures Over a 3-Year Period From a Tertiary Trauma Center, Sreedharan Sechachalam


1602 hrs End of session

P44


FREE PAPER SESSION 3A (General Orthopaedic)Chairmen : (1330 – 1410 hrs) James Hui / Lee Eng Hin (1410 – 1458 hrs) Matthew Cheng / Suresh NathanTime : 1330 – 1458 hrsVenue : Diamond Room, Lower Lobby Level

1330 – 1336 hrs Fracture Neck of Radius in Children - Factors Affecting Outcomes and Complications, Arjandas Mahadev

1336 – 1342 hrs A Good Technique in Restoring Rotation in Proximal Radioulnar Synostosis - 2 Cases of Promixal Radial Resection, Phoon Ee San

1342 – 1348 hrs Active Simple Bone Cysts in the Upper Limb are at Greatest Risk of Fracture, Tey Inn Kuang

1348 – 1354 hrs Arthroscopic Bankart Repair for Recurrent Traumatic Anterior Shoulder Instability with Absorbable Suture Anchors: A Two-Year Follow-Up Study, Tey Inn Kuang

1354 – 1400 hrs Percutaneous Pin Removal in the Paediatric Orthopaedic Clinic-Pain Score and Analgesia Requirement, Lokino Elvin Salioc

1400 – 1410 hrs DISCUSSION 1410 – 1416 hrs Liposarcoma Of The Extremeties, A Review of The Cases Seen and Managed In A Major Tertiary Hospital In Singapore, Ng Yung Chuan Sean

1416 – 1422 hrs A Review of Megaprosthetic Reconstruction in Limb Tumour Surgery: A study of 19 Patients, Tan Peh Khee



1422 – 1428 hrs Extracorporeal Irradiation Autograft as the Choice of Limb Salvage Procedure in a Patient with a Conventional Osteosarcoma of the Proximal Humerus, a Case Report, Satria Pandu Persada Isma

1428 – 1434 hrs Snapping’ Knee Secondary To a Tibial Osteochondroma, Oh Yoong-Leong, Jacob

1434 - 1440 hrs The Epidemiology and Clinical Outcomes of 678 Patients Presenting with Lower Limb Sepsis, Chan Ying Ho

1440 – 1446 hrs New Alternative Method of Vertebral Rotation Measurement To Evaluate Vertebral Rotation of Scoliosis Patient, Ariyanto Bawono


1500-1530 hrs TEA BREAK

P46


FREE PAPER SESSION 3B (General Orthopaedic)Chairmen : (1530 – 1618 hrs) Shamal Das De / Lo Ngai Nung (1618 – 1714 hrs) Brian LeeTime : 1530 – 1714 hrsVenue : Diamond Room, Lower Lobby Level

1530 - 1536 hrs Pars Repair Technique & Rationale of Treatment In Adults, S. Naresh Kumar

1536 – 1542 hrs Is there discordance between MRI reporting of knee injury patients and arthroscopic fi ndings? A clinical correlation study, Tan Tong Leng

1542 – 1548 hrs Intra-Medullary Nailing Of Femoral Fracture Combined With Acute Total Knee Arthroplasty In A Patient With Severe Knee Osteoarthritis - A Case Report , Sreedharan Sechachalam

1548 – 1554 hrs Ewing Sarcoma of The Left Big Toe With Trans-Articular Skip Lesion On The Left Diaphysis Tibia - A Case Report, Moch Nagieb

1554 – 1600 hrs Core Decompression for Osteonecrosis of Femoral Head - Outcome in Different Patient Groups and Correlation with Preoperative MRI, Lam Kwok Hang, Edwin 1600 – 1606 hrs Lumbopelvic Angle on Standing Lateral Radiographs of Normal Thais Adults, Siwadol Wongsak


1618 – 1624 hrs Evaluation Of The External Device In Treatment Of The Third Degree Tibial Opening Fracture In Khanh Hoa From 2004 – 2005, Phan Huu Chinh



1624 – 1630 hrs Chondroblastoma Bone, Garin Isagani

1630 – 1636 hrs The Effect of Sodium Hyaluronate on Fibronectin Expression At Peritendon and Intratendon During Fibroplasia Phase of Rabbit Achilles Tendon Rupture Healing, Fathurachman

1636 – 1642 hrs Cutaneos Complications From Low Molecular Weight Heparin Following Total Knee Arthroplasty : A Report Of 4 Cases Of Knee Blisters, Ramesh s/o Subramaniam

1642 – 1648 hrs Is Distal Femoral Lateral Condylar Hypoplasia Common In Asian Kness?, Ramesh s/o Subramaniam

1648 – 1654 hrs Autologus Chondrocyte Implantation - A 3 Years Prospective Review In A Regional Hospital, Chong Weng Wah

1654 – 1700 hrs Clinical Outcome of Anterior Cruciate Ligament Reconstruction – A Comparison Between Transfi x (Bioabsorbable Cross-Pin) Versus Endobutton Fixation Techniques, Lin Heng An


1714 hrs End of Session


ProgrammeDetailsProgramProgramFriday16 November 2007


Friday, November 16, 2007

MIS TKA – SYMPOSIUMChairmen : Yeo Seng Jin, Bambang TiksnadiTime : 0800 – 0900 hrsVenue : Ballroom 1 & 2, Level 2, Sheraton Towers

0800 – 0815 hrs MIS Knee Surgery - An Update Alfred Tria

0815 – 0825 hrs MIS TKA Tetsuya Tomita

0825 – 0835 hrs MIS TKA Vikram Shah

0835 – 0850 hrs Pitfalls in MIS TKA Alfred Tria


ADVANCES IN KNEE SURGERYChairmen : James Loh, Leslie LeongTime : 0900 – 1030 hrsVenue : Ballroom 1 & 2, Level 2, Sheraton Towers

0900 – 0910 hrs Results of Arthroscopic fi xation of Yasuyuki Ishibashi osteochondral dissecans lesions of the knee with cylindrical autogeneous osteochondral plugs.

0910 – 0925 hrs Cell-based therapy in Cartilage Lee Eng Hin Repair - Current Challenges

0925 – 0940 hrs Biocompartmental Knee Alfred Tria Arthroplasty - a new form of UKA

0940 – 0955 hrs Bicruciate substituting TKA Alfred Tria



P52


TECHNIQUES IN TKA & MOREChairman : Khong Kok SunTime : 1030 – 1230 hrsVenue : Ballroom 1 & 2, Level 2, Sheraton Towers

1030 – 1045 hrs TKA in the morbidly obese Alfred Tria

1045 – 1100 hrs Algorithm & Techniques of Arun Mullaji correction of the severe valgus deformity

1100 – 1115 hrs UKA – New techniques & Alfred Tria Midterm results

1115 – 1130 hrs Oxinium Alfred Tria

1130 – 1145 hrs Kinematics of high fl exion TKAs Tetsuya Tomita

1145 – 1200 hrs Torsional changes in the Arun Mullaji osteoarthritic limb & their implications in TKA – a study of 446 CT scans

1200 – 1230 hrs Panel Discussion Moderator : Lai Choon Hin Panel : Alfred Tria Arun Mullaji Tetsuya Tomita Vikram Shah

1230 – 1330 hrs LUNCH



YOUNG INVESTIGATOR’S AWARDChairman : Prof Chacha Pesi BejonjiTime : 1330 – 1410 hrsVenue : Ballroom 1 & 2, Level 2, Sheraton Towers

COMPLICATIONS AFTER TKAChairmen : Leslie Leong, James LohTime : 1410 – 1540 hrsVenue : Ballroom 1 & 2, Level 2, Sheraton Towers

1410 – 1425 hrs Patello femoral complications David Lewallen following TKA

1425 – 1440 hrs Infections after TKA Alfred Tria

1440 – 1455 hrs Periprosthetic fractures David Lewallen following TKA

1455 – 1510 hrs DISCUSSIONS


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COMPUTER NAVIGATION IN KNEE SURGERYChairman : Yang Kuang YingTime : 1540 – 1700 hrsVenue : Ballroom 1 & 2, Level 2, Sheraton Towers

1540 – 1555 hrs Navigation in MIS TKA – Alfred Tria eliminating the percutaneous pins.

1555 – 1610 hrs Results of computer assisted Arun Mullaji TKA in a single surgeon series of 1000 knees

1610 – 1625 hrs Computer navigation of TKA Richard Beaver versus conventional TKA 2 years results

1625 – 1640 hrs High Tibial Osteotomy using Yasuyuki Ishibashi Navigation



ProgrammeDetailsProgramProgramSaturday17 November 2007


Saturday, November 17, 2007

MORE TKASChairmen : Ooi Lai Hock, Lim Jit KhengTime : 0800– 0930 hrsVenue : Topaz Room, Level 1, Sheraton Towers

0800 – 0815 hrs TKA after osteotomies, tibial & Robert Trousdale femoral fracture & patella realignment procedure.

0815 – 0830 hrs Use of a monoblock porous David Lewallen tantalum tibial component

0830 – 0845 hrs High fl exion in TKA – Ameet P. Pispati myth or reality

0845 – 0900 hrs Mobile bearing Robert Trousdale

0900 – 0915 hrs Component alignment during David Lewallen TKA – most common errors & how to avoid them



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Saturday, November 17, 2007

REVISION TKAChairman : Andrew TangTime : 1000 – 1230 hrsVenue : Topaz Room, Level 1, Sheraton Towers

1000 – 1015 hrs Why some TKR fail – Vikram Shah lesions learnt from retrivals

1015 – 1030 hrs Principles & Techniques of Arun Mullaji Revision TKA

1030 – 1045 hrs Managing bone defects in Shekhar Agrawal Revision TKR

1045 – 1100 hrs Management of massive bone David Lewallen loss during Revision TKA

1100 – 1115 hrs Ligamentous laxity following TKA David Lewallen

1115 – 1130 hrs Indications for hinged TKA Robert Trousdale

1130 – 1145 hrs Stems in TKA Robert Trousdale

1145 – 1230 hrs Panel Discussion Moderator : Lai Choon Hin Panel : David Lewallen Robert Trousdale Arun Mullaji Shekhar Agrawal Ameet P. Pispati Vikram Shah

1230 hrs LUNCH / END OF MEETING


Compilation ofAbstractsCompilation oCompilation oCompilation ofAbstracts


Minimally Invasive THA - approach optionsRobert Trousdale

Complications of MIS THARobert Trousdale

Highly porous metals in adult reconstruction surgery What we have, What is coming and Where we may be goingDavid Lewallen

Metal on Metal articulations – what we know todayRobert Trousdale

Dealing with a high riding hip Zhou Yixin

Acetabular fractures/Fusion takedownsRobert Trousdale

Dislocation following THA – Causes, Prevention & TreatmentDavid Lewallen

Neurovascular complication of THADavid Lewallen

Management of Periprosthetic Fractures following THADavid Lewallen

Pelvic Osteotomies in Adults – Indication, Techniques, Results & ComplicationsRobert Trousdale

Hip resurfacing in IndiaAmeet P.Pispati

Hip resurfacing in Mayo ClinicRobert Trousdale

Computer Assisted Hip Resurfacing – Technique & ResultsAmeet P.Pispati

Failure in Hip Resurfacing + Revision Options - causes of failure and how to avoid themAmeet P.Pispati

(Abstracts not available at time of printing)

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Hip Arthroscopy + Treatment of Impingement SyndromeP Thiagarajan

Open Hip Surgery for Hip Impingement + Labral tears - Technique & ResultsRobert Trousdale

Keys to success in revision THRRobert Trousdale

Exposures in Revision THAAree Tanavalee

Revision THA – Management IssuesShekhar Agarwal

Planning + Management of Revision THAAmeet P. Pispati

The Jumbo Cup – the 95% solutionRobert Trousdale

Management of bone defects during revision THADavid Lewallen

Use of a porous ingrowth cup-cage construct for massive acetabular bone defi ciencyDavid Lewallen

Role of impaction grafting. Indication & technical tips David Lewallen

MIS Knee Surgery – An UpdateAlfred Tria

MIS TKATetsuya Tomita

MIS TKAVikram Shah

Pitfalls in MIS TKAAlfred Tria



Results of Arthroscopic fi xation of osteochondral dissecans lesions of the knee with cylindrical autogeneous osteochondral plugsYasuyuki Ishibashi

Bicompartmental Knee Arthroplasty – a new form of UKAAlfred Tria

Bicruciate substituting TKAAlfred Tria

TKA in the morbidly obeseAlfred Tria

Algorithm & Techniques of correction of the severe valgus deformityArun Mullaji

UKA – New techniques & Midterm resultsAlfred Tria

OxiniumAlfred Tria

Kinematics of high fl exion TKAs Tetsuya Tomita

Torsional changes in the osteoarthritic limb & their implications in TKA – a study of 446 CT scansArun Mullaji

Patello femoral complications following TKADavid Lewallen

Infections after TKAAlfred Tria

Periprosthetic fractures following TKADavid Lewallen

Navigation in MIS TKA – eliminating the percutaneous pinsAlfred Tria


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Results of computer assisted TKA in a single surgeon series of 1000 kneesArun Mullaji

Computer navigation of TKA versus conventional TKA 2 years results Richard Beaver

High Tibial Osteotomy using NavigationYasuyuki Ishibashi

TKA after osteotomies, tibial & femoral fracture & patella realignment procedureRobert Trousdale

Use of a monoblock porous tantalum tibial componentDavid Lewallen

High fl exion in TKA – myth or realityAmeet P. Pispati.

Mobile bearingRobert Trousdale

Component alignment during TKA – most common errors & how to avoid themDavid Lewallen

Why some TKR fail – lesions learnt from retrivalsVikram Shah

Principles & Techniques of Revision TKAArun Mullaji

Management of massive bone loss during Revision TKADavid Lewallen

Ligamentous laxity following TKADavid Lewallen

Indications for hinged TKARobert Trousdale



MINIMALLY INVASIVE TOTAL HIP ARTHROPLASTY WITH MODIFIED ANTEROLATERAL APPROACH

Aree Tanavalee, MDAssociate ProfessorDepartment of Orthopedics, Faculty of Medicine, Chulalongkorn UniversityBangkok, Thailand

IntroductionThe ideal surgical approach for minimally invasive total hip arthroplasty (MIS THA) is the one that provides good visualization of the hip through the inter-muscular, inter-nervous and inter-vascular planes. The modifi ed anterolateral approach is adapted from the Wason-Jones approach, entering into the plane between the gluteus medius and the tensor fascia lata without vascular or major nerve barrier. According to these criteria, this approach may be determined as an ideal MIS THA approach at the present time.

Patient selectionAlthough Rottinger recommended that there is no patient limitation for this MIS approach, because this approach can be extended to standard Watson-Jones approach. In his experience, this approach was also used in revision THA. However, in our learning curve, we found some surgical diffi culty in femoral side. There was high possibility to injure the superior gluteal nerve in patients who had short distance between the anterior superior iliac spine and the greater trochanter, marked collapsed femoral head or high center of rotation of the hip.

Special preparationThe operative table is detachable at both halves of the distal part and the posterior half distal to the pelvis is removed during the operation. With the lateral position, the patient’s affected side is up. The affected leg is mobile during the surgical procedure. A sterile pocket is prepared at the back of the patient for inserting the foot during femoral preparation. Special instruments include 1- and 2- prong Homann retractors, low-profi le reamers, offset rasp handle reamer and the offset acetabular reamer. The second assistant has role on handling the leg to keep a consistent minimal soft tissue tension during the procedure.

Surgical TechniqueA 5- to 8-cm skin incision is made on a line beginning at the anterior tubercle of the greater trochanter extending towards the anterior superior iliac spine. The intermuscular

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plane of the gluteus medius and the tenser fascia lata is divided by inserting a fi nger anteriorly along and deep to the fascia and posteriorly deep to the gluteus minimus over the anterior and superior femoral neck, and then 2 Hohmann retractors are placed overlying the hip capsule superior and inferior to the femoral neck. After the Z- or H-shaped capsulotomy is made, Hohmann retractors are repositioned to the intracapsular position. The femoral head and neck are then removed in 2 segments using 2 separate osteotomies. After femoral head and neck removal, the acetabulum can be well visualized with the leg externally rotated.

Distal traction on the leg may be helpful during inserting or removing of the reamer. The acetabulum then is prepared with a press-fi t technique, but screws may be used to augment acetabular fi xation. The cup positioning is performed according the recommended position; however, one should realize that there is a tendency to put the cup in excessive abduction or anteversion with this approach. The liner is then inserted with global visualization. The femur is prepared by putting the foot and leg in a pocket with the hip in hyperextension, adduction and external rotation. A retractor is placed postero-medial to the femoral neck and another retractor is placed to retract the gluteus medius and minimus away from the direction of broaching. The femoral preparation begins in direct line with the shaft of the femur. The visualization around the femoral cortex can be achieved during broaching. The appropriate femoral size is then selected. With trial components in place and hip reduction, the stability is tested. The appropriate leg length and offset are determined. Then, the fi nal implants are inserted and reduced. The wound is closed with secured capsular repair.

Postoperative careA pillow is placed below the knee of the affected side. On the day of surgery, the patient’s homodynamic is well monitored after surgery. Early blood transfusion is done if it is necessary. The multimodal postoperative pain control is consistently used. The drain is usually removed within 16 hours after surgery. Patients are allowed to sit upright without any strict leg abduction position. Usually, patients could walk after 16 hours postoperatively. If immediate stability is achieved, immediate full weight bearing are allowed. If any concerns, walking with a walking aid is recommended until radiographic assessment is verifi ed.


MINIMALLY INVASIVE TOTAL HIP ARTHROPLASTY WITH 2-INCISION APPROACH

Aree Tanavalee, M.D.Associate ProfessorDepartment of Orthopaedics, Faculty of MedicineChulalongkorn UniversityBangkok 10330, Thailand

Background In late 2001, the so-called MIS 2-incision THA has emerged. Comparing results between patients having THA with 2-incision technique and those undergoing surgery with the standard technique, the 2-incision THA provided surprisingly better results in terms of postoperative pain, faster ambulation and higher patient satisfaction. However, the procedure is technical demanding and dependent on specifi c instruments. According to recent literature, this technique had higher incidence of intra-operative fracture than that of standard technique. At the present time, this approach may be declined for popularity as it seems to be to an irreproducible MIS THA procedure. At our institution, we are still performing 2-incision THA mainly for academic purpose. Special preparationThe operative table is fl uoroscopic compatible. We found that it is helpful if both distal halves of the operative table are adjustable. During the femoral preparation, when the affected leg crosses over the non-operated side, slightly inclined distal half of the non-operative side can minimize the soft tissue tension. The fl uoroscopy should be prompt to move into the surgical fi eld from the opposite side of the surgeon and in the direction that is perpendicular to longitudinal axis of the table. The sterile draping should be prepared from the level that is just above the iliac crest and covering the hemi-buttock area of the affected side. Special instruments include long-armed Homann retractors, low-profi le reamers, and the offset acetabular reamer is very helpful. The second assistant may has role on pulling the leg during getting in and out the reamer.

Surgical TechniqueWith fl uoroscopic assist, an anterior 5- to 6-cm skin incision is started from inferior of the femoral head along the direction of the femoral neck. Carefully dissection through the deep subcutaneous layer is necessary in order to avoid injury to the lateral femoral cutaneous nerve. The intermuscular plane of the tenser fascia lata laterally and the satorius medially is divided after inserting a fi nger through the fascia. When a loose fatty tissue layer is seen anterior to the hip capsule, identifi cation and ligation

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of branches of lateral circumfl ex vessels, which usually run transversely across the femoral neck, is necessary. The muscle belly of rectus femoris is then seen anteriorly or antero-medially. Elevate of the muscle fi ber from the anterior hip capsule towards the medial side. Two Hohmann retractors are placed overlying the hip capsule laterally and medially in related to the femoral neck, and then a Z- or H-shaped capsulotomy is made. Hohmann retractors are then repositioned inside the capsule. The femoral head and neck are then removed in 2 segments using 2 separate osteotomies. After femoral head and neck removal, the acetabulum can be well visualized.

Distal traction on the leg may be helpful during inserting or removing of the reamer. The acetabulum then is prepared with a press-fi t technique, but screws may be used to augment acetabular fi xation. The cup positioning is performed under fl uoroscopic assist. The liner is then inserted with global visualization.

The femur is prepared by putting the leg across the opposite side. Imagination line along the side of the femur and along the front of the femur is drawn. The intersection of these 2 lines is the landmark for the posterior skin incision. A 3- to 4-cm skin incision is made along the longitudinal axis of the femur. Deep to the subcutaneous layer, fi ber of gluteus maximus is divided longitudinally. By fi nger palpation, the tendon of piriformis is identifi ed. Just anterior to the piriformis tendon, the posterolateral capsulotomy in the line along the femoral neck is done. The anterior and posterior incisions are then connected through this capsulotomy. Two long-armed retractors are placed anterior and posterior to the femoral neck. The femoral preparation begins in direct line with the shaft of the femur. The visualization around the proximal femoral cortex may not be achieved during broaching. The appropriate femoral size is then selected under fl uoroscopic assist. With trial components in place and hip reduction, the stability is tested. Again, the appropriate leg length and offset are determined under fl uoroscopic assist. Then, the fi nal implants are inserted and reduced. The wound is closed with secured capsular repair.

Postoperative managementAt the author’s institution, on the day of surgery, the patient’s homodynamic is well monitored after surgery. Early blood transfusion is done if it is necessary. The multimodal postoperative pain control is consistently used. The drain is usually removed within 18 hours after surgery. On the next postoperative day, all intravenous medications are discharged and walking ambulation is started. Although we use the proximally coated femoral stem, with immediate stability principle, we allow patients to have immediate weight bearing as tolerated.


COMPUTER NAVIGATION OF THE ACETABULAR CUP A CADAVERIC RELIABILITY STUDY

The Department of Elective Orthopaedics, Royal Perth Hospital, Western Australia

Richard Beaver FRACS Consultant Orthopaedic Surgeon Head of Department of Elective Orthopaedics Royal Perth Hospital Jonathan Spencer FRCS Arthroplasty Fellow Royal Perth Hospital Robert Day BEng Bio Med Eng Project BioengineerDepartment of Medical Engineering & Physics Royal Perth Hospital Karen Sloan MSc Project CoordinatorJoint Replacement Assessment Clinic Royal Perth Hospital

No benefi ts in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

The aim of this study was to assess the intra and inter-observer reliability in establishment of the anterior pelvic plane (APP) used in imageless computer assisted navigation of the acetabular component in total hip replacement. From this we determined the subsequent effects on cup version and inclination. A cadaveric model was developed with a specifi cally designed rod that held the cup tracker at a fi xed orientation to the pelvis, leaving the APP as the only variable. Eight surgeons determined the APP by palpating and registering the bony landmarks as reference points. The exact APP was then established by using anatomically placed bone screws as reference points. The difference between the surgeons was found to be highly signifi cant (P<0.001). The variation was signifi cantly larger for anteversion (+/- 9.6º) than inclination (+/- 6.3º). The present method for registering pelvic landmarks shows signifi cant inaccuracy, which highlights the need for improved methods of registration before this technique is considered safe.

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FRACTURES IN MISALIGNED CERAMIC ACETABULAR LINERS Richard J Beaver FRACS* Clem McCormick MB,BS * Alan Kop PhD,MsC**

* Elective Orthopaedic Department, Royal Perth Hospital**Bioengineering Department, Royal Perth Hospital

Introduction and AimsCeramic liner fracture during insertion has been reported in 1% of cases in some series of ceramic on ceramic hip arthroplasty. A possible cause for this is forced impaction of a misaligned liner into its metal shell. The aim of the study was to test this hypothesis in the laboratory setting.

MethodCeramic acetabular components from three different companies were obtained and tested. Each liner was fi rst impacted into its shell in a malaligned position. The degree of misalignment was gradually increased until the components became jammed. The liners were then impacted in this position with increasing force until failure occurred.

ResultsAt low angles of misalignment, liners self seated into their metal shells when impacted. As the angle of misalignment was increased, the liners continued to self seat up to a cut off angle at which point the components became jammed. This cut off varied between different companies products and also depended on the angle at which the force was applied (perpendicular to the liner or perpendicular to the metal shell). After jamming occurred, visible damage was evident to the metal shells. When the jammed liners were loaded to failure, they fractured in a spectacular manner with the formation of large amounts of ceramic powder and debris.

ConclusionForced impaction of mislaligned ceramic liners may lead to fracture. This problem should be recognised as it is a technical error that is easily avoided with meticulous insertion technique and attention to adequate exposure.


A MODULAR ANTIBIOTIC-IMPREGNATED HIP SPACER FOR INFECTED TOTAL HIP ARTHROPLASTY

Richard J Beaver FRACS Consultant orthopaedic surgeon, Royal Perth Hospital, Perth, Western Australia

IntroductionInfection remains a catastrophic complication of total hip arthroplasty. Estimates of incidence range from 0.1% to 2% of all primary total hip arthroplasties. In patients with risk factors including diabetes, psoriasis and rheumatoid arthritis the rate of infection may be as high as 6%. Approximately 30,000 hip arthroplasty procedures are performed each year in Australia. Infection therefore places a large burden of disease on the community.

Options for treatment of infected total hip arthroplasty include debridement and parenteral antibiotics with or without long term suppressive antibiotics and one, two or three stage revision arthroplasty. Salvage options include excision arthroplasty or, rarely, hip disarticulation. Poor functional results with these salvage options make retention of implants or revision arthroplasty attractive to most patients and surgeons.

A modular, antibiotic-impregnated hip spacer was developed by the author. It was fabricated and bench-tested by the Dept of Medical Physics, Royal Perth Hospital and its use commenced after completion of laboratory testing in 1995.

The spacer is loosely cemented into the proximal femoral metaphysis, but no cement is used in the diaphysis. Elution of antibiotic from the large mass of cement and from the bearing surface into the effective joint space allows the antibiotic to be pumped around the “effective joint space” during the gait cycle. This allows antibiotic to reach the femoral shaft. This provides access of joint fl uid, which has been shown to contain bactericidal concentrations of antibiotic,to the medullary canal of the femur. The modular hip spacer used in this study is a novel spacer designed for use in 2 stage revision for infected hip arthroplasty. It is able to adjust to variation in hip anatomy and different types of bone loss in the proximal femur, thereby conferring improved stability and consequently promoting more rapid ambulation. In a non selected study of 67 patients treated by a number of surgeons, it was associated with a successful clearance rate of 68%. It was most effective in the treatment of methicillin sensitive staphylococcus aureus infections, which suggests that some changes to the treatment regime may be required when other bacteria are isolated.

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SURGICAL APPROACHES IN REVISION THA

Aree Tanavalee, M.D.Associate ProfessorDepartment of Orthopaedics, Faculty of MedicineChulalongkorn UniversityBangkok 10330, Thailand

Introduction A satisfi ed outcome of revision hip arthroplasty depends on careful preoperative planning, and a key factor of that plan is the surgical approach. No single approach is suitable for all revision total hip arthroplasty procedures, so surgeons should be familiar with a range of approaches. Although a successful revision surgery can be done with a standard THA approach, the choice of the approach should be based on the indication for revision, implant to be removed, presence of acetabular or femoral bone loss, previous surgical approach, and surgeon’s skill or preference. More complex cases may necessitate an extended exposure or certain techniques developed specifi cally for revision arthroplasty. Usually, type of approach is designed after a careful preoperative assessment.

The Anterior Approach (Smith-Petersen)The dissection is plane between the tensor fascia lata (superior gluteal nerve) and the sartorius (femoral nerve). Although this approach provides excellent exposure of the anterior column and the medial wall of the acetabulum, it cannot provide a good access to the posterior column of the acetabulum and to the femoral medullary canal. So, it may not suitable for revision total hip arthroplasty.

The Antero-lateral Approach (Watson-Jones) The dissection plane is between the tensor fascia lata and the gluteus medius. This approach provides a rapid exposure of the joint in primary hip arthroplasty; however, proximal dissection to gain more acetabular exposure is limited by the risk of damaging the superior gluteal nerve to the tensor fascia lata. The proximal femoral shaft can be accessed by extensive muscle stripping. This approach does not provide a good access to the posterior column of the acetabulum, otherwise the anterior fi bers of the gluteus medius tendon may be injured.

The Transgluteal ApproachWith this soft-tissue approach to the hip, portions of the gluteus medius are detached from the greater trochanter in functional continuity with the vastus lateralis. As proposed by Hardinge, the gluteus medius is detached only the anterior half of the


tendon with preserving the attachment of the thick posterior part to the greater trochanter; however, a variation of this approach has been reported. It provides a similar exposure of the hip joint to that of the transtrochanteric approach, but it avoids problem related to trochanteric reattachment. However, this approach has increased incidence of prolonged abductor weakness, damage to the superior gluteal neurovascular bundle.

The Transtrochanteric ApproachThis approach was previously popularized by Charnley, but it is probably being used less today because of concerns about reattachment of the trochanteric fragment, which is commonly defi cient or absent. However, it provides an excellent circumferential exposure to the acetabulum. The diffi culty of trochanteric reattachment can be reduced by careful reattachment technique.

The Posterior ApproachThis approach is commonly used in primary total hip arthroplasty. Advocates of the posterior approach point to the minimal disturbance of the abductor mechanism, and the ease of exposure. The main disadvantage is a higher rate of postoperative dislocation. In the revision surgery, it allows good circumferential exposure of the acetabulum and excellent visualization of the sciatic nerve. In addition, it can be extended distally by combining the trochanteric slide or extended trochanteric osteotomy in order to visualize the femoral shaft.

The Extended Trochanteric Osteotomy (ETO)This technique is extremely useful for revision of both cemented and noncemented stems. With a posterior approach, extension distally along the posterior aspect of the greater trochanter and the posterior fascia overlying the vastus lateralis is done. A long osteotomy through both posterior and anterior of lateral femoral cortices is performed with an oscillating saw. This results in detachment of the proximal lateral femur in continuity with the greater trochanter. The length of the osteotomy should be determined during preoperative planning to ensure that the full extent of well fi xed cementless or the retained cement can be readily accessed. This approach is also useful in femoral revision with the femur with varus bowing or malalignment. It permits an easy access to the medullary canal for removal of cement and realignment of the femoral shaft. Fixation is easier to achieve with a noncemented revision stem. The osteotomy site fi xation can be achieved with the use of cerclage wires or cables.

At the author’s institution, we found that the ETO is very effective and reliable technique for revision of the well fi xed implant, especially, the femoral stem. This technique can be successfully done without the requirement for a special implant removal instrument set, as well as a high union rate of the osteotomy site.

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CELL-BASED THERAPY IN CARTILAGE REPAIR – CURRENT CHALLENGES

E H Lee MD, FRCS(C), FRCS(Ed), FRCS(Glas), FAMSProfessor in Orthopaedic Surgery and Director NUS Tissue Engineering ProgramNational University of Singapore

It is well known that articular cartilage does not respond well to damage, often repairing with fi brocartilage at best. Orthopaedic surgeons have over the years used many different techniques to aid in or enhance the repair of damaged articular cartilage. These techniques have included drilling the subchondral bone, microfracture, osteochondral allografts, continuous pressure motion and transplanting autologous osteochondral plugs (mosaicplasty).

More recently, tissue engineering researchers have advocated the use of autologous chondrocyte implantation (ACI) to repair chondral defects, especially in the knee joint. Although the early clinical results have been promising, the long term results in terms of the type of repair of tissue formed and the longevity of the new tissue is still questionable. This has led to the current interest in studying the use of stem cells or its derivatives for cartilage repair with the hope achieving a long-lasting repair with hyaline cartilage.

To take stem cells from the bench to the bedside, many problems need to be addressed. These cover all areas from the basic aspects to animal studies and fi nally clinical trials. Some of the key areas include:

l Generation of adequate numbers of correct phenotype of cells under animal-free culture conditions

l Appropriate cell-seeding into 3D structures with production of extracellular matrix

l Integration with host tissue with similar structural and biomechanical properties and vascularisation if necessary

l Little or no immunogenicityl Appropriate animal studiesl cGMP/cGTP facilities for expansion of cellsl Clinical trials with appropriate IRB approval

The NUS Tissue Engineering Program, with its multi-disciplinary research teams has been studying many of these problems. The program has stem cell biologists, engineers and clinicians working side by side who have expertise in the fi elds of


characterization, differentiation and expansion of stem cells, extra-cellular matrix, scaffold engineering, development of serum-free and xeno-free media and clinical trials. Much progress has been made and in the past few years and some of the fi ndings relevant to chondrogenesis and cartilage repair will be described and discussed in this presentation.

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UNICONDYLAR KNEE ARTHROPLASTY

Alfred J. Tria, Jr., M.D.Chief of Orthopaedic Surgery St. Peter’s University Hospital Clinical Professor of Orthopaedic Surgery Robert Wood Johnson Medical School New Brunswick, New Jersey

IntroductionUnicompartmental knee arthroplasty (UKA) has become more popular in the United States with the introduction of better instruments and the improved surgical approach using the Minimally Invasive Surgical (MIS) techniques. The prosthetic designs have been available for some twenty years and there are many surgical reports in the literature that review the results and emphasize the complications (1,2,3,4,5,6,7,8,9). The results are improving now and newer designs will appear. The replacement should once again be part of the orthopaedist’s armamentarium for the treatment of arthritis of the knee.

HistoryThe fi rst unicondylar type devices were inserted in the early 1950’s. Duncan McKeever used a fl at metallic insert that included a keel for press fi t fi xation on the tibial plateau (10). MacIntosh initially used an acrylic prosthesis, then, changed to titanium, and, fi nally, changed to a vitallium tray without the keel and relied on the soft tissues to hold the device in place (11). Gunston began working with Charnley in 1966 and published the fi rst paper on the cemented polycentric knee in 1971 (12). Following Gunston’s work, Marmor inserted the fi rst cemented unicondylar knee replacement in the United States using the Modular Knee design from Richards based on the concepts developed by McKeever (5). Insall and Walker published their experience with a unicondylar design that resulted in 15 patellectomies in 24 replacements and they concluded that the prosthetic technique was unacceptable (1). Laskin published his data in 1978 and he reported a high incidence of subsidence of the tibial component leading to a high revision rate (3). During the 1990’s the incidence of unicondylar replacement in the United States decreased signifi cantly. At the Mayo clinic during that decade from 1990 to 2000, 8500 total knee arthroplasties (TKA’s) were performed and only 3 unicondylar surgeries were completed (13). At the same time, the interest in the European communities remained somewhat high. Christiansen reported on 575 unicondylar replacements in 1991 with nine years of follow-up and only a 3.6% revision rate (14). Knutson reported on 7649 replacements in 1986 (15, 16). With the Sledge knee the survival rate was 96% at six years and 93% with the Marmor knee. Marmor published multiple papers in the late 1980’s


and reported some improvement in the results (5,6). Richard Scott’s papers in the 1990’s included multiple complications with the Brigham Unicondylar Knee (17, 18). In the mid 1990’s Repicci designed a unicondylar knee with Biomet and presented an MIS approach that began to rekindle interest in the United States (19). Berger published his long-term results with the Miller-Galante Unicondylar knee in 1999 and reported 98% success at 10 years (20). Repicci subsequently reported his own eight year follow-up data with 93% survival (21).

IndicationsThe initial indications for UKA were extremely limited. John Insall stated that only 7% of all knees qualifi ed for the surgery (22). There was competition from osteotomy and, subsequently, from arthroscopic procedures, such as bone grafting, cell grafting, and debridement. The indications for UKA need to be refi ned according to the patient history, physical examination, and imaging studies. Roentgenographic studies are part of the evaluation but do not represent the only criteria for UKA.

Patient History and Physical ExaminationThe history should be obtained with the best clarity possible concerning the location and duration of the pain. Localized pain on either the medial or the lateral joint line is critical. It is sometimes diffi cult to determine the extent of symptoms in the opposite compartment or in the patellofemoral. However, if the patient describes pain in all zones of the knee, UKA is not appropriate. The traditional conservative measures of physical therapy, COX 1 and COX 2 inhibitors, and external supportive devices should always be considered fi rst. UKA is the fi rst arthroplasty for the very young and the last arthroplasty in the elderly. Patients who are 40 to 60 years of age form the younger population and patients who are 75 years of age or older form the second group. Patients 60 to 80 years of age are commonly acceptable for traditional total knee arthroplasty. The younger group of patients is often considered for a high tibial osteotomy. The elderly population is minimally acceptable for any surgical procedure. With the MIS approach, these patients recover quickly, with less complications, and acceptable longevity. The physical examination begins with the patient’s height and weight. Either of these items alone may be misleading and the body mass index is probably more helpful. The authors have arbitrarily chosen a cut off of 250 pounds (114 kilograms). The literature has previously indicated a limit of 200 pounds (91 kilograms) with the concern of tibial component subsidence and/or excess polyethylene wear. The surgical technique has been changed for these patients in an attempt to address the weight increase.

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The angulation and range of motion of the knee on physical examination are of primary concern. UKA can be performed with a ten-degree maximum fl exion contracture, 10 degrees of varus deformity and 15 degrees of valgus deformity. The knee should have at least 110 degrees of fl exion to permit enough range of motion in the operating room to insert the femoral component on the cut surface. The coronal plane measurements should be correlated with the standing roentgenograms. There should be no medial or lateral thrust of the femur on the tibia through the stance phase of gait. The joint lines and the patellofemoral articulation should be palpated to evaluate the degree of tenderness. There should be a clear difference in the localization of the tenderness and this should correlate with the patient’s description from the history.

All four of the major knee ligaments should be tested. It is often said that the ACL defi cient knee is a contraindication to UKA. This is not true with fi xed bearing designs and may only have relevance in the mobile bearing prostheses (23, 24). Dislocation on either the medial or lateral side in the ACL defi cient knee is not commonly reported. In the PCL defi cient knee the UKA can conceivably roll posteriorly off of the tibial articulating surface or produce increased polyethylene wear. Thus, PCL defi ciency can be a more diffi cult problem and should be evaluated on a case-by-case basis in the operating room.

Imaging studiesPlain x-rays form the mainstay of the imaging studies. The standing fi lm is critical. A full-length study including the hip, knee and ankle, is desirable but not mandatory. An appropriate patellar view, such as the Merchant x-ray, helps to show the extent of the arthritic involvement and the alignment of the patellofemoral joint. The lateral fi lm is also helpful to see the patellofemoral joint and to evaluate the slope of the tibia plateau (Figure 1).

The slope of the tibial plateau from anterior to posterior varies between zero and fi fteen degrees and the slope effects the fl exion and extension gaps. The computerized tomography of the knee is not a mandatory study, but some groups have used this to precisely determine the patellofemoral alignment. The magnetic resonance imaging studies are also

Figure 1: Lateral x-ray of the knee showing a 17 degree slope to the medial tibial plateau.


not mandatory but give some information concerning the status of the menisci and ligaments. Undisplaced, asymptomatic, degenerative tears of the meniscus in the compartment opposite from the proposed unicondylar replacement are not signifi cant and do not require intervention at the time of the arthroplasty. If there is an extensive tear of the opposite meniscus associated with mechanical symptoms, this must be addressed and can be removed arthroscopically before the arthroplasty under the

same anesthetic (The author has only performed one arthroscopic surgery in 400 consecutive UKA’s). Arthroscopic evaluation can sometimes confi rm the extent of arthritic disease but is not mandatory or necessary.

Technetium 99 bone scanning can sometimes be helpful to determine if there is isolated unicompartmental disease or to compare the amount of uptake from one side to the other (Figure 2). But, it should be emphasized that the standing anteroposterior x-ray and the lateral x-ray are the primary diagnostic tools.

The alignment of the standing fi lm can be measured using the anatomic axes (Figure 3).

Ten degrees of varus or15 degrees of valgus are acceptable. In most cases the deformity is partially or fully correctable on physical examination. If the angulation is not correctable, the UKA can still be performed but the operative procedure will be much more diffi cult and will require a deeper tibial resection that can lead to fracture. Deformity outside these limits cannot be corrected with the implant surgical technique and may lead to early

Figure 2: Lateral view of a technetium 99 scan of the knee showing increased uptake in the patellofemoral joint.

Figure 3: Standing anteroposterior x-ray of the knee with the anatomic axis of the femur and the tibia drawn with white lines.

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failure. Translocation of the tibia beneath the femur is a relative contraindication (Figure 4).

In the younger population translocation is not acceptable. However, in the elderly patient, with slight translocation and isolated symptoms on one side of the joint, UKA will provide good symptom relief with minimal surgical procedure and a small chance of failure or progression of disease.

Surgical TechniqueThe anesthesiologist in consultation with the patient typically chooses the anesthetic technique. In our experience general anesthesia has been equally as effective as a spinal or epidural technique with no higher incidence of complication. We have not attempted procedures under femoral block or local anesthesia with sedative techniques, but certainly these approaches may be effective in the proper setting. The operation is performed with tourniquet control. The standard TKA surgical

approach including patellar eversion and quadricepsplasty is acceptable for the UKA but will not afford the rapid recovery or the lower complication rate. The MIS surgical approach does not evert the patella and does not violate the quadriceps mechanism. The extensor mechanism is left completely intact, thus, permitting earlier range of motion with less swelling, better proprioception, andless associated pain.

The MIS approach begins with a short medial or lateral skin incision, approximately ten centimeters in length (Figure 5).

Figure 4: Standing anteroposterior x-ray of the knee showing translocation of the lateral tibial spine against the lateral femoral condyle.

Figure 5: The medial MIS incision is 8 cm long and extends from the proximal pole of the patella to 1 cm distal to the tibial joint line. “B” marks the outline of the medial femoral condyle and “A” marks the tibial joint line.


The incision starts at the superior pole of the patella and continues distally to the tibial joint line. It is a common error to centralize the incision on the tibial joint line. The proximal exposure is more essential for the procedure. Minimal medial and lateral fl aps are elevated. The arthrotomy is, then, performed on either the medial or lateral side in the line of the incision. On the medial side, in the varus knee, a transverse cut is made just beneath the vastus medialis in front of the medial collateral to join

the arthrotomy incision as a “T” (Figure 6).

The deep medial collateral is elevated from the tibial plateau line for visualization of the joint and not for the purposes of release. The superfi cial ligament must be protected at all times and not released.

UKA is not TKA. The principles of ligament balancing and overall alignment of the knee cannot be applied completely to UKA. In TKA

it is important to reestablish a valgus knee with balanced ligaments and equal forces across the joint on the medial and lateral sides. The ligaments are balanced with releases on the concave, tight side, or tightening on the convex, loose side. In the UKA both sides of the joint are not replaced. With medial or lateral isolated replacement the balancing is much more diffi cult. If a full release of the medial or lateral ligament is performed the opposite condyle can become overloaded and develop rapid arthritic changes with resultant failure. There is no present technique to reliably perform a partial release and, therefore, this is discouraged. With further development, these subtle additions may become possible.

On the lateral side, the arthrotomy is taken down to the joint line and the capsule is peeled back along the tibial plateau line. No transverse incision is made. If the visualization is not adequate, the arthrotomy incision can be extended proximally for a centimeter along the medial or lateral side of the quadriceps tendon without everting the patella. The patellar fat pad can also be cut back but this sometimes leads to increased bleeding. The soft tissue approach is critical for the MIS exposure and the rapid recovery.

Figure 6: The medial incision is expanded with a transverse “T” cut beneath the vastus medialis extending to the anterior margin of the medial collateral ligament.

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With the completion of the soft tissue approach, the osteophytes can be removed from the affected femoral condyle and tibial plateau line. Generalized joint debridement is not recommended and can lead to excess bleeding and prolongation of the recovery. The meniscus should be debrided to facilitate visualization. It is sometimes diffi cult to see the entire knee joint through the MIS incision. Some surgeons do use the arthroscope to examine the entire knee before performing the procedure. The authors do not recommend this as a standard practice. Diagnostic arthroscopy will certainly give further information but the addition of the procedure is not necessary and may possibly increase the incidence of complications. The decision to perform the UKA is made preoperatively on the basis of the history, physical examination, and imaging studies. The fi ndings at the time of surgery should not be surprising and should agree with the original diagnosis and surgical plan. The

authors do not enter the procedure with the option of conversion to a TKA and the patient only expects the UKA. With the completion of the approach, the next step is the bone cuts. The distal femoral

Figure 7A: The intramedullary guide is inserted into the canal through a centrally placed entrance hole.

Figure 7B: The distal femoral cutting block is, then, set on top of the medial femoral condyle to guide the saw blade.


cut is made fi rst with either an intramedullary reference(Figure 7) or an extramedullary guide (Figure 8).

Figure 8A: The extramedullary distractor is positioned between the femur and the tibia.

Figure 8B: Long reference rods are attached to the distractor and reference the femoral head and the malleoli of the ankle.

Figure 8C: The cutting block is pinned in place and the cuts on the distal femur and the proximal tibia are complete.

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While the literature indicates that the intramedullary femoral references are more accurate (25), some surgeons do not like the possibility of fat embolism associated with intramedullary devices and also believe that extramedullary instrumentation allows a smaller incision.

Once the distal femur is cut, the remainder of the femoral cuts can be completed with the appropriate blocks for guidance of the jigs. If the intramedullary approach is used, an intramedullary retractor can be used for the patella (Figure 9).The femoral runner should be a slight bit smaller than the original femoral condyle

Figure 9: The intramedullary retractor is to the right of the femoral cutting block and holds the patella laterally, away from the surgical site.

Figure 9A: The femoral runner is perpendicular to the tibial component in this anteroposterior x-ray.


surface and should be perpendicular to the tibial plateau component in full extension and in ninety degrees of fl exion (Figure 10).

Figure 10B: The femoral runner is oblique to the tibial component in this anteroposterior x-ray and can lead to some edge loading on the lateral side of the runner.

Figure 10C: The femoral component should be perpendicular to the tibial component in 90 degrees of fl exion (black oval). The gray oval is the anatomic position of the component and will produce edge loading if there is increased femoral condyle divergence.

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The femoral component should also be centered medial to lateral on the tibial polyethylene surface. The anatomicvalgus of the distal femur is determined by the depth of the femoral cut. The author removes the standard amount of bone from the medial femoral condyle (6 mm) if the distal femoral valgus is 5 degrees or less. If the distal femoral valgus is 6 degrees or more, the author removes an additional 2 mm

of bone (8 mm total) to avoid excess increase of the distal femoral valgus (Figure 11).

By avoiding this increase, the resultant tibial plateau resection is decreased, conserving bone on the tibial side. The total amount of femoral resection with the

deeper cut (8mm) is still less than the bone removal for a customary TKA which is 9 mm.

In the valgus knee the depth of the distal femoral cut should not be changed. If the standard cut is made, the author has found that the cemented femoral component adds 2 mm to the distal femur. Thus, if the distal femur has an anatomic valgus of 15 degrees, the standard resurfacing will decrease this angle to 13 degrees. This will slightly correct the valgus deformity without requiring ligament releases. Therefore, in the valgus knee the standard distal femoral cut should be used routinely.

The tibial cut is made with an extramedullary instrument. If the fl exion space is very small, the tibial cut should be made before the femoral cuts are completed to allow more room for the femoral jigs. The tibial cut can be angled from anterior to posterior. Most systems favor a 5 to 7 degree posterior slope for roll back. However, sloping this cut can also help with the fl exion-extension balancing. The balancing is not the

Figure 101: A deeper cut on the medial femoral condyle increases the space in full extension but also decreases the distal femoral valgus. If the distal femoral valgus is greater than 6 degrees, the deeper cut gives greater space in full extension to correct a fl exion contracture and corrects excess valgus.


same as the techniques for total knee replacement. In the UKA surgery, the fl exion gap is larger than the extension gap because of the fl exion contracture. As the fl exion contracture increases to ten degrees, the extension gap becomes tighter. If the slope of the tibial cut is decreased, the cut can be made deeper anteriorly to give greater space in extension while maintaining the same fl exion gap (Figure 12).

Changing the slope of the tibial plateau may affect roll back in some designs, especially if the tibial polyethylene is dished. Once the tibial cut is completed, the proper size tray for the plateau should be chosen. The entire surface should be covered out to the cortical rim. Overhang is not desirable but complete coverage is important to prevent subsidence. The tibial cut should be perpendicular to the long axis of the tibia in the coronal plane and not in any degree of varus. Some few degrees of valgus are tolerated but not desirable. In the obese patients, the tibial plateau cut is extended more laterally (in the varus knee) and more medially (in the valgus knee) to increase the total plateau coverage and increase the bone support for the component. Once the preliminary cuts are completed, the fl exion-extension gap should be tested. In the ideal case there should be 2 millimeters of laxity in full extension and at ninety degrees of fl exion. It is best not to over tighten the joint and to accept greater, rather than less, laxity. In TKA it is often desirable to have a tight articulation for stability, especially with the posterior stabilized designs in fl exion. In the UKA excess tightness can lead to early polyethylene failure and also contributes to increase pressure transmission to the contra lateral side. Once again, this reiterates the fundamental differences between TKA and UKA. If the spacing is unequal by more than 1 mm, the tibial slope should be changed to correct the mismatch. Table 1 outlines the corrections. The authors suggest that all of the components be cemented for better fi xation and longevity. Cementless devices have not had as good a result in this setting. It is best to cement the tibial component fi rst and then the femoral. This permits better exposure

Figure 12: The fl exion space is usually greater than the extension space (black arrows). The tibial slope can be decreased from the red line to the black line with a deeper cut anteriorly and the same cut posteriorly equalizing the gaps.

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and evacuation of cement from the posterior aspect of the joint. Modular tibial components are easier to cement because the metal tray can be inserted without the polyethylene and there is more space for inspection. Back side wear has also not been a problem with modular UKA components and revision of the polyethylene itself is a simple exchange. The all polyethylene tibial insert does give more thickness of polyethylene but it is more diffi cult to cement and exchange requires invasion of the underlying bone. The tourniquet is released before the closure and adequate hemostasis is established. The closure of the arthrotomy is performed with non-absorbable sutures in an interrupted fashion over a single drain. The vastus closure should be anatomic without over tightening or residual laxity. The patellar tracking should be checked before closing the subcutaneous tissues. There is a tendency to over tighten the medial capsule with the “T” incision and this should be avoided because it may lead to increased forces across the patellofemoral joint with increased pain. At the time of closure, some surgeons prefer to inject the surrounding tissues with a local anesthetic to permit more comfortable activity immediately after the surgery. The author has not found this to be particularly helpful.

The ProsthesisThe unicondylar components that are presently available were designed over 10 years ago (20). Most of the femoral runners have one or two lugs. The tibial components are either monoblock or modular. With either type of device the authors recommend an onlay approach. The peripheral cortical contact gives the prosthesis better support and does not lead to subsidence, which can be present if the component is inlaid. The inlay techniques have lead to early sinkage and failures. Cortical contact is preferred.

The components are also available in a fi xed or mobile bearing design. The discussions concerning mobile bearing prostheses are the same in this environment as in TKA. The arguments against the ACL defi cient knee for UKA began with the mobile bearing designs that incurred some dislocations (23, 24). These dislocations do not occur in the fi xed bearing design. It is also not advisable to implant a mobile bearing knee on the lateral side because of the increased possibility of dislocation as the knee internally rotates in high degrees of fl exion. Postoperative ManagementThe MIS surgery permits rapid recovery and a different protocol than the TKA approach. The patient is encouraged to walk, full weight bearing, within two to four hours after the surgery and fl exion is instituted before discharge from the hospital. Most patients


stay one night in the hospital; however, there are some surgeons who perform the procedure as an outpatient surgery and discharge the patient home on the same day. Outpatient physical therapy is very helpful to increase the early motion. CPM machines are often prescribed although they are not mandatory for a good result. The author presently uses a low molecular weight heparin for anticoagulation. This regimen may be changed to aspirin with the introduction of the new guidelines from the AAOS. In the fi rst year the cases were not subjected to deep venous thrombosis observation. Doppler ultrasound analysis has now been instituted for diagnostic evaluation at 10 to 14 days after surgery. Sutures are removed within a two-week period and the patient is usually moved to a cane for support within the fi rst fi ve days. Physical therapy is used for about four weeks and the patient should have restored full range of motion at that time. Effusion resolves within six to eight weeks and most patients are back to their usual levels of activity at that point. “Full activity” includes tennis, golf, and most recreational activities. High impact aerobics, jogging, contact sports, and heavy lifting are discouraged.

ResultsThe author began performing the surgery in February of 2000. The fi rst 63 knees are now at the fi ve year follow-up period. The average age of the patients was 67 with the range from 42 to 93. There were two age peaks, one at 55 and one at 75 and the differences were statistically signifi cant between the two groups and the total knee population. There were 25 males and 32 females with 61 varus knees and 2 valgus knees. There were 6 bilateral surgeries and 2 patients returned for the opposite side within the fi rst six months. There were no cases of infection, loss of motion, DVT, pulmonary embolism, myocardial infarction or death. There was one case of a tibial plateau fracture that occurred ten days after the surgical procedure when the patient was walking normally. The fracture line was vertical, non-displaced, beneath the lateral aspect of the medial tibial tray in the area of the vertical cut at the base of the tibial spine. The knee was immobilized for four weeks and the fracture healed with no loss of range of motion and no shift of the tibial component. The fracture may have been a result of inadvertent deepening of the posterior vertical cut at the time of surgery. One knee developed patellar dislocations 6 months after the original surgery and went on to revision TKA at 15 months. The dislocations may have been due to laxity of the medial arthrotomy closure. Over the past seven years only one other knee has come to revision (for patellofemoral arthritic symptoms).

The results reported by Berger are excellent with ten years of follow-up (20). This study was extremely conservative. The average age of the patients was 67. The UKA was only performed if the patient had isolated disease, and the procedure was often changed to a TKA during the surgery if the other areas of the knee appeared to have

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more involvement than the surgeon expected preoperatively. A full arthrotomy approach was also used.

The authors have expanded the indications for the UKA but hope and expect that the results will mimic those of Berger.

RevisionRevision of the UKA to TKA should not be a common procedure with the newer techniques and follow-up as indicated with Berger’s article. However, if this does become necessary the bone loss on the tibial side is not typically severe and can be addressed with a primary total knee with perhaps a block wedge augmentation. The modifi cation of the depth of the distal femoral bone resection helps to preserve tibial bone and makes the revision easier to perform than the conversion from a high tibial osteotomy, although there is some argument about this in the literature (25).

ConclusionsUnicondylar knee arthroplasty is now evolving into a more acceptable surgical approach that can be included in the armamentarium of procedures for arthritis of the knee. The concepts of balancing, instruments and not overcorrecting have been emphasized. The UKA is not at all a TKA and should not be thought of as such. Some balancing and some modifi cations can be made during the surgical procedure but they are based on different principles than the TKA. UKA represents a good alternative in the very young or the elderly with unicompartmental disease of the knee.


COMPUTER NAVIGATION VERSUS CONVENTIONALTOTAL KNEE REPLACEMENT FUNCTIONAL RESULTS AT TWO YEARS

R. J. Beaver, J. M. Spencer, S. K. Chauhan, K. Sloan, The Royal Perth Hospital, Perth, Western Australia

We compared the component alignment in total knee replacement using a computer-navigated technique with a conventional jig-based method. We randomly allocated 71 patients either to undergo computer-navigated or conventional total knee replacement. An improved alignment was seen in the computer-navigated group.

The patients were followed using the Knee Society score, the Short Form-36health survey, the Western Ontario and McMaster Universities osteoarthritis index, the Bartlett Patellar pain questionnaire and the Oxford knee score. At two years post-operatively, no patient in either group had undergone revision. All variables were analysed for differences between the groups either by Student’s t-test or the Mann-Whitney U test.

The statistical differences between the two groups did not reach signifi cance for any of the outcome measures at any time point. At two years post-operatively, the frequency of mild to severe anterior pain was not signifi cantly different, varying between 47% for the computernavigated group, and 44% for the conventionally replaced group.

The Bartlett Patellar score and the Oxford knee score were also not signifi cantly different (t test p < 0.161 and p < 0.607, respectively). The clinical outcome of the patients, when assessed with recognised scoring systems, with a computer-navigated knee replacement appears to be no different to that of a more conventional jig-based technique at two years post-operatively, despite the better alignment achievedwith computer-navigated surgery.

The author also will explain why, despite the above fi ndings, he regards computer navigation of knee arthroplasty to be an indispensable tool for the orthopaedic surgeon who wishes to improve the standards and safety of total knee arthroplasty.


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PATELLAR RECONSTRUCTION USING DISTAL FEMORAL AUTOGRAFT IN A PATELLECTOMIZED PATIENT UNDERGOING TOTAL KNEE ARTHROPLASTY

Hee-Nee Pang MBBS, MRCSEdSathappan SS, MBChB, FRCSEd, MMed (Ortho), FRCS (Ortho)

Patellectomized patients have less satisfactory clinical outcomes following total knee arthroplasty due to a decreased extensor mechanism effi ciency; and potential instability attributable to loss of anterior restraint. We report a patient, with a prior history of patellectomy, who underwent simultaneous patellar reconstruction using distal femoral autograft during the total knee arthroplasty (TKA). The patient has been followed-up for 24 months with excellent post-operative knee scores with radiographically established graft viability.

Keywordspatellectomy, patella, reconstruction, knee, arthroplasty

Address correspondence and reprint requests to: Dr S.S.SathappanConsultant & Clinician Scientist

Adult Reconstructive Surgery & Complex TraumaDept of Orthopaedic SurgeryTan Tock Seng Hospital11 Jalan Tan Tock Seng Singapore 308433Tel: 65-63577713Fax: 65-63577715E-mail: [email protected]

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A PROSPECTIVE, RANDOMISED COMPARISON OF MULTIMODAL ANALGESIC REGIME AFTER UNICONDYLAR KNEE ARTHROPLASTY

BackgroundGood postoperative pain control is paramount in patient comfort, in the rehabilitation of the patient and shortening the hospital stay. The intraoperative local injection of corticosteroids in patients undergoing unicondylar knee arthroplasty can reduce postoperative infl ammation and pain. This is a prospective, randomised control trial to compare the effects of intraoperative periarticular triamcinolone injection in patients undergoing unicondylar knee arthroplasty.

MethodsWe randomised 100 patients into 2 groups. The study group (55 patients) received injection of triamcinolone, bupivacaine, morphine and epinephrine. The control group (45 patients) received the same drugs with the exception of triamcinolone. We studied immediate outcome in terms of length of stay, adequacy of pain control, amount of parenteral morphine required, time to ambulation, range of motion and time able to perform straight-leg raise. Later assessment was performed at 1, 3, 6 months and 2 years, using the SF-36 questionnaire and the Oxford Knee Questionnaire. The presence of postoperative infection was also documented.

Results:There was a signifi cant reduction of length of stay (5.02 versus 6.72 days) and a lower pain score after 100 hours postoperatively in the study group. The patients who received corticosteroid injection were able to perform straight-leg raises earlier and had better range of motion from post-operative day 2 onwards. In addition, patients in the study group had signifi cant reduction in pain of up to 1 month, signifi cantly improved range of motion at 3 and 6 months and increased ambulation distance at 3 months. At 2 years, there was no statistically signifi cant difference in the range of motion, ambulation distance, SF-36 and Oxford Knee scores between the 2 groups of patients. There was no signifi cant difference in the rate of infection at short and intermediate term follow-up.

Conclusion:Periarticular corticosteroid injection during unicondylar knee arthroplasty has both immediate and short-term benefi ts in terms of length of hospitalization, pain control, rehabilitation and range of motion, with no increased risk of infection.Level of Evidence: Therapeutic Level I.

KeywordsKnee; Steroid; Pain; Arthroplasty; Replacement; Rehabilitation.


EARLY RESULTS OF A NOVEL HYDROXYAPATITE-COATED TOTAL KNEE REPLACEMENT

A.Cheung, I.Mcnamara, J.Chitnavis Department of Orthopaedics, Addenbrooke’s Hospital, Cambridge, United Kingdom

ObjectivesWe prospectively reviewed the results of 12 cementless, hydroxyapatite-coated, posterior-cruciate-ligament-retaining, stemmed, total knee replacements (TKRs) performed in nine patients over a period of three years. The Knee Society clinical rating score was used pre- and post-operatively.

Materials and MethodsBetween 2004 and 2007, 12 primary TKRs were performed using the Genesis II uncemented TKR system (Smith and Nephew, Memphis, USA). All the operations were performed by the senior author (JC) using a standard technique.

ResultsThere were four male and fi ve female patients, with a mean age of 58 years (52 to 63). The mean length of follow up was 14 months (2 to 40). A total of 12 procedures had been undertaken (6 unilateral, 3 bilateral performed simultaneously). Osteoarthritis was the primary diagnosis in the majority of patients (90%). The mean pre-operative knee score was 119, which had improved to 172 at latest review. The mean post-operative range of movement was 0˚-110˚. Routine roentography at follow up showed no evidence of tibial or femoral osteolysis, prosthethic loosening, or tibial tray subsidence. No TKR has required revision.

ConclusionThe early results of this series of primary, hydroxyapatite-coated, cementless TKRs are good. Cementless TKR has proven results which are comparable to cemented TKR and has the added advantages of reduced operating time and preservation of bone stock.

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A NOVEL SELECTIVE MULTIPLE INJECTION TECHNIQUE FOR INTERSCALENE BLOCK IN SHOULDER SURGERY

Cheung A, Lambert S,Tennent D,Allt-Graham JRoyal National Orthopaedic Hospital, Stanmore and St George’s Hospital, London, United Kingdom

ObjectivesWe describe a modern approach for safe, reliable shoulder blocks in orthopaedic surgery.

Materials and MethodsThe technique is a multiple injection technique aimed selectively at the upper cervical roots and trunk (C5,6) providing anaesthesia of the shoulder only. It utilizes a nerve stimulator and is performed on awake or sedated patients. Plain Bupivicaine 0.375% was used as a regional anaesthetic agent. Low volumes of local anaesthetic in divided doses up to a total of 20 mls provided selective blockade of the roots and upper trunk.

Results We report a series of 865 interscalene brachial plexus blocks (ISBPB’s) performed for shoulder surgery in 865 patients, roughly sex equal (age range 13-99, mean = 48.3 years) between 1999 – 2004. In the majority of cases (95.8%) the patient was awake or able to breathe spontaneously under light general anaesthetic. Opiates were required peri-operatively in only 3.3% of cases during ISBPB. Overall complication rate was 1.5% which compares favourably to the literature. All complications were transient.

ConclusionsInterscalene brachial plexus blocks (ISBPB’s) have proven to be a relatively safe, reliable and effective method of regional anaesthesia in shoulder surgery. This selective novel technique avoids total anaesthesia of the arm and hand which is unnecessary and may be unpleasant for the patient.


CLINICAL AND RADIOLOGICAL RESULTS OF A POROUS TANTALUM ACETABULAR SYSTEM IN REVISION HIP SURGERY

*Teo YH, **Zwar R, ***Bergman NR *Adult Reconstructive Surgery Clinical Fellow, Austin Health, Melbourne, Australia**Consultant Musculoskeletal Radiologist, Austin Health, Melbourne, Australia***Consultant Orthopaedic Surgeon, Austin Health, Melbourne, Australia

ObjectivesInitial stability and rigid fi xation of uncemented acetabular cup is critical in the long term success of revision hip surgery. Revision surgeries present issues of poor bone quality, bone defect, and lack of structural support. We use a modular tantalum revision cup that allows screws fi xation both into the ischium and ilium, supplemented by myriads of modular tantalum augments and buttresses where necessary.

Methods60 consecutive patients who underwent revision acetabular reconstruction with a minimum 2 years follow up were studied. Paprosky classifi cation was used to grade all defects pre-operatively. All surgeries were performed by the senior author (Bergman NR). All patients were assessed clinically and radiologically at 6 weeks, 12weeks, 1 year, and 2 years post surgery. Harris hip score was charted on each visit. Radiographs were assessed for stability as well as ingrowth at 1 year, and again at 2 years post surgery.

ResultsRadiological analysis demonstrated all acetabular shells to be stable at 1 year, and evidence of ingrowth were seen at 2 years post surgery. Harris hip score was increased comparing pre-op to 12 weeks, and continues to increase at 1 year review. No re-revision was performed in our series.

ConclusionsIt is crucial to achieve immediate acetabular shell stability intra-operatively to ensure long term success of acetabular component. The good scratch fi t of the shell, coupled with augments provided positive results in hostile revision condition for bone defi ciency of up to Paprosky IIIb in our revision series.

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PAIN IN THE ASSESSMENT OF OXFORD PHASE 3 UNICOMPARTMENTAL KNEE ARTHROPLASTY (UKA). Lukas Lisowski1, Joanne Bloemsaat-Minekus2, Inez Curfs3, Andrzej Lisowski3

Academic Medical Center Amsterdam, the Netherlands1

Biomet, Dordrecht, the Netherlands2

Atrium Medical Center, Kerkrade, the Netherlands3

ObjectivesThe results of knee arthroplasty are commonly assessed by survival analysis using revision as the endpoint. We have used the assessment of pain by a patient based questionnaire as an alternative after the Oxford Phase 3 UKA implanted by a minimally invasive technique.

Materials and MethodsBetween January 1999 and May 2007, 223 consecutive Oxford arthroplasties were implanted by a single surgeon in a county hospital. Mean follow-up period was 35 months. Patients were assessed prospectively pre-operatively and after UKA in each year subsequently by a questionnaire. Survival analysis was undertaken.

ResultsPreoperatively 85.8% had moderate or severe pain. Postoperatively, of fi ve patients(2.6%) with persisting pain due to failure of using proper patient selection three were revised to TKA and two are still being followed. Three patients(1.6%) with moderate pain after using proper indication criteria accepted their complaints. Ten other patients (5.2%) experiencing moderate pain some time during the eight year period were successfully treated by arthroscopy. If after surgery patients experienced pain which had spontaneous improved by the second year, the initial pain was ignored. Totally 9.6% of patients experienced moderate or severe pain at some stage, and the failure rate was 4.2% in this period of 8 years´ experience.

ConclusionWhen strict indications are followed the failure rate of the procedure can be minimised till 1.6% when moderate pain is considered the endpoint. As relief of pain is the primary reason for joint replacement, this is likely to be the most important factor in determining the long-term outcome for the patient.


COMPLICATIONS IN 223 CASES OF THE OXFORD PHASE 3 UNICONDYLAR ARTHROPLASTY (UCA) IN A COUNTY HOSPITAL. Lukas Lisowski1, Joanne Bloemsaat-Minekus2, Inez Curfs3, Andrzej Lisowski3




ObjectivesAim of this study was to analyse the complications during the fi rst eight years of experience with the Oxford Phase 3 prosthesis for treatment of osteoarthritis by a minimally invasive technique.

Material and MethodsBetween January 1999 and May 2007, 223 arthroplasties were implanted by a single surgeon in a non-teaching hospital. 191 cases had a minimal FU of one year (mean FU 35 months). Mean age was 69 years (range 49-91yrs).

Results: Complications, cause and management I Dislocation of the meniscal insert in three patients (1.6%): two due to technical error (revised to TKA and Vanguard UCA respectively) and one traumatic (open reduction). II Three (1.6%) patients with persisting pain complaints due to failure of proper patient selection were revised to TKA. III Five (2.6%) patients with moderate pain complaints of which three had correct and two doubtful indications followed a wait and see policy. IV One intra-operative fracture of the proximal tibia due to surgical error was treated by CPM and casting. V Ten (5.2%) additional arthroscopic procedures were performed with good results.

ConclusionThe rate of revision surgery was 2.6%. Persisting pain complaints after one year of FU occurred in 4.2 %. Failure of using strict indication criteria e.g. three revisions to TKA due to pain and two patients with persisting moderate pain complaints, emphasizes once more the importance of strict patient selection. When strict indication criteria are considered the unicompartmental Oxford Phase 3 prosthesis is in our opinion the fi rst choice of treatment of anteromedial osteoarthritis.

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INDEPENDENT STUDY OF THE OXFORD PHASE 3 UNICOMPARTMENTAL ARTHROPLASTY (UCA) FOR TREATMENT OF ANTEROMEDIAL OSTEOARTHRITIS OF THE KNEE: 8 YEARS RESULTS

Lukas Lisowski1, Joanne Bloemsaat-Minekus2, Inez Curfs3, Andrzej Lisowski3




ObjectivesAim of this study was to analyse the clinical results of the fi rst eight years of experience with the Oxford Phase 3 unicompartmental prosthesis for anteromedial osteoarthritis of the knee joint.

Material and MethodsBetween January 1999 and May 2007, 223 consecutive Oxford arthroplasties were implanted by a single surgeon. A total of 191 cases met the required follow-up period of one year. Pain, function of the knee and health-related-quality of life were evaluated by the WOMAC-Questionnaire, the Knee Society Score(KSS), Oxford Score and VAS for pain and satisfaction.

ResultsMean age at operation was 69 years and mean follow-up time was 35 months. The mean pre-and postoperative knee society knee scores were 46 and 91 respectively. The pre-and postoperative knee society function scores were 47 and 87. The WOMAC-scores, the Oxford-score and the VAS for pain and satisfaction all improved signifi cantly. Major complications that occured in our series were: dislocation of the meniscal insert in three patients of which two were revised to TKA and Vanguard-UCA respectively, and one reduced by an open procedure succesfully. Three patients with persisting pain complaints due to failure of proper patient selection were revised to TKA. Five others with a correct indication in three and a doubtful indication in two, had a wait and see pollicy.

ConclusionEvaluation of our patients after a mean follow up of 35 months revealed a signifi cant improvement of the clinical and function scores. Patients’ satisfaction is high and major complication rate is low when strict indication criteria are followed.


CEMENTING TECHNIQUE IN TOTAL KNEE REPLACEMENT: A RANDOMIZED CONTROL TRIAL COMPARISON BETWEEN STANDARD AND MINIMALLY INVASIVE APPROACHES AT 2 YEARS

Wee Lim Loo, MBBS MRCSWilliam Dy Chuasuan, Jr., MD, DPBOSean Ng, MBBS, MRCS, MMed(Ortho)Seng Jin Yeo, MBBS, FRCSNgai Nung Lo, MBBS, FRCSKuang Ying Yang, MBBS, FRCSHwei Chi Chong, BSc(PT)

IntroductionMinimally invasive total knee arthroplasty may hinder the ability to apply optimal pressure during cementing thus leading to an inadequately fi xed component and premature implant loosening. We performed a prospective randomized control trial to evaluate for the presence of radiolucent lines around the bone-cement interface using the knee society total knee arthroplasty roentgenographic evaluation and scoring system and evaluated for its signifi cance in patients who underwent the minimally invasive compared to the standard total knee replacement surgery at 2 years time.

Methods108 subjects were enrolled in the study. Randomization was done using computer generated numbers. 51 (47.2%) underwent the minimally invasive approach and 57 (52.8%) underwent the standard approach. Radiolucent lines were determined and measured digitally by a single blinded observer using the knee society total knee arthroplasty roentgenographic evaluation and scoring system (Fig.1)as a guide.

ResultsRadiolucent lines were noted under the tibial component in twenty two (20.1%)patients; eleven (21.56%)for MI-TKR and ten (17.5%) for STD-TKR (p=>0.05). Radiolucent lines were also found under the femoral component in seven (6.48%) patients (Figure 2B). One (1.75%)of which underwent STD-TKR and six (11.76%)others underwent MI-TKR (p=>0.05).

ConclusionThe minimally invasive approach is no deterrent to proper cementing technique in total knee replacement arthroplasty.

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DEEP INFECTION FOLLOWING HEMIARTHROPLASTY OF THE HIP

Tan ZP, Lingaraj K, Das De SDepartment of Orthopaedic Surgery, National University Hospital, Main Building Level 3, 5 Lower Kent Ridge Road, Singapore 119074, Republic of Singapore

ObjectivesDeep infection following hemiarthroplasty of the hip entails signifi cant morbidity and sometimes mortality. This study was carried out to determine the incidence of deep surgical site infection following hemiarthroplasty of the hip, analyze the outcome of such infections, and identify risk factors for the development of these infections.

MethodsAll patients who underwent hemiarthroplasty of the hip in our institution from 2004 to 2006 were included. The relevant data was obtained from the hospital’s computerized database. These included age, co-morbidities, delay to surgery, length of surgery, surgeon experience, pre-operative sources of infection, development of deep surgical site infection, modes of management of the infection (Antibiotic therapy, Debridement and retention of prosthesis, 1-stage revision, 2-stage revision and Girdlestone excision arthroplasty), and outcome measures (Duration of hospitalization, Mortality, Need for revision) following this complication.

ResultsA total of 236 patients were identifi ed. 21 patients (8.90%) developed infections. The overall mortality rate following such infections was 4.76%. Of these, 7 patients (33.33%) developed deep surgical site infections. The mortality rate following deep surgical site infections was 14.29 %. The main risk factors identifi ed were presence of diabetes mellitus and ischemic heart disease.

ConclusionThe deep infection rate following hemiarthroplasty is low. However, such infections portend serious morbidity and mortality. The main risk factors are diabetes and ischemic heart disease. Prevention of infection is of utmost importance.


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EVOLUTION OF TOTAL HIP ARTHROPLASTY IN SINGAPORE OVER THE PAST DECADE

Singh G1, Lingaraj K2 , Cheok L3, Das De S4

Medical Offi cer (Trainee), Department of Orthopaedic Surgery, National University Hospital, Singapore1

Associate Consultant, Division of Adult Reconstruction Surgery, Department of Orthopaedic Surgery, National University Hospital, Singapore2

House Offi cer, Department of Orthopaedic Surgery, National University Hospital, Singapore3

Professor and Senior Consultant, Head, Division of Adult Reconstruction Surgery, Department of Orthopaedic Surgery, National University Hospital, Singapore4

IntroductionTotal hip arthroplasty (THA) has been performed in Singapore since 1974. In this study we compare overall numbers, demographic profi le of patients, diagnoses and indications for THA, implants used and proportion of revision cases over a period of 10 years in an academic orthopaedic department in Singapore.

Materials and Methods:The study design is a retrospective review of cases from 1994 to 1996 and from 2004 to 2006. Patient data was obtained from operating theatre record books. The case records of these patients were then retrieved and relevant data fi elds captured. Data was analysed using Microsoft Excel and SPSS Version 13.

Results:There was a three-fold increase in the number of THA cases, from 40 in 1994-1996 to 133 in 2004-06. The mean age of patients increased from 57.2 years in 1994-1996 to 61.5 years in 2004-2006. Female patients outnumbered males in both series. There was also a signifi cant increase in the number of revision operations done in 2004-06 (25) compared with the earlier group (3), and most of these revisions were done for periprosthetic fractures, aseptic loosening and infection. There was also a signifi cant shift towards cementless femoral fi xation.

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METAL ON METAL TOTAL HIP ARTHROPLASTY IN YOUNG PATIENTS WITH NECK OF FEMUR FRACTURE – A REPORT OF 2 CASES

Chung KTK, Ooi LHTan Tock Seng Hospital, Singapore

ObjectivesTo increase the awareness of the indication of metal on metal total hip arthroplasty includes neck of femur fracture in young patients

Materials and MethodsAll the metal on metal total hip arthroplasty (THA) cases performed by one orthopaedic surgeon in Tan Tock Seng Hospital in 2006 was retrospective reviewed. Cases for which the indication for THA was young patients (30-50 year old) with a displaced neck of femur fracture were included in the review. Cases were identifi ed and their follow up and progress was reviewed.

Results Two patients were identifi ed in this study. Both patients were discharge within 8 days of hospital stay. At one year post operation, both patients have a painless hip with full range of movement with no leg length discrepancy.

ConclusionsMetal on metal THA is usually performed on young active male patient who suffers from avascular necrosis of the femoral head or osteoarthritis. A less common indication of THA is young active patients with a displaced neck of femur fracture. In such patients one will need to consider monopolar, bipolar hemiarthroplasty, or THA as the management of choice. Monopolar or bipolar hemiarthroplasty have a reduced survivorship compared to THA and are not as suitable for the young active patient. THA provides better hip function compared to the hemiarthoplasty. The traditional THA with metal or ceramic heads in combination with polyethylene may lead to periprosthetic osteolysis and increase wear in such young active patients. An alternative management to this problem is a metal on metal THA. In the literature, no cases have been reported on metal on metal THA in patients with a displaced neck of femur fracture. This paper aims to increase the awareness that metal on metal THA is a feasible option for young male patients with a displaced neck of femur fracture.


DOES COMPUTER-ASSISTED SURGICAL NAVIGATION TOTAL KNEE ARTHROPLSTY REDUCE VENOUS THROMBOEMBOLISM COMPARED WITH CONVENTIONAL TOTAL KNEE ARTHROPLASTY? A PILOT STUDY

L H Ooi* MBBS, MRCS(Edin), MMed(Ortho)(S’pore), FRCS(Edin)(Tr & Ortho) N N Lo** MBBS, FRCS(Edin), FAMSS J Yeo** MBBS, FRCS(Edin), FAMSB C Ong*** MBBS, MMed(Anaes), FAMSZ P Ding****MBBS, MMed(Int Med), FAMSA Lefi *****MD* Consultant, Dept of Orthopaedic Surgery, Tan Tock Seng Hospital ** Senior Consultant, Dept of Orthopaedic Surgery, Singapore General Hospital*** Senior Consultant, Clinical Associate Professor, Department of Anaesthesia, Singapore General Hospital****Senior Consultant, Department of Cardiology, National Heart Centre*****Clinical Fellow, Department of Cardiology, National Heart Centre

ObjectivesThe study aims to show that total knee arthroplasty using computer-assisted surgical navigation without intramedullary rodding is safer than conventional intra-medullary techniques in preventing venous thromboembolism.

Materials & MethodsThirty patients were grouped into groups of 10. Group A and B had conventional intramedullary rodding of the femur and/or tibia. Group C had no rodding of the femur and tibia using computer-assisted surgical navigation. The degree, duration and size of the embolic shower were captured by a transoesophageal echocardiography probe. The echogenic emboli were graded according to the Mayo Clinic score. Haemodynamic parameters such as pulse oximetry oxygen saturation, end-tidal carbon dioxide, heart rate and mean arterial pressure were also recorded.

ResultsThere was a signifi cant difference in the size of the emboli and the Mayo Clinic score when comparing the groups with intramedullary rodding and those without. There was also a signifi cant difference in the pulse oximetry oxygen saturation and heart rate when the group without intramedullary rodding was compared with groups with rodding.

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ConclusionSurgical navigation total knee arthroplasty may be safer than conventional total knee replacement with intramedullary rodding in preventing venous thromboembolism.


A CASE OF RECURRENT ANTERIOR HIP DISLOCATION

Tan Sok Chuen , Tan Meng Kiat David, Lai Choon HinTan Tock Seng Hospital, Singapore

ObjectiveAnterior hip dislocations constitute 10-15 % of all hip dislocations. Recurrent anterior hip dislocations are even more rare. Most of these are due to ligamentous or capsular laxity, a dysplastic acetabulum, or bony malalignment of proximal femur. Here we look at a case of recurrent anterior hip dislocation in a 62 year old Chinese lady.

Materials and MethodsWe studied the clinical presentation of this patient, examined for risks factors that would predispose the patient to recurrent hip dislocation. Radiological features such as acetabular angle, Wiberg angle and acetabular version were studied. MRI was also performed to look for capsular laxity and labral tears. Various treatment options were discussed.

ResultsThe patient was found to have recurrent anterior hip dislocation which was attributed to acetabular dysplasia and increased acetabular version. The patient was counselled for conservative treatment and for surgical interventions such as pelvic osteotomy, capsulorrhaphy and femoral osteotomy. She chose conservative management and was thus treated with hip brace and physiotherapy.

ConclusionRecurrent anterior hip dislocations are rare, and through this case various factors are studied. The different surgical options are also discussed. This patient would have been a good candidate for pelvic osteotomy and capsulorrhaphy if she chose to have surgery done.

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VASCULAR INJURIES IN TOTAL HIP REPLACEMENT ARTHROPLASTY

Amarjit Singh, MS,MRCS, Viren Mishra, FRCS, Frank Howell, FRCS (Orth), Naresh Kumar, MS, FRCS(Orth)

ObjectiveTo assess the prevalence of vascular injuries in total hip replacement primary or revision, the reasons and mode of presentation.

Material and Methods The postal survey was conducted among the members of British Hip Society. They were requested to report on their practice and the vascular injuries they had encountered in the past.

Results We receive 42 replies out of 82 questionnaires sent. Total of 26 complications reported which included 3 from our centre. Median experience of surgeon was 12.5yrs.Complication rate was 0.09% in revision cases and 0.02% in primary joint replacement. 38% of all complications presented intraoperatively.

In Primary Total Hip Replacement 66% of complications were presented with in 48 hr and in revision group 86% presented with in 48hr. In majority of revision cases lateral approach was used with direct injury as the commonest mechanism.Femoral vessels were involved most commonly followed by iliac vessels.

Discussion Direct mechanism of injury includes inappropriate application of retractors, sharp dissection, power tools and acetabular screws. Indirect mechanism includes heat from polymerisation of bone cement, redundant cement spicules, protruding acetabular cups and superimposed sepsis.

Conclusion Vascular complication rate in THR is 0.2-0.3%. Early presentations were characterized by hemorrhage from major vessel or a branch from it. Late presentation was characterized by pseudoaneurysm or AV fi stula.

Complications are relatively more common in revision cases but expect more in primary cases also. None of the approaches to hip was exempted from complications.Outcome is Good if recognised early. Preoperative assessment and high index of suspicion postoperatively with monitoring is emphasized.


THE AETIOLOGY AND SURGICAL OUTCOMES OF PATIENTS UNDERGOING REVISION TOTAL HIP REPLACEMENT IN A TERTIARY INSTITUTION IN SINGAPORE

Tan Sok Chuen , Sathappan S SathappanTan Tock Seng Hospital, Singapore

ObjectiveIn comparison to knee arthroplasty, total hip replacement (THR) is less commonly performed in Singapore and we have presented our institution data previously. The number of revision THR is therefore expected to be much lesser. A case series study was undertaken to review all the revision total hip arthroplasty performed in our institution over the last 5 years.

Materials and MethodsThis is a retrospective study of all patients undergoing revision THR between Jan 2003 to March 2007. All patient bio-data was collected and some of the variables that were critically reviewed were: clinical indication, surgical approach; mode of implant fi xation; use of bone graft/augments, wound drainage; immediate complications (e.g. infection, dislocation and deep vein thrombosis); hospital length of stay; and functional outcomes using d’Aubigne and Postel scoring system.

ResultsThere were a total of 30 patients. The common clinical indications for revision THR included: prior implant-related infection, aseptic loosening and recurrent hip instability. A signifi cant proportion of the patients had substantial improvement in the functional hip scores post surgery. Further details of these results will be discussed in the paper.

ConclusionRevision THR is an uncommon surgical procedure in the local setting. From this study, the important indications are instability, infection and aseptic loosening. Patients have improved functional outcomes following revision THR with minimal complications.

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CLINICAL OUTCOMES FOLLOWING COMPLEX PRIMARY TOTAL KNEE ARTHROPLASTY (TKA) - A CASE SERIES

Reuben CC Soh1, Sathappan S. Sathappan2

Medical Offi cer, Department of Orthopaedics, Tan Tock Seng Hospital1

Consultant, Department of Orthopaedics, Tan Tock Seng Hospital2

Introduction and AimIn our institution, many patients often present late with severe knee osteoarthritis coupled with ligamentous instability and signifi cant knee deformity. In these patients a complex TKA would be required entailing careful soft-tissue balancing, bone augmentation and possible need for constraint. This retrospective study aims to review the clinical outcomes of complex TKAs carried out at our centre.

Materials and MethodsA retrospective analysis of all complex TKAs done by a single surgeon was analyzed. The following variables were collated: clinical diagnosis, soft-tissue balancing techniques, need for bone augmentation, degree of constraint required, type of implant fi xation used, patella re-surfacing, post-operative complications, pre and post-operative knee society scores.

ResultsA total of 30 knees underwent complex TKA (28 patients) in our regional hospital by the senior author with a mean follow up of 12 months. The mean age of patients is 68 years. All had one or more of the following knee deformities prior to surgery i) varus > 200; (ii) valgus deformities of >150; (iii) knee fl exion contractures >100 ;(iv) severe collateral ligament compromise; (v) defi cient proximal tibial or distal femoral bone stock. Most patients attained satisfactory improvement in knee range of motion. Post-operative outcomes were modest in a few patients who presented with more severe preoperative disease.

ConclusionComplex TKA in this select group of patients can achieve good to excellent results in spite of technical diffi culties often encountered during surgery. Combining good surgical technique with implant modularity can facilitate in addressing the multi-planar deformities in patients with severe and late presentation of osteoarthritis.


THIRTY-DAY MORTALITY AND MORBIDITY AFTER TOTAL KNEE ARTHROPLASTY

*Seah Vwt, *Yang Ky, *Yeo Sj, *Lo Nn, *Seow Kh, **Singh G, *Department Of Orthopaedic, Singapore General Hospital**New Dehli, India

IntroductionTotal knee arthroplasty (TKA) is one of the most successful orthopaedic procedures to date. It is estimated that over 130,000 of TKAs are performed in the United States every year. Whilst the procedure is safe, it nevertheless carries a risk of perioperative mortality and morbidity. This study aimed to report the mortality rate within 30 days after a total knee arthroplasty, as well as to assess the incidence of early postoperative morbidities.

Materials and MethodsWe reviewed a total of 2219 TKAs performed by multiple surgeons in our centre from 1998 to 2001. All mortalities within 30 days of a TKA were recorded. Morbidities such as infection, thromboembolic phenomenon, and any re-admissions within 30 days of operation or 15 days of discharge were recorded.

ResultsThe mortality rate within 30 days of a total knee arthroplasty was 0.27% (6 of 2219 patients). The incidence of early postoperative infection was 1.8%, of which 1.44% were superfi cial and 0.36% were deep infections. There were 3 cases (0.13%) of pulmonary embolism and 22 cases (0.99%) of deep vein thrombosis.

ConclusionsThe 30-day mortality rate, and the incidence of infection after total knee arthroplasty performed in our institution is comparable to other centres around the world, and further emphasises that TKA is a safe procedure. However, the small number of mortalities in this study does not allow us to identify a predominant cause of perioperative mortality.

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TOTAL KNEE ARTHROPLASTY COMPLICATED BY SYMPTOMATIC VENOUS THROMBOEMBOLISM: AN OBJECTIVE OUTCOME MEASUREMENT

KH Lin, NN Lo, SJ Yeo, KY YangDepartment of Orthopaedic, Singapore General Hospital

IntroductionVenous thromboembolism following total knee arthroplasty and its sequelae post-phlebetic syndrome has long been a major health concern. Patients who have acquired symptomatic DVT following total knee arthroplasty may be expected to have a higher level of limb morbidity, decrease range of joint movement and lower level of overall satisfaction with their knee operation. The aim of this study is therefore to determine the outcome of total knee replacement (TKR) following patients with and without symptomatic deep venous thrombosis using clinical rating scores.

Patients and MethodsPatients with documented symptomatic post TKR DVT and post TKR without DVT were examined from our prospectively collected arthroplasty database during the period from January 2001 to December 2003. We compared the clinical outcome measurements of patient post TKR with and without DVT.

All patients were followed up for 2 years after operation and scored at pre-operation, 6 months and 2 years post operation using Medical Outcomes Study Short Form-36 (SF-36), Knee Society Clinical Rating System (knee and function scores), Oxford 12-item Knee Score. Routine thromboprophylaxis consisted of graduated compression stockings and early mobilization. Routine chemical thromboprophylaxis was not given.

ResultsDuring long term follow up at 2 years, the overall level of satisfaction with their knee operation is similar in these 2 groups of patient. Our study therefore do not support the routine use of chemical thromboprophylaxis in this group of patient.


EFFECT OF COMBINED ISOTONIC EXERCISES PROTOCOL ON UNILATERAL SYMPTOMATIC OSTEOARTHRITIS KNEE

Objective Knee Osteoarthritis is the leading cause of chronic disability in older person. Dynamic stability of the knee joint depends on the appropriate strength ratio of Quadriceps and Hamstrings (H (concentric)/Q (concentric) value of 0.66 is accepted as normal during low speed). It is usually seen that for the rehabilitation management of O.A knee, Physiotherapists use to recommend Quadriceps strengthening exercise but several studies advocated that both Quadriceps and Hamstring weakness taken place in O.A knee. To investigate whether combined isotonic strength training of quadriceps and hamstring is better than isolated quadriceps strength training.

Material and MethodAn experimental design, different subject group-Randomized control trial. A sample of 30 subjects age group 40 to 60 years were randomly assigned in to two different groups. Group A was given combined isotonic muscle strengthening of quadriceps and hamstring. Group B was given isolated quadriceps isotonic muscle strengthening exercise. Patients were assessed pre treatment on Walking speed test, Step test and Pain on VAS scale. Patients were instructed to do each exercise Twenty fi ve to thirty fi ve repetitions in one set and single set is done in one treatment session. Treatment module was limited to 5 weeks duration. For the fi rst 3 weeks all the exercises were carried out using 1kg weight and for the next 2 weeks exercises were carried out using 1.5kg weight. Data was collected for day 0, week 3, and week 5 measurements of walking speed, step test and pain on VAS scale.

ResultThe data obtained was analyzed using students t- test. For all the dependent variables objective and subjective evaluation was done (Pain on VAS, Walking speed and Step test) during the procedure. The overall data which was analyzed revealed signifi cant improvement on the effective variables in both the groups. The result obtained were found to be signifi cant at p<0.05 which shows that Combined isotonic strength training of quadriceps and hamstring is more effective than isolated quadriceps strength training in the management of Osteoarthritis Knee.

ConclusionThe degenerative disease decreases the strength of all the groups across the joint and hence better recovery found in Group A is well supported. Stability of knee joint is governed by both hamstrings and quadriceps and decreased stability might be a factor for pain and decreased functional performance.

Key Wordsoa knee, Isotonic Exercises, strength ratio of Hamstrings and Quadriceps


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CONSENT FOR MEDICAL PHOTOGRAPHY IN ORTHOPAEDIC SURGERY AND THE EMERGENCY DEPARTMENT

Cheung A, Al-Ausi M, Hathorn I, Hyam J, Jaye PDepartment of Orthopaedics, Addenbrooke’s Hospital, Cambridge and Department of Emergency Medicine, St Thomas’s Hospital, London, United Kingdom

Objectives

To investigate patients’ attitudes toward medical photography as a guide to consent and usage of digital photography in the context of the emergency department and in orthopaedic theatres.

Materials and Methods

An anonymised questionnaire was used to collect data regarding patients’ attitudes toward medical photography in the minor injuries unit of an inner city emergency department between January 2004 – April 2004. Data was collected by emergency department Medical Offi cers.

Results

100 patients completed the questionnaire. Although the majority (84%) would consent to medical photography for the purposes of medical education, only a fi fth (21%) would allow all forms of consent, and two thirds (63%) had reservations for certain types of consent. Most patients interviewed were happy for all body areas to be photographed with the exception of genitalia (59% negative response) citing invasion of privacy or embarrassment. Most patients (70%) interviewed would give consent for publication of images in a medical journal or book but were more likely to refuse consent for use of images on internet medical sites (53%).

Conclusion

From an ethical and legal standpoint it is vital that patients give informed consent for use of images in medical photography, and are aware that such images may be published on the internet.

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TRAUMATIC KNEE DISLOCATIONS IN AN URBANIZED ASIAN CITY: A RETROSPECTIVE REVIEW OF CASES FROM 2000-2005

1Dr KL Ong, 2Dr MH Chew, 3Eng MY, 4Dr WS Tan, 5Dr SB Koh, 6Dr CC Chang 1Medical Offi cer, Department of Orthopaedic Surgery, Singapore General Hospital2Yong Loo Lin School of Medicine, National University of Singapore 3Medical Offi cer, Department of Orthopaedic Surgery, Singapore General Hospital4Associate Consultant, Department of Orthopaedic Surgery, Singapore General Hospital5Senior Consultant, Department of Orthopaedic Surgery, Singapore General Hospital

IntroductionTraumatic knee dislocations represent a distinct subset of patients with multi-ligamentous injuries of the knee. Higher incidences of neurovascular injuries could lead to potential amputations and poorer clinical outcome. The focus of this study is to review the clinical presentations and management of patients presenting to the emergency department with knee dislocations.

Materials & MethodsA retrospective study was carried out on consecutive cases of knee dislocations presenting to the Accident and Emergency Department from January 2000 to December 2005. We reviewed variables including mechanisms of injury, types of knee dislocations, complications involving neurovascular compromise as well as early and defi nitive surgical management.

ResultsEleven patients (ten males and one female), with median age of 32 years old (range 19-54, SD 12.1), presented to the Accident & Emergency during this period. 72% of our patients sustained two or more ligamental injuries with the Anterior and Posterior Cruciate Ligamental injuries being the most common. Two patients had popliteal artery injury with one presenting late as a compartment syndrome. One patient had a complete rupture of the common peroneal nerve. None of the patients required amputation.

Conclusions Traumatic knee dislocations are associated with a high incidence of neurovascular compromise which may present late, thus the need for increased vigilance and possible routine arteriography.

KeywordsKnee dislocation, neurovascular complication, arteriography


ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTIONS WITH HAMSTRING GRAFTS – OUR 5 YEAR FOLLOW-UP

Lee Yee Han Dave, Sarina Abdul Karim, Chang Haw ChongDepartment of Orthopedic Surgery, Changi General Hospital

IntroductionThe purpose of our study was to review the long-term results of Anterior Cruciate Ligament Reconstruction using Hamstring Grafts. A review of the literature show limited reviews that look at the outcomes of ACL reconstruction using Hamstring grafts beyond 5 years, especially in the Asian context.

MethodsOur patients had their surgeries performed in 2000 and 2001 for subacute or chronic tears of their anterior cruciate ligament. They were recalled to our clinic 5 years after their surgery for review.

The outcomes of these patients were assessed with Tegner, Lysholm Scores as well as the International Knee Documentation Committee (IKDC) Form. The knees were also assessed with a KT-1000 arthrometer to determine the side-to side difference between the operated and non-operated knees A radiograph of the operated knee was also performed

Results64 patients consented to return to for review. The average age of our patients was 25 years and they had their surgery at a mean of 10 months after sustaining the injury.

The mean Lysholm score was 85.2 and mean Tegner Score was 6. The mean subjective IKDC score was 80. 79.7 % of our patients had normal or nearly normal knees (IKDC A or B) with remaining 20.3% were IKDC grade C. The mean side-side difference for anterior translation using the KT-1000 arthrometer at maximal manual traction 1mm.

Conclusion We have compared our results with published data, many of which have a less than 5 year length of follow-up and found that our results are comparable. Many of our patients have achieved their pre-surgery aim of having a stable knee and return back to sports.

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PATIENT REPORTED OUTCOMES AND HEALTH RELATED QUALITY OF LIFE FOLLOWING MICROSUGICAL DECOMPRESSION FOR SYMPTOMATIC LUMBAR SPINAL STENOSIS IN OCTOGENARIANS

ObjectivesTo assess the safety and health related quality of life following lumbar decompression for spinal stenosis in octogenarians.

Materials Retrospective cohort study of prospectively collected data.

MethodsProspective pre and post-operative Oswestry Disability Index (ODI) scores and Medical Outcomes Short Form-36 (SF-36) scores were collected for 25 octogenarians who had undergone lumbar decompression for spinal stenosis. Outcomes, as well as adverse events, post surgery were prospectively collected.

ResultsThere were 15 females and 10 males in our cohort, mean age at the time of surgery was 84.6 ± 2.7 years. Mean follow up was 29.6 months (minimum 12 months, maximum 86 months). Average co-morbidities per patient were 3.1 ± 1.7. Signifi cant improvement was seen in ODI and SF-36 physical component summary scores from 61.8 ± 14.4 to 37.1 ± 22.2 and 23.2 ± 8.3 to 33.7 ± 10.3 respectively. We also found signifi cant improvement in physical function, role limitations physical, bodily pain and social function scores. There were 10 adverse events total in 9 patients. Musculoskeletal co-morbidities limited ODI improvement (p=0.02).

ConclusionLumbar decompression for neurogenic claudication in octogenarians results in signifi cant improvement in functional outcome and health related quality of life. However, due to impact of multiple co-morbidities, including a degenerative spine, the postoperative functional outcome and physical HRQOL will still be signifi cantly below age specifi c norms. Consequently, additional pre-operative counselling is recommend in this growing demographic regarding realistic postoperative expectations.


A RARE CASE OF LUMBAR FACET JOINT SEPTIC ARTHRITIS AFTER ACUPUNCTURE TREATMENT IN A TERTIARY HOSPITAL SETTING.

Singh G1, Liu G2, Wong H K3

1Dr Gurpal Singh, Medical Offi cer (Trainee) Department of Orthopaedic Surgery, National University Hospital, Singapore1

2Dr Gabriel Liu, Consultant, Spine Division, Department of Orthopaedic Surgery, National University Hospital, Singapore2

3Professor Wong Hee Kit, Senior Consultant, Head of Spine Division, Chief of Department of Orthopaedic Surgery, National University Hospital, Singapore3

Introduction Acupuncture has become a popular “alternative medicine” modality in the treatment of back pain. Randomized prospective studies demonstrate that acupuncture provides better symptomatic control in these patients, compared to placebo cohorts. However, there is limited data on this treatment’s complications. This study reports a rare case of septic arthritis of the lumbar facet joints, developing after the use of acupuncture, and its devastating effects upon the patient.

Materials and Methods A case report and literature review were performed.

ResultsA 65 year old female developed septic arthritis of the lumbar facet joints after acupuncture for symptomatic control of lumbar spondylosis and stenosis while waiting for surgery. Clinical, hematology, serology investigations and MRI fi ndings confi rmed the diagnosis. The surgery was cancelled with patient continued to suffer back pain. Subsequent, successful control of the infection required a total of 4 hospital admissions over a 2-year period, a CT guided spinal biopsy and 6months of antibiotic therapy. In addition, 6 follow-up MRI scans, 49 blood tests and a total bill of $10,000 were incurred.

Conclusion: Septic facet arthritis is rarely seen after diagnostic and therapeutic procedures. The overall incidence of spinal infection occuring after discogram, facet and nerve block and epidural anaesthesia is estimated to be less than 1 %, and epidural abscesses between 0.01-0.001%. This report demonstrates that spinal infection can result after the routine use of acupuncture treatment in a hospital setting and adds awareness for physicians in patients’ risk-benefi t counseling before the routine prescription of acupuncture.

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ASSOCIATION BETWEEN LONG DISTANCE RUNNING AND LOWER LIMB INJURIES: A RETROSPECTIVE STUDY.

Ng YH, Chiang JB, Chan YH, Lee KBL National University Hospital, Singapore

ObjectivesThe purpose of this study is to investigate the relationship between long distance running and lower limb injuries.

Study DesignRetrospective study

Materials and MethodsQuestionnaires were sent out to all triathletes and long-distance runners in Singapore via the various national associations, recreational running clubs, the army sports association and schools. The respondents were divided into those who had done triathlons before and those who only did long-distance running, and each group was further stratifi ed into the types of injuries previously sustained. Analysis of the relationship between age, sex, weekly running mileage, medical care received, and the injuries sustained was done for both groups. In the triathlete group, further analysis of the relationship between weekly cycling and swimming mileage, and the injuries sustained was done.

ResultsOur preliminary results showed that there is no association between the cumulative running and cycling distance and patient demographics, with the incidence of lower limb injuries. The use of joint supplements also has no effect on the incidence of knee pain.

ConclusionLong distance running and triathlon training have no signifi cant detrimental effect to the lower limbs.


EPIDEMIOLOGY AND CLINICAL OUTCOMES OF PATIENTS UNDERGOING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: AN ASIAN PERSPECTIVE

Saiful Nizam, Sathappan S. Sathappan

Introduction and AimAnterior cruciate ligament (ACL) tears remain as one the commonest soft-tissue injuries that are treated surgically by the orthopaedist. Though there are various clinical outcome studies, few describe the epidemiology of this patient cohort. The aim of this study was to evaluate the etiology, associated injuries and clinical outcomes of patients undergoing ACL ligament reconstruction in our institution.

Materials and MethodsA retrospective study was conducted based on the surgical database of all patients who underwent ACL reconstruction in 2005. The following variables were collated: patient demographics, mechanism of injury, intra-operative fi ndings and graft type used. Post-surgical functional outcomes were evaluated by clinical reviews using the Lisholm Knee score and the Tegner Scale.

ResultsThe total study cohort consisted of 134 patients. ACL injuries occur predominantly in males and are often associated with meniscal and collateral ligament injuries. The hamstring tendon autograft remains as one of the commonest type of graft that is used in our institution. At a mean follow-up of 2 years, most patients made signifi cant improvement in functional knee scores with satisfactory return to work. Further details will be discussed in the paper.

ConclusionACL tears are fairly common injuries in the young and active age group. Reconstruction of the ACL provides satisfactory knee stability, signifi cant improvement in functional outcomes with minimal post-operative complications.

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ANALYSIS OF THE EFFECTS OF PERCUTANEOUS VERTEBROPLASTY IN OSTEOPOROTIC COMPRESSION FRACTURES

Tan HMB, Hee HT Department of Orthopaedic SurgeryNational University Hospital Republic of Singapore

ObjectivesPercutaneous vertebroplasty in the treatment of symptomatic vertebral compression fractures has become a popular and common treatment modality. Although the main purpose of the procedure is pain relief, an associated benefi t of the procedure is possibly a partial restoration of the height of the collapsed vertebral body with potential improvement in the biomechanics of the spine. Our purpose is to analyze the effects of vertebroplasty on the vertebral height, Cobb angle, kyphosis angle and sagittal alignment of the spine.

Method:Digital radiographs of 71 osteoporotic compression fractures in 57 patients were reviewed retrospectively before and after vertebroplasty for changes in the vertebral height, Cobb angle, kyphosis angle and thoracolumbar and lumbar sagittal angles. Only wedge compression fractures occurring in the region of the thoracolumbar region were included in this study (T10 to L3).

ResultsThe mean increase in anterior height was 27mm, middle height 15mm and post height 4.9mm. Increase in anterior and middle heights were strongly statistically signifi cant but not increase in posterior height. There were also statistically signifi cant improvements in the wedge angle of 2.0° and thoracolumbar sagittal angles of 2.4°. There was statistically non-signifi cant mean increase in Cobb angle was 0.04° and increase in lumbar lordosis of 0.69°.

ConclusionPercutaneous vertebroplasty effectively increases anterior and posterior heights resulting in improvements in the wedge angles. These improvements are achieved solely by placing patient in the prone position during the procedure. In addition, there was improvement in the thoracolumbar sagittal angle. The signifi cance of these improvements is not clear but may potentially result in improved biomechanics of the spine.


ACCURACY OF PEDICLE SCREW PLACEMENT ON HUMAN-CADAVER VERTEBRA USING SUBROTO-SALIM SCOLIOMETRY DEVICE (S3D) AS A GUIDANCE

Rahyus Salim , Hanung Sunarwibowo, Luthti Gatam, Subroto Sapardan

IntroductionScrew placement method is very important to achieve accurate screw placement and indirectly to decrease risk of paralysis complication. This paper introduce new method of pedicle screw placement using guidance of S3D that is developing in Orthopaedic & Traumatology Department, Faculty of Medicine University of Indonesia / Cipto Mangunkusumo Hospital.

Material and MethodsFour stages of procedures are cadaver preparation, spinal exposure, pedicle screw placement and placement screw evaluation. Cadaver was in prone position when its spines were exposed. The handiwork pedicle screw placement method was performed on the left pedicles of thoracolumbar vertebrae of T7 until L1 (technique 2). The new method using S3D guidance was on the right one (technique 1). Pedicle Gravity angle will be gained using ‘LPG formula’ from Lamina Gravity angle on axial and sagittal plane. The entry point of both techniques kept pace with the anatomical landmark of intersection technique. Afterwards axial dissection right on the pedicles was performed to evaluate accuracy of pedicle screw placements pertaining to the in-screw and the ideal trajectory. Statistical analysis of this data were non parametric test.

ResultsAxial dissection analysis of the T7-L1 specimens showed that 3 screws (3/7) were in the left pedicles and 6 screws (6/7) were in the right pedicles (p=0.059). In-screw pedicle analysis showed that no screw (0/3) was in the ideal trajectory of the left pedicles and 3 screws (3/6) were in the ideal trajectory of the right pedicles (cannot be analyzed by statistical).

Discussion & ConclusionLPG Formula analyzes the association among lamina, pedicle and gravity in both axial and sagittal plane. The new technique may have superiority in respect of feasibility and simple procedure; but the reliability, reproducibility and intra – and inter observer error has to be evaluated.

Key wordsScrew placement, S3D, Ideal trajectory, LPG Formula.


Compilation ofAbstractsCompilation oCompilation oFree Paper Session 2b


THE CHANGING FACE OF FRACTURE CLINICS: NOT JUST BROKEN BONES

SL Goh, SS Randhawa, D GillRoyal Newcastle Centre, New Lambton NSW Australia

Background The fracture clinic is an essential part of orthopaedic training as well as obligations of orthopaedic surgeon in the public hospital. It represents the frontline of hospital orthopaedic care in the public eye; the clinic is a major intake point for non-urgent referral from hospital and external practitioners with respect to relevant fractures and associated injuries. The nature and format of this clinic requires succinct assessment and prompt treatment within limited time, space and resources.

There is little information on how fracture clinic are run internationally, particularly in the Australian context. Furthermore, there is increasing pressure on the hospital fracture clinic to provide a wider and diverse range of care within and outside the domain of a normal orthopaedic practice. This demand is often not matched by concurrent increase in resources. The lack of published research on how we run the fracture clinic in different setting makes it diffi cult for adequate manpower planning and resource allocation. This will adversely affect the public image of outpatient orthopaedic care provided by the medical community.

Objectives And MethodsThe objective of this pilot study is to assess various aspect of administrative setup and workload of fracture clinic in public hospitals. In early 2007, orthopaedic registrars in metropolitan and rural hospitals in New South Wales have been approached to complete a questionnaire-based audit of their current hospital. There is 60% response rate to the audit.

ResultsSome 30% fracture clinic polled are run primarily as followup clinic for patients who had elective or emergency surgery in hospital, in contrast to the traditional view of reviewing emergency department and GP referrals regarding fracture management. There is a wide range of workload expected even within metropolitan centres, ranging from 3 to 15 patients per hour per doctor (consultant or registrar). Surprisingly about 40 % of fracture clinic appointments are block booking, where all patients are told to turn up at the same time at the beginning of the session rather than staggered appointment times. Plaster rooms are run 20% by allied health professionals other than physiotherapists. 30% clinics are located between 2 to 5 minutes’ walk (up to 400 metres) from the X-ray department, a distance not necessarily easy for disabled patients. 20% of fracture clinics are unsupervised (no consultant).

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ConclusionThis preliminary analysis of fracture clinic audit reveals signifi cant variation of hospital practice with respect to clinic setup, referral system and work allocation even within metropolitan centres. There is a need for further studies for future manpower planning and setting service standards. This is even more important in view of recent changes in establishing new surgical training posts and training bodies.


THE ORTHOPAEDIC SURGEON AND FRAGILITY FRACTURES: BEYOND FIXING THE BONE; AN AUSTRALIAN PERSPECTIVE

Goh, S.L. and Ghabrial, Y.Department Of Orthopaedic Surgery, Royal Newcastle Centre, New Lambton, NSW, Australia

Background Orthopaedic surgeons have traditionally been involved in the care of fragility fractures, a clinical presentation of osteoporosis. However, there is increasing demand for them to act beyond just fi xing the fractures, to provide a more holistic management of patients with respect to future injury prevention. Currently there is no formal published recommendations for perioperative osteoporosis care specially tailored for orthopaedic surgeons in Australia.

ObjectivesThis paper collates various articles and views published by major journals and several Australian and international organisations on the role of orthopaedic surgeons in treatment of patients with osteoporotic fractures, including immediate perioperative treatment and long term care post discharge. It is hoped that this will aid in formulation of a concerted approach by hospital departments of orthopaedic surgery and Area Health Services in the care of osteoporotic patients.

DiscussionSeveral arguments promoting increased active management of osteoporosis by surgeons were discussed. Commonly raised rebuttals against this stand were addressed. Using a recently published approach format by Kaufman et al (JBJS-A, 2003) and latest Australian recommendations by various groups, we attempt to formulate an ideal management strategy for orthopaedic surgeons who are interested in initiating a holistic care plan for their patients with osteoporotic fractures. Various themes were raised, including patient education, pharmacological management as well as role of other specialists and allied health professionals in sceondary and tertiary injury prevention. Special mention is made with respect to role of Vitamin D in Australian population.

ConclusionThere is increasing call for an active role by the treating orthopaedic surgeon in the care of the patient’s osteoporotic condition to improve prevention of future fragility injury. It is hoped that this paper will further promote interests in Australia by surgeons and patients alike to address this chronic and insidious disease.

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LOOSE BODY FORMATION WITHIN THE KNEE JOINT FOLLOWING RETROGRADE INTRAMEDULLARY NAIL FIXATION OF A FEMORAL SHAFT FRACTURE

CC Yong, L Krishna, V P Kumar, S Das DeDepartment of Orthopaedics, National University Hospital, Singapore

ObjectivesTo detail an uncommon complication following retrograde intramedullary nail fi xation of a femoral shaft fracture.

Materials and MethodsA case study of a 44 year old male whom sustained a traumatic closed fracture of the left distal femoral shaft is presented.

ResultsThe patient underwent retrograde intramedullary nailing of the left femur and made an initial uneventful recovery. However, the patient continued to complain of left knee pain and stiffness. Range of motion was limited at 20 – 90 degrees. X-rays done showed a 1.3cm x 1.6cm loose body projected over the distal femoral condyles within the left knee joint. Surgical removal of the loose body was offered to the patient but he was initially not keen to undergo surgery. The patient fi nally agreed to surgery 19 months after the initial procedure. A large 4cm x 3cm loose body situated in the intercondylar notch blocking knee fl exion was removed. Arthrolysis was performed and passive range of motion in the left knee was restored to 10 - 120 degrees on table. The residual fi xed fl exion deformity was attributed to a posterior capsule contracture.

Conclusion Loose body formation is a possible complication of retrograde femoral intramedullary nailing and it may be prevented by doing a through knee washout following retrograde nailing and performing a X-ray in the operating theatre before wound closure to detect any loose bodies in the knee joint.


TRAUMATIC RETROSTERNAL DISLOCATION OF THE STERNOCLAVICULAR JOINT IN A YOUNG ADULT WITH GENERALISED LIGAMENTOUS LAXITY

Lim K S Andrew, Lingaraj K and Das De S Department of Orthopaedic Surgery, National University Hospital, Singapore

Retrosternal dislocation of the sternoclavicular (SC) joint is rare. The ratio of posterior to anterior SC joint dislocation is about 1:9 due to greater stiffness of the posterior sternoclavicular ligaments compared to anterior ligaments.

Retrosternal joint dislocation may follow signifi cant direct trauma to the anteromedial aspect of the clavicle. More commonly, anterior SC joint dislocation arises from an indirect force applied to the shoulder which compresses the clavicle toward the sternum.

We report a case of indirect traumatic posterior dislocation of the SC joint in a young adult patient with signifi cant anteroposterior laxity of the contralateral SC joint and generalised ligamentous laxity. We believe the underlying laxity of the posterior sternoclavicular ligaments in our patient predisposed him to the development of this injury. To our knowledge, this is the fi rst time a sternoclavicular dislocation has been reported in a patient with documented laxity of the SC joint.

Following inadequate closed reduction, we employed the method of open reduction and stabilization with non-absorbable polyester fi ber tapes from the medial end of the clavicle to fi rst rib with good functional results.

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OPERATIVE FIXATION OF A SUBTROCHANTERIC FRACTURE IN A PATIENT WITH PREVIOUS SPONTANEOUS HIP FUSION

Kelvin Tan, Sathappan S Sathappan

IntroductionIn the literature, there are descriptions of patients with a fused hip presenting with various clinical problems: contralateral hip arthritis, ipsilateral knee arthritis and degenerative disc disease. We report a patient with a spontaneously fused right hip who sustained a complex proximal femur fracture on the same side secondary to trauma. Optimal operative fi xation of this patient posed as a surgical challenge and we discuss the management options in this paper.

Materials & MethodsWe describe a 66 -year-old Chinese gentleman who presented with right hip pain after a road traffi c accident. Following clinical examination and radiological evaluation, a fused right hip with subtrochanteric fracture was diagnosed.

ResultsThe following surgical treatment options were considered: (a) Conversion to total hip arthroplasty with a long-stemmed femoral prosthesis; (b) Cobra plate fi xation to ilium; and (c) intra-medullary nailing. We opted for intra-medullary nailing so as to minimize the blood loss and due to its favorable biomechanical characteristics. Though the fracture was a proximal femur fracture, we used retrograde nailing since an antegrade approach requires hip motion. Since the interlocking screws were placed into the femoral neck, the femoral nerve was identifi ed and retracted prior to screw placement.

ConclusionIn patients with a fused hip who have ipsilateral subtrochanteric fractures, there are signifi cant deforming forces at the proximal femur and retrograde nailing of such fractures can serve as an optimal treatment option.


SEVERE LOWER EXTREMITY INJURIES – EARLY FLAP VERSUS DELAY FLAP

Lau Leok Lim, Lingaraj Krishna, Fareed Kagda, Aymeric LimNUH

IntroductionSevere extremity fractures treated aggressively with immediate bony stabilisation and early soft tissue coverage (< 72 hours) is believed to produce good result compared to delay soft tissue coverage (> 72hours). This paper aims to examine the outcome of early soft tissue coverage compared to delay soft tissue coverage in patients with severe lower extremity fractures in this Asian population.

Materials and MethodsWe examined retrospectively all the patients who suffered from grade IIIB/C Gustilo open fractures in the lower extremity from 2002 to 2006 inclusively with the minimum follow-up of 6 months. 50 consecutive patients were identifi ed. 6 patients were loss to follow-up. Patients would have early fl aps or delay fl aps. The reason of delay fl ap is often due to the lack of availability of the operating theatre, patient transferred from another unit or other systemic medical condition unrelated to the extremity injuries. The early treatment group would have soft tissue coverage within 72 hours post injury whereas delay treatment group will achieved the same more than 72 hours post injury.

ResultsWe had 19 and 24 patients in early and delay treatment groups respectively. The mean age of the former was 34.5 and the latter was 38.6. Early fl ap group has less deep infection, general anaesthesia, day of hospital stay and incurred less hospitalisation charges. The overall lower limb preservation rate was 92.1%. The overall fl ap failure rate was 10% with no difference between both groups.

ConclusionsEarly soft tissue coverage in severe lower extremity produces better outcome in this Asian population

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MANAGEMENT AND OUTCOME OF SEVERE OPEN LOWER EXTREMITY INJURIES

Lau Leok Lim, Lingaraj Krishna, Fareed Kagda, Aymeric LimNUH

ObjectivesSevere open extremity injuries are diffi cult to manage. Limb salvage or amputation is often debatable. This paper aims to examine the outcome of severe open lower extremity injuries in this population where limb salvage was primary intention.

Material and MethodsThis study retrospectively reviewed patients admitted to this hospital with severe open lower extremity fractures from 2002 to 2006. All patients with Gustilo 3B and 3C open fractures of the lower extremity were included.

Results50 consecutive cases were identifi ed. 7 cases were loss to follow-up. The remaining 43 had a minimum follow-up period of 6 months. Mean follow-up was 81.8 weeks. 38 out of 43 patients were male. Mean age is 37 year-old. Most of the injury was a result of motor vehicle accident. 49% of the long bone injuries (tibia and femur) were grade C on AO Muller Classifi cation. 57% had external fi xation as initial bony stabilisation. 57% had internal fi xation as defi nite bony stabilisation. All the patients had fl ap coverage. Primary union rate 52%. Deep infection rate 39%. Amputation rate was 4.8%. Patient on average stay had 6.7 number of general anaesthesia, stayed in hospital for 44.5 days and incurred on average $51,000 for hospitalisation stay alone.

ConclusionPatients with severe lower extremity injuries had a low amputation rate with high deep infection rate and non-union in this population. Patients need to be aware of the protracted course of management involved if they elect limb salvage procedure.


MANAGEMENT OF HOFFA FRACTURES- REVIEW OF 2 CASES WITH A LITERATURE REVIEW

Eileen Tay, Sathappan SS, Ooi LHDepartment of Orthopaedics, Tan Tock Seng Hospital, Singapore

Introduction and Aim Hoffa fractures refer to coronal plane condylar fractures of the femur. These are unusual injuries with limited descriptions in the literature. Due to the diffi cult surgical access, fi xation of these fractures can be technically demanding. We report on 2 patients with these fractures and present the surgical techniques and clinical outcomes.

Materials and MethodsWe report on two patients (20 and 45 years of age) who sustained osseous injury to the knee with Hoffa fracture patterns. Radiographs and CT scans were obtained to better delineate the personality of the fracture. One patient had an associated medial collateral ligament injury.

ResultsBoth patients underwent operative fi xation. In one patient a novel technique whereby the distal radius locking plate was applied to the femoral condyle to augment the rigidity of fi xation after placement of a 6.5mm lag screw. Both patients were mobilized early and full weight bearing was attained within three months. At 18 months follow-up, radiographs reveal fracture union. An overview of the literature pertaining to the surgical techniques and clinical outcomes is further elaborated in the paper.

ConclusionHoffa fracture patterns are uncommon injuries and early operative fi xation coupled with knee mobilization provides optimal clinical outcomes.

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MANAGEMENT OF EXTENSOR MECHANISM DISRUPTION FOLLOWING TOTAL KNEE ARTHROPLASTY USING A “RAILROAD” TECHNIQUE WITH A PATELLA TENDON ALLOGRAFT: A CASE REPORT AND LITERATURE REVIEW

Wee JLH, MBBSSathappan SS, MBChB, FRCSEd, MMed (Ortho), FRCS (Orth)

ObjectivesDespite advances in total knee arthroplasty (TKA), complications involving disruption of the extensor mechanism remain a serious cause of poor post-operative outcome. Our aim is to present a novel technique for the uncommon complication of a comminuted avulsion fracture of the tibial tuberosity in a patient who underwent TKA.

Materials and MethodsWe present a case report on a patient with rheumatoid arthritis who underwent total knee arthoplasty with patella resurfacing. She presented after a fall with loss of knee extension. Intra-operative fi ndings revealed a comminuted avulsion fracture of the tibial tuberosity, associated with a torn medial retinaculum. The tibial tuberosity was reduced with a lag screw. The extensor mechanism was further augmented by a patella tendon-bone allograft alongside the native patella ligament (“railroad” technique). The bony component of the allograft was anchored medial to the tibial tuberosity. The proximal tendinous component was attached superiorly to the patella by a biotenodesis screw. The allograft was carefully plicated to the following structures: quadriceps tendon, medial retinaculum, and native patella tendon.

ResultsAt 12 months following the index procedure, the patient achieved a full active range of motion from 0-110 degrees, with no extension lag. She is able to ambulate independently without using walking aids.

ConclusionPatella tendon-bone allograft augmentation secured with a biotenodesis screw is a novel method of managing patients with a post-TKA comminuted avulsion fracture of the tibial tuberosity. A broad overview on the treatment options for post-TKA extensor mechanism disruption is presented in detail.


INTRA-MEDULLARY NAILING OF FEMORAL FRACTURE COMBINED WITH ACUTE TOTAL KNEE ARTHROPLASTY IN A PATIENT WITH SEVERE KNEE OSTEOARTHRITIS – A CASE REPORT

IntroductionIn a patient with underlying severe osteoarthritis of the knee and an ipsilateral traumatic femoral shaft fracture, various combinations of conservative and surgical modes of management are available. If both the problems are to be managed surgically, the commoner option would be to perform staged procedures: fracture fi xation followed by a delayed knee arthroplasty. Alternatively, a simultaneous fracture fi xation with an acute knee arthroplasty may be performed; this option is discussed in the article.

Clinical Picture The patient was an elderly female with underlying bilateral knee osteoarthritis. She had undergone a previous left total knee arthroplasty. Current presentation was for a traumatic right femoral shaft fracture. She underwent a simultaneous intramedullary nailing of the femur and an acute total knee arthroplasty. Postoperatively, good functional recovery was achieved.

ResultsThe article discusses the advantages of a simultaneous femoral fracture fi xation with acute total knee arthroplasty in comparison to a staged procedure, especially with regards to the rehabilitation and surgical complications. The technical details of such a simultaneous surgery are also discussed.

ConclusionSimultaneous femoral intramedullary nailing with acute total knee arthroplasty is a viable option in a select patient group. Good functional results can be achieved with careful surgical planning and an intensive rehabilitation regime.


CompilationofCoCo

Free Paper Session 3a


FRACTURE NECK OF RADIUS IN CHILDREN – FACTORS AFFECTING OUTCOMES AND COMPLICATIONS.

Arjandas M, Kevin Lim B L and Lee E HDepartment of Orthopaedic Surgery, KK Women’s and Children’s HospitalSingapore

AimsThe aims of this study are to determine the local incidence and identify the factors that affect outcomes of the treatment of radial neck fractures. We also aim to suggest an algorithm for treatment.

Materials And MethodsThis was a retrospective case note and Xray review of consecutive 108 radial neck fractures treated at the KKH from 1997 to 2001

The treatment was classifi ed as cast immobilization (CI), closed manual manipulation and reduction (MR), percutaneous K-wire assisted manipulation and reduction (PKWR) and open reduction (OR). All patients were then requested to return to ascertain treatment outcome.

Xrays were independently assessed. The angular displacement at the fracture site was measured.

Results Of the 108 patients 54% were boys, with an average age of 8.7 years and ranging from 2 years to 14 years.

86 patients were treated by CI alone. 8 had MR, 7 had PKWR and 7 were had OR. They were followed up for an average of 2.7 years. 86% patients had excellent clinical outcome, 4% had fair and none had poor outcome.

The factors associated with a poorer outcome and increased rates of complications include age, degree of angulation, associated fractures and interestingly open surgery

ConclusionRadial neck fractures can produce signifi cant poor outcomes and complications which are dependent on age, degree of angulation, associated fractures and open surgery.A stepwise approach starting from the response to closed reduction leading to open reduction based on fracture angulation is proposed with fracture less than 300 being treated conservatively.

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A GOOD TECHNIQUE IN RESTORING ROTATION IN PROXIMAL RADIOULNAR SYNOSTOSIS - 2 CASES OF PROXIMAL RADIAL RESECTION.

Dr W Y C Chew, Dr E S PhoonDepartment of Orthopaedics, Tan Tock Seng Hospital

BackgroundSynostosis of the proximal radioulnar joint occurs uncommonly following trauma about the elbow. This results in severe functional disability, particularly loss of forearm rotation. The usual treatment is surgical take-down of synostosis and soft tissue interposition. More recently, excision of a segment of proximal radius to create a pseudoarthrosis has been reported to give good results.

Methods and Materials Two cases of post traumatic type 3 proximal radioulnar synostosis were managed by proximal radial resection. Both presented with severe elbow stiffness and ankylosis in 20 degrees pronation.

Case 1 – 40 year old male with fi xation of Monteggia fracture, complicated by heterotropic ossifi cation a year after. We performed surgery 15 months after initial trauma. Follow up of 23 months. Case 2 – 54 year old female with fi xation of radial head fracture, developed stiffness 3 years later. She underwent surgery 5 years after initial trauma. Follow up of 4 months.

Surgery involved excision of heterotropic ossifi cation and resection of 1cm of proximal radial shaft just distal to synostosis, and soft tissue interposition of the cut bone ends. Capsulotomy was also performed. Adjuctive course of indomethacin was prescribed post operatively. Intensive rehabilitation with supervised mobilization.

Results Vast improvement of forearm rotation by 135 and 100 degrees in case 1 and 2 respectively. We also achieved a good fl exion-extension arc of 135 and 110 degrees respectively. There was no loss of stability nor pain. No recurrence of heteotropic ossifi cation in both cases to date.

ConclusionResection of 1cm thick section of proximal radial shaft is a simple, safe and reliable technique in the operative management of post traumatic synostosis of the proximal radioulnar joint.


ACTIVE SIMPLE BONE CYSTS IN THE UPPER LIMB ARE AT GREATEST RISK OF FRACTURE

Tey Inn Kuang, Arjandas Mahadev, Kevin Lim Boon Leong ,Lee Eng Hin and Saminathan S NathanDepartment of Orthopaedic Surgery, KK Women’s & Children’s Hospital

ObjectiveWe evaluated the natural history of progression of unicameral bone cysts (UBC) by performing an audit on all patients conservatively managed in the department over 10 years.

MethodsTwenty-two patients with the radiological diagnosis of UBC were identifi ed via a department database in this IRB approved study. Serial measurement of the bone cysts on radiographs were done using the Cyst Index, ratio of the widest cyst to growth plate diameter and distance of the highest point of the cyst border from the growth plate.

ResultsThere were 8 female and 14 male patients. Mean age was 9.2±SD3.6 years. There were 11 upper limb and 11 lower limb cysts. The mean cyst index (CI) was 3.6±SD4.2. The mean ratio of widest cyst diameter to growth plate was 0.6±SD0.3. In the study period 7 UBCs underwent resolution, 5 of 13 which had fractured and 2 of 9 which had not.

Cysts in the upper limb were overwhelmingly at higher risk for fracture. 2 of 11 cysts in the lower limb and all 11 cysts in the upper limb underwent a fracture (p=0.0001). Cysts that fractured were larger (mean CI 4.5±SD5.1) than those that did not (2.2±SD1.5; p=0.07). This paralleled the occurrence of larger cysts in the upper limb (mean CI 4.9±SD5.6) compared to the lower limb (2.3±1.4). There was no difference in the mean ratio of the widest cyst to growth plate diameter in fractured (0.6±SD0.3) and non-fractured (0.5±SD0.3) cysts. Interestingly, while the normalized mean distance of the cyst from the growth plate was the same in both categories of fractured (0.94±SD0.53) and non-fractured (0.81±SD0.76) cysts, active cysts were commonly seen to fracture. Accordingly, the mean growth away from the growth plate for fracture-prone cysts was negligible (0.01±SD0.68) whereas growth away from the plate was demonstrable in non-fracture prone cysts (0.67±SD0.76).

ConclusionThe established practice of aggressive treatment of UBCs to obviate fracture risk is most prudent in the upper limb.

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ARTHROSCOPIC BANKART REPAIR FOR RECURRENT TRAUMATIC ANTERIOR SHOULDER INSTABILITY WITH ABSORBABLE SUTURE ANCHORS: A TWO-YEAR FOLLOW–UP STUDY

Tey Inn Kuang,Sedeek Mohamed Sedeek , Andrew Tan Hwee ChyeSports Medicine Service, Department of Orthopaedic SurgerySingapore General Hospital

IntroductionThe arthroscopic method offers a less invasive technique of Bankart repair for recurrent traumatic anterior shoulder instability. Better results are seen with the advances made in arthroscopic instrumentation and technique.

ObjectiveThis study aims to evaluate the outcome of arthroscopic Bankart repair with the use of suture anchors for cases that were followed at least two years from the date of surgery.

MethodsA consecutive series of forty shoulders in thirty-seven patients underwent arthroscopic Bankart repair with suture anchors. The mean age at time of operation was 26.25 years. The patients were assessed with two different outcome measurement tools, ie. University of California (UCLA) shoulder rating scale and modifi ed simple shoulder test (SST) score. The mean duration of follow up was 30.18 months. The recurrence rate, range of motion, and post-operative function were evaluated.

ResultsThe two shoulder scores signifi cantly improved after surgery (p<0.05). According to UCLA scale, 37 shoulders (92.5%) had excellent or good scores, 1 shoulder (2.5%) had fair scores, and 2 (5%) had poor scores. Also, all 12 components of SST showed improvement, which was statistically signifi cant. Overall, the rate of postoperative recurrence was 7.5 %(3 shoulders). All patients either maintained or demonstrated improvement of range of motion. There was no loss of external rotation postoperatively.

ConclusionArthroscopic Bankart repair with the use of suture anchors is a reliable treatment option that can provide good outcomes in terms of recurrence rate and range of motion.


PERCUATNEOUS PIN REMOVAL IN THE PAEDIATRIC ORTHOPAEDIC CLINIC – PAIN SCORE AND ANALGESIA REQUIREMENT

E.S. Lokino,K. Lim, M. Babu, L.S. Yeo, E.H. LeeDepartment of Orthopaedic Surgery, KK Women’s and Children’s Hospital, Singapore

IntroductionPercutaneous pin removal in children is a common outpatient procedure dreaded by both patients and their caregivers. We are not aware of any reports in the literature that evaluate the pain associated with this procedure, or that study the preferences with regard to analgesia requirement in paediatric orthopaedic practice.

Method All patients in our clinic who had percutaneous smooth Kirschner wires removed between August 2006 and January 2007 were recruited into the study. Patient demographic data and injury sustained were recorded. Telephone interviews were conducted one month following the procedure. In each case, the primary caregiver who accompanied the child for the procedure was asked to score the pain retrospectively, and also to select one of four analgesia requirement options from the following: no analgesia, paracetamol, sedation, or general anaesthesia.

ResultsForty-two consecutive patients were recruited; none had any analgesia for the procedure. They ranged from 1 to 15 years of age (mean 6.7). Twenty-three (54.8%) were male and19 (45.2%) were female. Forty-one (97.6%) sustained elbow injuries: 36 (85.7%) sustained supracondylar humeral fracture, 3 (7.1%) sustained lateral humeral condyle fracture, and 2 (4.8%) sustained transphyseal fracture of the distal humerus. One patient (2.4%) sustained a fracture of the distal phalanx of the great toe. The mean pain score (one a ten-point scale) was 3.83. Thirty-one (73.8%) felt that analgesia was not necessary for this procedure, while10 (23.8%) felt paracetamol before pin removal would help. One (2.4%) felt sedation was necessary, but none thought that a general anaesthetic was required.

ConclusionPercutaneous pin removal in children in the outpatient clinic setting is not regarded as an excessively painful procedure and is generally well tolerated. While a minority felt that paracetamol might reduce procedure-related pain, the vast majority did not see a need for any analgesia requirement.

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LIPOSARCOMA OF THE EXTREMITIES, A REVIEW OF THE CASES SEEN AND MANAGED IN A MAJOR TERTIARY HOSPITAL IN SINGAPORE.

Ng Y C, Tan M HNg Yung Chuan Sean, Tan Mann Hong: Department of Orthopaedic Surgery, Singapore General Hospital, Singapore.

BackgroundLiposarcoma is one of the more common types of soft tissue sarcomas, presenting with a wide spectrum of clinical behaviour. There is little information on the outcome, management and survivability of patients however, with extremity liposarcoma in Singapore.

MethodsA retrospective review of all the patients diagnosed with extremity liposarcoma, diagnosed between 1997 and 2007, was performed. Univariate and multivariate statistics were used on the data to evaluate the clinical presentations, treatment, outcome and survivability of patients seen.

Results Over a 10-year period, 30 patients were seen for liposarcoma of the extremities. 27 presented as a primary tumour and 3 presented with recurrence. Management at initial presentation included surgery and/or radiotherapy. Histological subtypes included 14 (46.7%) with well-differentiated variant, 6 (20%) with myxoid variant, 5(16.7%) with de-differentiated variant, and 2(6.7%) each with round cell and pleomorphic variants. One patient presented with local recurrence but histology turned out negative. The median follow-up was 50 months. The 50-month overall survival rates with primary disease (n=27) and metastatic disease (n=2) was 92.6% and 50% respectively. The 50-month local recurrence free survival, distant recurrence (metastases) free survival, and disease free survival were 93%, 89%, and 85% respectively. 4 patients (14.8%) also had either local or metastatic recurrent disease. Amongst the subtypes, there was no recurrence in patients with the well-differentiated variant. 1 of 2 (50%) of the pleomorphic variant developed local recurrence. 2 of 5 (40%) of the de-differentiated variant developed recurrence, one with metastatic disease, and the other with both recurrent local and metastatic disease. 1 of 6 (16.7%) of the myxoid variant developed metastatic disease.

ConclusionLiposarcoma of the extremities is relatively rare compared to other major soft tissue tumours. It is a highly pleomorphic disease, whose outcome is dependent on the histologic subtype. Limb sparing management includes wide resection of the tumour with/or without radiation post-operatively.


A REVIEW OF MEGAPROSTHETIC RECONSTRUCTION IN LIMB TUMOUR SURGERY: A STUDY OF 19 PATIENTS WITH BONE TUMOURS

P K TAN , Changi General Hospital, SingaporeM H TAN, Singapore General Hospital, Singapore

Introduction and aimsIn the treatment of bone tumours, reconstruction with megaprosthesis has been shown to play an important role in limb slavage and in giving good functional and pain-free results. The aim of this study is to evaluate the functional outcome and complications of patients treated with megaprosthetic reconstruction.

MethodsNineteen patients were retrospectively reviewed . They had wide resection with megaprosthetic reconstruction performed between 1999 to 2006 in a Singapore Hospital Functional evaluation was performed based on the Musculoskeletal Tumour Society scoring system, with numerical values from 0 to 5 points assigned for each of the following six categories: pain, function, emotional acceptance, use of supports, walking ability, gait. These values were added, and the functional score was presented as a percentage of the maximum possible score. Complications were also analysed.

ResultsThe fi nal mean functional score was 78.3% +_ 16.6%. 8 patients had complications related to surgery, such as infection, and subluxation of hip implant. None had implant breakage, loosening, fracture or non-union.

ConclusionMegaprosthetic reconstruction as limb salvage is provides a good functional outcome in patients with malignant bone tumours. Megaprosthetic implants are a good form of custom made products which have been added to the armoury of the orthopaedic surgeon. Early results are encouraging.

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EXTRACORPOREAL IRRADIATION AUTOGRAFT AS THE CHOICE OF LIMB SALVAGE PROCEDURE IN A PATIENT WITH CONVENTIONAL OSTEOSARCOMA OF THE PROXIMAL HUMERUS, A CASE REPORT

Isma SPP*, Kamal AF**, Hutagalung Errol U***Department of Orthopaedic Surgery, University of Indonesia-Cipto Mangunkusumo Hospital, Jakarta** Teaching Staff of Orthopaedic Surgery Department, Resident of Orthopaedic Surgery, University of Indonesia, Jakarta

IntroductionOsteosarcoma is the most common non-hemopoietic primary malignant bone tumor. Chondroblastic osteosarcoma is a subtype which comprise 25% of all conventional osteosarcoma. In a 12 year period between 1995-2006 we found 17 (8.71%) cases of conventional osteosarcoma in the proximal humerus. One of the case underwent limb salvage procedure with extracorporeal irradiation autograft. Limb salvage procedure is the most widely accepted choice of treatment in patients with musculoskeletal malignancy and can be applied to 80-85% of all cases. Extracorporeal irradiation is one of the few alternatives in limb salvage procedure.

ObjectiveTo describe the patient’s profi le and the use of extracorporeal irradiation autograft in conventional osteosarcoma.

Material and MethodsThe data is taken from a patient with chondroblastic osteosarcoma who came to our hospital and underwent neoadjuvant chemotherapy continued with en-bloc resection, extracorporeal irradiation, and reimplantation procedure.

ResultsThe operation was done in two stages and gave good result where 6 months after the procedure there is no signs of recurrence and metastatic process. The functional evaluation using the Musculoskeletal Tumor Society criteria shows 66% of the function has returned 6 months after surgery where the ability for abduction is 0-20°, adduction 0-20°, fl exion 0-25°, endorotation 0-40°, dan exorotation 0-15°


ConclusionThis is our fi rst case of conventional osteosarcoma in the proximal humerus treated with limb salvage procedure using the extracorporeal irradiation autograft. In 6 months after operation we have a stable shoulder with radiological union in the osteotomizedarea area. Extracorporeal irradiation as one alternative of limb salvage procedure offers a cost effective treatment in patients with conventional osteosarcoma.

keywordschondroblastic osteosarcoma, limb salvage procedure, extracorporeal irradiation

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‘SNAPPING’ KNEE SECONDARY TO A TIBIAL OSTEOCHONDROMA

Jacob Yoong-Leong Oh, Ker-Kan Tan; Yue-Shuen Wong Department of Orthopaedic Surgery, Alexandra Hospital, Singapore

IntroductionOsteochondroma is the most common bone tumour and are usually found around the knee. Their presentations vary widely. Snapping of the knee caused by an osteochondroma however has not been described in literature.

MethodAn active19 year old gentleman presented with snapping of the left medial hamstring tendon for over 5 years, but with recent increase in frequencies of attack. The patient was initially diagnosed to have a sporting injury. Radiological investigation showed an opaque lesion on the medial border of the proximal tibia, which was suggestive of an osteophyte.

ResultsThe lump was surgically excised and the patient made good recovery with resolution of symptoms. Histological results revealed the lesion to be that of an osteochondroma.

ConclusionAlthough rare, osteochondroma should be a considered as a differential when approaching a case of snapping knee pain. This case also highlights the importance of thorough clinical evaluation and not to mislabel it as sporting injury.


THE EPIDEMIOLOGY AND CLINICAL OUTCOMES OF 678 PATIENTS PRESENTING WITH LOWER LIMB SEPSIS

Chan Ying Ho, Sathappan S SathappanFrom Tan Tock Seng Hospital, Singapore

Introduction and AimPatients with peripheral vascular disease often present to the orthopedist with lower limb sepsis. Often these patients require multiple surgical debridements and if limb salvage is unsuccessful amputation may be required. The aim of this study is to review the epidemiology and clinical outcomes of patients presenting to our institution with lower limb sepsis and also to identify the risk factors that lead to major limb amputations.

Materials and MethodsAll patients admitted in 2006 with lower limb sepsis were included in this retrospective study. The following clinical variables were collated: demographic data; associated co-morbidities (diabetes mellitus, renal impairment, hypertension, hyperlipidemia, previous cerebral vascular accidents, ischaemic heart disease, etc.); surgical procedures; length of stay; functional outcome; and re-admission data.

ResultsA total of 678 patients were reviewed in this study. Amongst this cohort, 263 patients required minor surgical treatments while 132 patients required one or more major amputations (BKA/ AKA) for the defi nitive control of sepsis. The mortality rate was 1.7%. The major risk factors identifi ed are diabetes-mellitus, renal impairment, previous surgical procedures and poor glycaemic control.

ConclusionAggressive management of lower limb sepsis is warranted to avoid major limb amputations. The latter has signifi cant impact on the patient’s quality of life as well as to the healthcare system. It is therefore important to address the pertinent risk factors to reduce the rates of morbidity and mortality pertaining to lower limb sepsis.


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Free Paper Session 3b


PARS REPAIR TECHNIQUE & RATIONALE OF TREATMENT IN ADULTS.

Singh G, A. Kumar*, V.G. Gowda*, S Naresh Kumar** *Department of Orthopaedics, Royal Wolverhampton NHS Trust, United Kingdom. **Department of Orthopaedics, National University Hospital, Singapore.

BackgroundBack pain in adult patients with a pars-interarticularis defect may be due to movement at the defect or abnormal inter-segmental movement at the adjacent degenerate disc. The suggested treatment of segmental fusion may not be necessary, if the defect alone was source of pain. We hypothesize that the defect may be the only source of pain in certain adults, even if the MRI scan shows an abnormal disc.

ObjectiveTo form a protocol of management in adults with pars defect and adjacent level disc degeneration. To study the results of primary lysis repair using ‘AO Morscher clamp’ in patients with ‘spondylolysis’ or ‘Grade 1 ‘spondylolisthesis’.

This is a prospective study involving adults with ‘spondylolysis’ or ‘Grade 1 ‘spondylolisthesis’ not responding to conservative management and requiring interventional treatment. We investigated this subgroup of patients with a lysis block and discography. On this basis seven patients were offered a lysis repair and bone grafting using ‘Morscher’s clamp’; three were offered spinal fusion, of a total of 10 patients. Outcome was assessed using Visual Analogue Score (VAS) and Oswestry Disability Index (ODI) done pre-operatively and six months post-op.

ResultsOut of ten patients (28 to 45 years; 4males and 6 females), seven patients underwent primary lysis repair using ‘AO Morscher clamp’ showing union of pars by 4 months (Follow-up duration of 2 years). Three underwent fusion. Mean VAS improved from 7.2 to 1.2 in lysis repair group. Mean ODI improved from 68 % to 24%. All patients had full range of spinal movement postop.

ConclusionA thorough pre-operative workup of patients with pars defect and adjacent level disc degeneration showed that pain is due to the pars defect in 70% of our cohort. This subgroup of patients could successfully be treated with ‘lysis repair’ rather than a more morbid procedure –‘spinal fusion’.

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IS THERE DISCORDANCE BETWEEN MRI REPORTING OF KNEE INJURY PATIENTS AND ARTHROSCOPIC FINDINGS? A CLINICAL CORRELATION STUDY

Tan TL, Sathappan S SathappanSingapore

Introduction and AimsKnee injuries are increasingly common secondary to road traffi c accidents and sports injuries. The rationale of MRI in knee injuries is for surgical planning i.e. preparation of suitable allograft and selection of ideal implant fi xation materials. We wanted to evaluate if there was any discordance between MRI reports and intra operative fi ndings during arthroscopic procedures.

Materials & MethodsA retrospective study was conducted based on the surgical database from the year 2006 to 2007. Only patients who had pre-operative MRI were included in this study. The following data was collated: patient demographics, injury mechanisms, and documentation of both osseous and soft tissue injuries in MRI, intra-arthroscopic fi ndings. Statistical analysis was performed to defi ne the correlation coeffi cient between radiological and surgical diagnoses.

ResultsThere is a reasonable discordance rate between MRI reports and arthroscopic fi ndings in patients with knee injuries. This places signifi cant emphasis on clinical assessment of patients and less reliance on MRI for routine knee disorders. Further details of these results are discussed in this paper.

ConclusionTherefore, in patients with persistent knee symptoms related to trauma the fi ndings of equivocal MRI reports does not absolutely negate the possibility of soft tissue/bony injury. Arthroscopic procedure remains the gold standard in diagnostic and therapeutic purposes.


A REVIEW OF MANAGEMENT OF OPEN TIBIAL FRACTURES OVER A 3-YEAR PERIOD FROM A TERTIARY TRAUMA CENTER

Introduction and AimsOpen tibial fractures are prone to complications of soft tissue injury, infection and non-union. The objectives of this study were to review the management of open tibial fractures and to assess the outcome based on various modes of management.

Materials and Methods This was a retrospective study and included patients managed by our department for open tibial fractures from 2003 to 2005. All patients were followed up for a minimum time period of 18 months. The following clinical variables were collated: patient demographics, fracture classifi cation, surgical treatments (orthopaedic and soft-tissue procedures), complications, hospital length of stay and functional outcomes.

Results There were a total of 130 patients managed for open tibial fractures by our department during this study period. Approximately 20% of these were of Gustilo type 1, 20% of Gustilo type 2 and 60% of Gustilo type 3. Approximately 10% of the fractures were treated by primary internal fi xation; 50% of the fractures were treated by defi nitive primary external fi xation; 30% were treated by primary external fi xation followed by secondary internal fi xation. Less than 5% of the patients had to undergo limb amputation as the defi nitive surgery. As selection of treatment for the patients were individualized, complications of non-union and infection were relatively low in all three cohorts. Further details are discussed in this paper.

Conclusion The defi nitive surgical management of open tibia fracture is dependent on the soft-tissue injury, osseous injury, time to presentation and also the expertise available. Complications associated with each method should be anticipated and appropriately managed.

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EWING SARCOMA OF THE LEFT BIG TOE WITH TRANS-ARTICULAR SKIP LESION ON THE LEFT DIAPHYSIS TIBIA A CASE REPORT

Nagieb M*,Kamal AF**,Hutagalung Errol U**Departement of Orthopaedic Surgery, University of Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia*Orthopaedic Resident Department of Orthopaedic Surgery, University of Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia **Teaching Staff Department of Orthopaedic Surgery, University of Indonesia, Cipto Mangunkusomo Hospital, Jakarta, Indonesia

AbstractEwing sarcoma with skip lesion is a rare case, which has never been reported before.The term skip lesion has been used to describe a separate focus of Osteosarcoma that developed synchronously in the same bone as another Osteosarcoma, in the absence of direct anatomical extension between the lesions or of metastases. Trans-articular skip lesion is skip lesion in the same region on the extremity that developed synchronously. Treatment for Ewing sarcoma can be done with surgery, chemotherapy, radiotherapy or combination between those therapies, depending on the site and volume of the tumor. Chemotherapy for Ewing Sarcoma has improved signifi cantly with modern multi agent chemotherapy.

We report the case of the patient who had Ewing Sarcoma in whom radiological and hystopathological appearances revealed a tumor mass in the left big toe along with trans-artikular skip lesion on the left diaphysis of tibia. The diagnosis was established in clinicopathological conferrence, that involve orthopaedic surgeon, radiologist, pathologist and also hemato-oncologist. The patient’s got Ray Amputation on his left big toe and open biopsy on his left leg and continued with chemoterapy. After that he was planned to have Limb Salvage Procedure for trans-artikular skip lesion on the left diaphysis tibia. Up to now we still evaluate the evidence of local recurrences or distance metastases, healing process and function left lower extremity.

Key wordsEwing sarcoma;trans-articular skip lesion.


CORE DECOMPRESSION FOR OSTEONECROSIS OF FEMORAL HEAD – OUTCOME IN DIFFERENT PATIENT GROUPS AND CORRELATION WITH PREOPERATIVE MRI

Lam KH, Ng YS, Cheng HCUnited Christian Hosptial

IntroductionCore decompression for osteonecrosis of the femoral head continues to be a controversial procedure. The purpose of this study is to assess the clinical results of this technique in different conditions and the relationship between the preoperative MRI fi ndings and the progression to collapse after the core decompression.

MethodsWe retrospectively reviewed the results of core decompression for osteonecrosis (ON) of the femoral heads in 19 patients (27 hips) in United Christian Hospital. Eight patients had bilateral involvement. Seven patients (13 hips) suffered from SARS and had received high dosage of corticosteroids. 3 patients (5 hips) suffered from SLE, 6 patients (7 hips) were chronic alcohol drinker and 2 patients (2 hips) suffered from idiopathic ON.

Clinical symptoms and radiographic outcomes were assessed. Collapse of the femoral head was regarded as failure. 3 different quantitative measurements from the preoperative magnetic resonance imaging were also assessed.

ResultsThe mean age was 41 years. The average follow-up was 27 months. Overall, 56% of the hips progressed to collapse after operation. 38% of the hips in SARS patients progressed to collapse. Only 22% of patients required further surgery. Measurement of the weight bearing cortex involvement from preoperative magnetic resonance imaging demonstrated the most signifi cant correlation with progression to collapse. None of the patients with less than 2/3 of the weight bearing cortex involved had their femoral head collapsed while 81% of the hips collapsed if they had more than 2/3 of the weight bearing cortex involved. There is no relationship between Ficat stage I or II and the collapse.

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ConclusionsIn selected cases of early stage of osteonecrosis (Ficat stage I and II), core decompression is an effective procedure to prevent femoral head collapse. In these early cases, Ficat staging is not a useful parameter for decision. MRI should be performed for all these early cases and measurement of the weight bearing cortex involvement is important. If less than two-third of the weight bearing cortex is involved, core decompression has a high chance of success. However, if more than two-third of the weight bearing cortex is involved, other modalities of treatment should be considered.


LUMBOPELVIC ANGLE ON STANDING LATERAL RADIOGRAPHS OF NORMAL THAI ADULTS

Mr.Siwadol Wongsak MD.Department of Orthopaedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University Siwadol Wongsak, MD, Pongsathon Chanplakorn, MD, Wiwat Wajanavisit, MD,Wichian Laohacharoensombat, MD, Patarawan Woratanarat, MD, PhD. Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University.

Summary of Background Data Some structural features of the pelvis substantially modulate and largely determine the standing lumbar lordosis, as well as the sagittal pelvic alignment and spinopelvic balance. Radiographic parameters for spinopelvic balance over the hips in sagittal spinal alignments have not been defi ned in normal Thais. Measurement techniques for spinal alignments and quantitative pelvic morphology need to be standardized.Objectives: To determine sagittal spinopelvic alignments in normal Thai adults by using pelvic radius technique. Materials and MethodsA cross-sectional study was conducted at Ramathibodi Hospital between July 2006 and August 2006. One hundred healthy Thai adult volunteers, aged 20-60 years, who had no history of back pain at least 6 months, were included. After providing informed consent, all subject underwent standing lateral radiographs of the lumbosacral spine included both hips. Radiographic measurements were made by using the pelvic radius (PR) technique. Angles were measured from the pelvic radius to tangents along the vertebral end plates. PR to sacral 1 level (PR-S1), PR-T12, pelvic angle (PA), sacral translation (HA-S1), total lumbosacral lordosis (T12-S1), and regional lumbopelvic lordosis (PR-L2, PR-L4, and PR-L5) were measured twice by two orthopaedic surgeons. All variables were analyzed as mean and standard deviation. The correlation coeffi cients were calculated to determine interobserver reliability.

ResultsThere were 70 men and 30 women. Most of them (78%) came from northeastern part of Thailand. The average age was 33.3 ± 6.8 years. The average body weight was 59.1 ± 7.9 kilograms, and the average height was 164.6 ± 7.2 centimeters.The average PR was 123 ± 8.2 millimeters, and the average HA-S1 was 40.8 ± 11.0 millimeters. The average angle was 37.4 ± 9.5 degrees for PR-S1; 19.5 ± 5.5 degrees for PA; 92.4 ± 8.2 degrees for PR-T12; 54.7 ± 9.9 degrees for T12-S1; 86.7 ± 7.9 degrees for PR-L2; 71.4 ± 9.0 degrees for PR-L4; and 57.7 ± 10.5 degrees for PR-L5. The interobserver reliability of all measurements were higher than 0.98.

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ConclusionThe study of healthy Thai adult volunteers provides the normal value of lumbopelvic angle and the association between pelvic morphology and lumbar lordosis. The pelvic anatomy may play a role in the causation of chronic low back pain or spondylolisthesis and possibly be contributory to its severity. Further studies are required to identify if any signifi cant parameter predicting chronic low back pain.


EVALUATION OF THE EXTERNAL DEVICE IN TREATMENT OF THE THIRD DEGRRE TIBIAL OPENING FRACTURE IN KHANH HOA FROM 2004 – 2005

Chinh Phan Huu MD, PhD.** Head of Orthopeadic anh Burn Department of Khanh Hoa hospital province – Viet Nam.

1. Preface In the progress of industrial science and economy. Vietnam in the stage of

openingdoor of society and economy. The life of people is improved clearly, quality of life changes day by day, but another side of the following changes is traffi c and labor accident. The level of accident have been increased and the most common tibial opening fracture is usually met.

The arm of this survey is the evaluation of the treatment result of third degree opening fracture of tibia in Khanh Hoa hospital during 01.01.2004 to 31.12.2005.

2. Candidate and method

2.1. Candidate 31 patients suffering from tibial opening fracture with third degree (Gustilo’s

classifi cation) were operate to fi x by external device at the orthopaedic department of Khanh Hoa hospital from 2004 to 2005.

The improved external device is produced in Cho Ray hospital – Ho Chi Minh city – Vietnam. There are 4 styles of device which was used in this study.

- Arch style device for 1/3 upper tibial opening fracture. - Straight style device for 1/3 middle tibial opening fracture. - T-style device for 1/3 lower tibial opening fracture. - Illizarov-style device for tibial – condyle opening fracture.

The patient did not enough the time and parameter were eliminated from the study.

2.2. Method of study Cut-off research.

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3. Result 3.1. Age: Age 15 - 25 26 - 35 36 - 45 46 - 55 >56

Patients 7 9 9 4 2

% 22,5 29 29 12,9 6,4

3.2. Giôùi:

Sex Male Female

Patients 27 4

% 87 13

3.3. Opening degree: (Gustilo)

Opening degree III

A B C

Patients 20 8 3

% 64,5 25,8 9,7

3.4. Time of pre-operation:

<6 h 6 – 12 h 13 – 24 h >24 hø

23 5 2 1

% 74,1 16,1 6,5 3,3

3.5. Average follow: 19,3 months.

Style of device Arche Straight T- style Illizarov

Patients 9 14 7 1

% 29,1 45,1 22,5 3,3


3.6. Complications:

patients %

Pins tract infection 6 19,3

Surgical site infection 3 9,7

Bone infection 1 3,3

Angle >100 2 6,5

Rotation >100 1 3,3

False joint 3 9,7

Calcifi cation retardation 4 12,9le

3.7. Time of device bear: (month)

<3M >3M

Patients 25 6

% 80.6 19.4

3.8. Cause of device remove:

Good bone False bone

Patients 24 7

Tae lea % 77,4 25,6

3.9 Bone false by styles of device:

Arche Straight T- style Illizarov

Patients 0 4 2 1

% 0 12,9 6,5 3,3

1 case ampuated because IIIc degree open fracture by T-stye.

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3.10. Limitation of joint movement:

Knee Amkel

Patients 4 3

% 12.9 9.7

3.11. Hospitalisation: (week)

<2w 2-4 w >4 w

Patients 8 18 5

% 25,8 58 16,2

3.12. To come back to work:

Yes No

Patients 27 4

% 87 13

4. DiscussThird degrre tibial opening fracture offen met in the youth, labor age (15-45) occupies high ratio 80,5%, the most number is male 87%. In Khanh Hoa hospital, almost the patients are operated to fi x by the external device.

The device have been use in Khanh Hoa hospital- Vietnam which is improved and produced in Cho Ray hospital, its price (50-80USD) is suitable for almost people, but the method is still has some complications:

Pin tracts infection caused by dirty trauma enviroment and the low knowledge of the patient and his or her relatives in taking care and nutrition some authors’ studies. This ratio is reduced by cleaning dissection and wound – coashing as well as using antibiotics limitation of joint movement by not good guidance and the patient scares of pain.


Rotation >100: affecting on gesture when walking and running and day activities This complication caused by technical mistake and in case of comminuted fracture and polytrauma patient needed to save the life.

Surgical site and bone infection occupied high ratio because the wound is so dirty in the trauma situation in Vietnam, especialy traffi c accident. The patient came late and was easily gotten hospital infection with the compound fracture.

False joint and the calcifi cation retardation is the important matter of treatment. The device is hard and not automatic compression. The surgeon must adjust the device and this make the patient inconvenient when they live far away from the hospital.

Age Chinh PH Long.LT Linh TN Thuy DV Phuc Le Bay TV (Khøanh (Cho Ray (Cho Ray (Gia Ñònh (Orth Cen (Chôï Ray Hoa VN. VN. 2002) VN. 2002) VN. 2004) VN. 1990) VN. 1995)

Pins 19,3 38,7 42,2 22,23 60 40Tractinfection

Surgical 9,7 11,7 siteinfection

Bone 3,3 7,84 6,1infection

Angle 6,5 19 7,1 >100

Rotation 3,3 >100

False 9,7 5,3 5,1 Joint

Calcifi cation 12,9 Retardation

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Limitation 21,3 29,6 7,84 5,6of jointmovement

Union 77,4 75,7 84,3 88,8bone

5. ConclusionThe external device is a necessary equiment in treatment of comminuted fracture and gets a good result during decades. The device has many styles, in Vietnam there are some medical settings has been applying external device which is improved and home made. Following primary evaluation, the treatment gets optimistic. There are some matters we need to concern:- Third degree tibial opening fracture is ussually met in the youth, label age, almost the male.- Applying easily in surgical units.- Low price.- Ratio of bone and spin infection reduces.- False joint and calcifying retardation gets high ratio.- The head and upper 1/3 tibial fracture does not has false joint.

ReferenceThi Cao. External fi xation for opening tibial fracture. Internal Doctor dissertation. HoChiMinh Medical College. 1992.Phuc Le, Tinh Vu Tam, Kinh Le. External fi xation be used at Lower limb of Orthopeadic and Trauma Center of HoChiMinh city - Vietnam. Orthopeadic Journal, 1 no. 7/1990. Bay Tran Van. External fi xation for opening tibial fracture by Fixano style for Schanz and Stainmann pin at Cho Ray Hospital. Orthopeadic reseach, 1994-1995. Burgess. A.M.D.D., F.A.C.S, Priciples of external fi xation. Skeletal Trauma, I, 1992. Chapman, M.W. Open Fractures. Rock wood and Green’s Fracture in Adult, VI, 1991. Christian, C.A. Open Fractures. General Principle of Fracture Treatment. Campbell’s Operative Orthopaedics, III, 1998.Russel, T.A. Treatment of open Fractures. Fractures of Tibial and Fibula. Rockwood and Green’s Fractures in Adult, VII, 1995.Whittle, A. P. Fractures of lower extremity. Campbell’s Operative Orthopaedics, III, 1998.HoChiMinh Medical College. 1992. Phuc Le, Tinh Vu Tam, Kinh Le. External fi xation be used at Lower limb of Orthopeadic and Trauma Center of HoChiMinh city - Vietnam. Orthopeadic Journal, 1 no. 7/1990.Bay Tran Van. External fi xation for opening tibial fracture by Fixano style for Schanz and Stainmann pin at Cho Ray Hospital. Orthopeadic reseach, 1994-1995.


Burgess. A.M.D.D., F.A.C.S, Priciples of external fi xation. Skeletal Trauma, I, 1992.Chapman, M.W. Open Fractures. Rock wood and Green’s Fracture in Adult, VI, 1991.Christian, C.A. Open Fractures. General Principle of Fracture Treatment. Campbell’sOperative Orthopaedics, III, 1998.Russel, T.A. Treatment of open Fractures. Fractures of Tibial and Fibula. Rockwood and Green’s Fractures in Adult, VII, 1995 Whittle, A. P. Fractures

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CHONDROBLASTOMA OF BONE

Garin, IE MD*, and Wang, EHM MD MSc†

Investigation performed at the Department of Orthopedics, Musculoskeletal Tumor Unit, Philippine General Hospital, University of the Philippines, Manila, Philippines

*Fellow, Musculoskeletal Tumor Unit, Department of Orthopedics, Philippine General Hospital, University of the Philippines, Manila.

†Associate Professor, Musculoskeletal Tumor Unit, Department of Orthopedics, Philippine General Hospital, University of the Philippines, Manila.

Correspondence to: Edward HM Wang MD, MSc, Head, Musculoskeletal Tumor Unit, Department of Orthopedics, Philippine General Hospital, University of the Philippines, Manila 1000. Phone: (02)-521-8450 loc: 2471; Fax: (02)-526-0149;

E-mail: [email protected]

PurposeThe aim of the study is to describe and analyze the treatment of all cases of chondroblastoma seen by our Musculoskeletal Tumor Unit between 1993 and 2004.

MethodsWe report ten cases of histologically proven chondroblastoma treated by our Musculoskeletal Tumor Unit. This is a descriptive, retrospective study. All cases were collected by reviewing our tumor registry, patient case records, radiograph collection and histopathology reports from the Department of Orthopaedics and the Department of Pathology and Laboratory. ResultsThe proximal tibia and the proximal femur were the most frequently involved sites. There were six male and four female patients, mean age at presentation was 20.9 years (range 13-33 years). Most common presenting symptom was pain; two patients with tibial lesions had knee effusion. On radiographs, four cases were classifi ed as latent, 3 active, and 3 aggressive. All patients underwent intralesional curettage and bone grafting with or without bone cement. Mean follow-up was 65.5 mos (range, 24 -141mos). Two recurrences developed at fi ve and 28 mos, both of which were treated without further recurrence.


ConclusionChondroblastoma was an uncommon primary benign bone tumor presenting most commonly with pain. Management was usually curettage and reconstruction with bone grafts. All patients were free of disease on last follow-up. The resultant functional status was usually noted to be good or excellent. Keywordschondroblastoma

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THE EFFECT OF SODIUM HYALURONATE ON FIBRONECTIN EXPRESSION AT PERITENDON AND INTRATENDON DURING FIBROPLASIA PHASE OF RABBIT ACHILLES TENDON RUPTURE HEALING

Fathurachman, Hidajat NN, Tiksnadi B, Ismono D.Department of Orthopaedic and Traumatology Hasan Sadikin Hospital Faculty of Medicine Padjadjaran University Bandung, West Java Indonesia

IntroductionExperimental study on animal has been conducted to fi gure out the effect of Sodium Hyaluronate (SH) administration on fi bronectin expression as well as adhesion formation during Achilles tendon rupture healing.

MethodWe use SH, administered 0.1 ml in the injured area. The concentration of SH is 10 mg/ml and the molecular weight is 9 x105 dalton. On control group, we use 0.1 ml normal saline. We use immunohistochemistry evaluation to categorize fi bronectin expression within provisional matrix of healing tendon, particularly within peritendon and intratendon region.

ResultThe results of fi bronectin expression revealed no signifi cant different of peritendon expression on both groups (P=0.294). However there is signifi cant different on intratendon expression (P=0.049). There are also signifi cant different between peritendon and intratendon expression on both groups (P=0.00). The adhesion grading and healing grading evaluation revealed no signifi cant different (P=0.50 and P=0.05).

DiscussionThe result of this study, that revealed no signifi cant different, possibly because of the lower concentration and molecular weight of SH compare to the concentration and molecular weight that is recommended from previous researches.

ConclusionTherefore, SH with concentration 10 mg/ml and molecular weight is 9 x105 dalton, will not be able to inhibit fi bronectin expression in peritendon, also will not be able to inhibit adhesion formation in peritendon on healing tendon. In contrast, this SH preparation will be able to inhibit fi bronectin expression in intratendon.

Key wordsSodium Hyaluronate, fi bronectin expression, tendon healing


CUTANEOUS COMPLICATIONS FROM LOW MOLECULAR WEIGHT HEPARIN FOLLOWING TOTAL KNEE ARTHROPLASTY : A REPORT OF 4 CASES OF KNEE BLISTERS

Ramesh S, Sathappan SSRamesh s/o Subramaniam, Sathappan S SathappanDepartment of Orthopedic Surgery,Tan Tock Seng Hospital

IntroductionAfter knee replacement surgery, the use of low molecular weight heparin (LMWH) is an effective method of decreasing thromboembolism. There are documented complications associated with the use of LMWH such as thrombocytopenia, bleeding and local cutaneous manifestations at the injection sites. Interestingly, cutaneous complications from the use of LMWH at the site of the TKA have not been reported so far.

Clinical PictureWe report four cases of cutaneous blistering over the operated anterior knee in patients receiving a single daily dose of enoxaparin (40mg) for thromboprophylaxis after total knee arthroplasty. In all cases, the patients had no preoperative risk factors for bleeding and the blisters were noted on 3rd postoperative day (POD) in 3 patients and 5th POD in 1 patient.

Treatment/OutcomeThey were all managed with dressings and antibiotic prophylaxis and withdrawal of enoxaparin administration. Physical therapy and discharge from hospital were delayed in all 4 cases. No other complications were seen.

ConclusionWhile LMWH is increasingly used in patients following TKA, it is important to monitor for bleeding and cutaneous complications in these patients. We recommend that the wound should be inspected regularly and at the fi rst manifestation of cutaneous complications at the surgical site, the LMWH should be discontinued. Regular TG dressings and antibiotic prophylaxis have a role for subsequent management of these cutaneous complications.

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IS DISTAL FEMORAL LATERAL CONDYLAR HYPOPLASIA COMMON IN ASIAN KNEES?

Ramesh s/o Subramaniam, Sathappan S Sathappan, Soh Chee Cheong ReubenDepartment of Orthopedic Surgery,Tan Tock Seng Hospital

Introduction and AimIt is important to understand the distal femoral condylar anatomy in the treatment of osteoarthritic knees for sizing of femoral implants and determination of femoral component rotation. From the author’s observation, lateral femoral condyle hypoplasia, which is often observed in valgus osteoarthritic knees, is also commonly seen in Asian patients with varus osteoarthritic knees. The purpose of this study was to evaluate this observation.

Materials and MethodsDistal femur measurements carried out during total knee arthroplasty surgeries done for varus osteoarthritic knees by a single surgeon were analyzed over a 1-year period. The following variables were collated: medial femoral condyle anterior-posterior (AP) length, lateral femoral condyle AP length and sizes of femoral implants used.

ResultsA total of 50 knees were evaluated in this series so far. The mean age of patients is 67 years. There were 10 males and 40 females. The average medial femoral condyle AP length is 54mm and the average lateral femoral condyle AP length is 54mm. Smaller lateral femoral condyle AP lengths were observed in 18 knees out of this cohort.

ConclusionLateral femoral condylar hypoplasia is commoner than thought in varus osteoarthritic knees in our local Asian population. Furthermore this condylar anatomy emphasizes the importance of using the transepicondylar axis and Whiteside’s line as rotational guides, and not the posterior condylar axis, so as to avoid internal rotation of the femoral component.


AUTOLOGOUS CHONDROCYTE IMPLANTATION – A 3 YEARS PROSPECTIVE REVIEW IN A REGIONAL HOSPITAL

ObjectiveTo date, no technique has been completely successful in achieving exactly normal regenerative articular cartilage. Cultured autologous chondrocytes in Autologous chondrocyte implantation (ACI) fi lls the defect with cells of a committed pathway to develop hyaline-like cartilage. We present a 3-year prospective cohort study conducted from the 2nd May 2002 to the 2nd May 2007.

Materials and Methods25 patients with documented knee osteochondral lesions were selected for Autologous chondrocyte implantation and followed-up for 36 months. A 2-Staged Autologous chondrocyte implantation procedure consisting of Chondrocyte Harvest and Chondrocyte Implantation was performed. Outcome measures included the International Knee Documentation Committee (IKDC), Short Form-36 and Knee Pain scores.

ResultsThe size of lesion ranged from 1.0 cm2 to 16.0 cm2 (mean 6.2 cm2). The patients selected had grade III and IV lesions with 71.4% grade IIIC lesions. Patients showed signifi cant improvement in IKDC, SF-36 (Physical Component Survey) from 12 months post-operation onwards. SF-36 (Mental Component Survey) showed improvement from 6 months onwards. Pain score also improved from 5.5 to 2.7 in the 36-month period. The majority of our patients recovered with no (70.4%) early post-operative complications. 70.4% of the patients underwent concomitant knee surgeries including ligament and meniscus repair.

ConclusionACI showed signifi cant improvement for our patient from 12 months onwards with minimal complications. However, a large percentage of patients have concomitant injuries to other structures in the knee requiring surgery and this may account for confounding factors to the improvement of knee scores. Patient selection remains an important factor in ensuring better outcome.

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CLINICAL OUTCOME OF ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION – A COMPARISON BETWEEN TRANSFIX (BIOABSORBABLE CROSS-PIN) VERSUS ENDOBUTTON FIXATION TECHNIQUES

H.A.Lin, A.Tan

AimTo compare the clinical outcome of 2 different methods of ACL reconstruction at 2 years of follow up.

IntroductionDifferent methods of femoral fi xation devices were developed for biologic tissue graft ACL reconstruction, and were classifi ed according to their fi xation mechanism. Currently, two of the most popular techniques for hamstring graft fi xation are Endobutton fi xation (Smith and Nephew) and Transfi x cross-pin fi xation (Arthrex) technique. The aim of the study is to compare the outcomes of these 2 techniques.

Methods and MaterialsThis is a prospective study of 24 patients with ACL reconstruction done by a single surgeon in 2005. 11 of the 24 patients had ACL repair via Transfi x femoral fi xation and bioabsorbable interference screw tibial fi xation using doubled semitendinosus and gracilis grafts, while 13 patients had Endobutton femoral fi xation and tibial post fi xation using quadrupled semitendinosus graft. Post-operatively, subjects were treated with a standardised rehabilitation programme. Data collection and patient assessment were done at 2 years of follow up by the same physiotherapy team. The assessments were done using International Knee Documentation Committee (IKDC), Lysholm and Tegner activity scales as well as Biodex score.

ResultsBoth groups show a good outcome post-operatively at two years of follow up. There is no statistical signifi cance between the two groups in all the assessment scores.

ConclusionBoth techniques exhibit similar operative outcome at 2 years of follow up in spite of differences in length, size, number of grafts used and the fi xation devices.


Compilation ofAbstractsCompilation oCompilation oYOIA Abstracts


EXTRACORPOREAL IRRADIATION AUTOGRAFT AS THE CHOICE OF LIMB SALVAGE PROCEDURE IN A PATIENT WITH CONVENTIONAL OSTEOSARCOMA OF THE PROXIMAL HUMERUS, A CASE REPORT

Isma SPP*, Kamal AF**, Hutagalung Errol U*** Department of Orthopaedic Surgery, University of Indonesia-Cipto Mangunkusumo Hospital, Jakarta Resident of Orthopaedic Surgery, University of Indonesia, Jakarta** Teaching Staff of Orthopaedic Surgery Department, University of Indonesia, Jakarta

IntroductionOsteosarcoma is the most common non-hemopoietic primary malignant bone tumor. Chondroblastic osteosarcoma is a subtype which comprise 25% of all conventional osteosarcoma. In a 12 year period between 1995-2006 we found 17 (8.71%) cases of conventional osteosarcoma in the proximal humerus. One of the case underwent limb salvage procedure with extracorporeal irradiation autograft. Limb salvage procedure is the most widely accepted choice of treatment in patients with musculoskeletal malignancy and can be applied to 80-85% of all cases. Extracorporeal irradiation is one of the few alternatives in limb salvage procedure.

ObjectiveTo describe the patient’s profi le and the use of extracorporeal irradiation autograft in conventional osteosarcoma.

Material and MethodsThe data is taken from a patient with chondroblastic osteosarcoma who came to our hospital and underwent neoadjuvant chemotherapy continued with en-bloc resection, extracorporeal irradiation, and reimplantation procedure.

ResultsThe operation was done in two stages and gave good result where 6 months after the procedure there is no signs of recurrence and metastatic process. The functional evaluation using the Musculoskeletal Tumor Society criteria shows 66% of the function has returned 6 months after surgery where the ability for abduction is 0-20°, adduction 0-20°, fl exion 0-25°, endorotation 0-40°, dan exorotation 0-15°

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ConclusionThis is our fi rst case of conventional osteosarcoma in the proximal humerus treated with limb salvage procedure using the extracorporeal irradiation autograft. In 6 months after operation we have a stable shoulder with radiological union in the osteotomized area. Extracorporeal irradiation as one alternative of limb salvage procedure offers a cost effective treatment in patients with conventional osteosarcoma.

keywordschondroblastic osteosarcoma, limb salvage procedure, extracorporeal irradiation


EWING SARCOMA OF THE LEFT BIG TOE WITH TRANS-ARTICULAR SKIP LESION ON THE LEFT DIAPHYSIS TIBIA A CASE REPORT

Nagieb M*,Kamal AF**,Hutagalung Errol U***Departement of Orthopaedic Surgery, University of Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia**Teaching Staff Department of Orthopaedic Surgery, University of Indonesia, Cipto Mangunkusomo Hospital, Jakarta, Indonesia

Ewing sarcoma with skip lesion is a rare case, which has never been reported before.The term skip lesion has been used to describe a separate focus of Osteosarcoma that developed synchronously in the same bone as another Osteosarcoma, in the absence of direct anatomical extension between the lesions or of metastases. Trans-articular skip lesion is skip lesion in the same region on the extremity that developed synchronously. Treatment for Ewing sarcoma can be done with surgery, chemotherapy, radiotherapy or combination between those therapies, depending on the site and volume of the tumor. Chemotherapy for Ewing Sarcoma has improved signifi cantly with modern multi agent chemotherapy. We report the case of the patient who had Ewing Sarcoma in whom radiological and hystopathological appearances revealed a tumor mass in the left big toe along with trans-artikular skip lesion on the left diaphysis of tibia. The diagnosis was established in clinicopathological conferrence, that involve orthopaedic surgeon, radiologist, pathologist and also hemato-oncologist. The patient’s got Ray Amputation on his left big toe and open biopsy on his left leg and continued with chemoterapy. After that he was planned to have Limb Salvage Procedure for trans-artikular skip lesion on the left diaphysis tibia. Up to now we still evaluate the evidence of local recurrences or distance metastases, healing process and function left lower extremity.

Key wordsEwing sarcoma;trans-articular skip lesion.

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ANALYSIS OF STRESS DISTRIBUTION IN THE VERTEBRAL BODIES USING TWO DIMENSIONAL FINITE ELEMENT MODEL.

S Naresh Kumar, J Meakin*, R C Mulholland.* Department of Bio-Medical Physics & Bio-Med Eng., Foresterhill, Aberdeen. AB25

2ZD Institute of Study for Spinal Disorders, Queen’s Medical Centre, Nottingham. NG7

2UH.Department of Orthopaedics, Royal Wolverhampton NHS Trust, United Kingdom.Department of Orthopaedics, National University Hospital, Singapore.

BackgroundBack pain may be related to abnormal segmental movement and suggested treatment is segmental fusion. Recent techniques using cages can achieve fusion rates of over 90% but the clinical results are no better.

ObjectiveWe hypothesize that the cages integrate fully to adjacent vertebrae altering the loading pattern, as a result producing abnormal stress patterns in the vertebrae. This may be the cause of persistent pain in certain patients.

MethodsIn this study a simple FE model of a disc and its adjacent vertebral bodies was developed using ANSYS software. The dimensions of the model were based on those of a human lumbar disc. The normal disc was modelled as having nucleus with fl uid properties (bulk modulus 1720 MPa). To model the degenerate disc, the material properties of the nucleus were changed to be the same as the annulus (Young’s modulus, E=5 Mpa; Poisson’s ratio, v=0.49). To model fusion of the disc, the nucleus was replaced with a simple representation of a one of three of the commonly used cages. In all the models the material properties of the cancellous bone (E = 100 MPa; v = 0.3) and the cortical bone (E=12000MPa; v =0.3) remained the same. The model was loaded axially with 1.5 kN.

Cancellous bone

Nucleus

Cortical bone

Annulus


ResultsThe vertical and horizontal stress patterns around a loaded degenerate disc showed areas of increased loading in the endplate and cancellous bone. The inclusion of cages in the model showed high concentration of tensile and compressive stresses at the point of contact with the cages and in the cancellous bone of the vertebral bodies. The stress pattern showed more similarity to that of degenerate disc, than a normal one. ConclusionFusion cages alter the pattern of stress distribution in the adjacent vertebral bodies from that of the normal disc. The excellent fusion rates of the cages are not mirrored by improvement in clinical results. It supports the concept that abnormal load transfer may be a more signifi cant cause of back pain than abnormal movement.

Vertical Stress Pattern in Cancellous Bone

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REPAIR OF LARGE OSTEOCHONDRAL DEFECTS USING HYBRID SCAFFOLDS WITH BONE MARROW- DERIVED STEM CELLS AND NANOFIBRE MESH

H.K. DOSHI, S.T.B. HO, H.P. JAMES HUI, D.W. HUTMACHERDepartment of Orthopaedic Surgery, National University of SingaporeDepartment of Orthopaedic Surgery, National University Hospital, Singapore

IntroductionMusculoskeletal ailments involving load-bearing joints constitute a prevalent health problem confronting the greying population of today. Among these, osteochondral defects pose a challenge to orthopaedic practitioners due to the avascular and acellular nature of cartilage which, results in the inability for self repair compounded by underlying defective bone tissue.

ObjectiveTo evaluate repair potential in large osteochondral defects on load bearing areas in a pig model using hybrid scaffolds (PCL – cartilage phase, PCL-TCP – bone phase) with bone marrow derived mesenchymal cells (BMSC) and a nanofi bre mesh (PCL – Collagen) as artifi cial periosteum. With conventional therapies, such defects exhibit poor or inadequate healing and this tissue engineering approach aims to resolve this longstanding issue.

Materials And MethodsThis construct comprises of a PCL-TCP composite scaffold which serves as the bone phase and an overlying PCL matrix as the cartilage phase and capped by an artifi cial periosteum consisting of a PCL - Collagen nanofi bre mesh. These scaffolds were specifi cally engineered and fabricated using rapid prototyping, while the nanofi bre mesh was electrospun. The critically sized defects (8mm x 8mm) are located at the medial condyle (high loading) and the patellar groove (low loading). After 6 months the animals were sacrifi ced and evaluations were made based on gross appearance, histology, microindentation and micro CT.

ResultsIt was noted from gross morphology that the defects in the experimental group with seeded cells showed signifi cant osteochondral repair with the restoration of articulating surfaces. It is also suspected that the nanofi bre mesh has assisted tissue restoration by providing a smooth articulating surface while allowing nutrient exchange from the synovial fl uid to the cellular implant.


ConclusionThis investigation shows that PCL-TCP hybrid scaffolds with PCL-Collagen nanofi bre meshes may be an alternative clinical treatment for osteochondral defects in high loading sites.

KeywordsPCL – TCP ( polycaprolactone – tricalcium phosphate )PCL – Collagen ( polycaprolactone – collagen ) BMSC ( bone marrow derived mesenchymal cells )

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KINEMATICS OF THE STIFF TOTAL KNEE ARTHROPLASTY

S S Sathappan, Gavin Pereira, Scott Banks William Jaffe, Paul Di Cesare,

IntroductionA major postoperative goal after total knee arthroplasty (TKA) is to achieve good fl exion beyond 90 degrees. Kinematcics is the study of the motion of a joint without taking into account the forces acting upon it. The incidence of stiffness (<90 degrees) after TKA has a reported incidence of 3.7 %. A search of the literature found no kinematics study performed on stiff knees with limited range of motion. The purpose of this study was to determine whether stiffness after TKA could be due to abnormal kinematics.

Materials and Methods The kinematics of 10 TKA with poor fl exion (<90 degrees) were compared with 11 replacements with good fl exion (>110 degrees) at a mean of 3 years from surgery using optical calibration with implant shape-matching techniques from radiographs taken in standing, early lunge and late lunge positions.

ResultsThere were no signifi cant differences between the groups in anteroposterior translation of the medial and lateral femoral condyles or tibial rotation during standings and early lunge. Groups differed in amount of posterior translation of the femoral condyles during late lunge due to poor –fl exion group’s inability to achieve the same amount of fl exion as the good-fl exion group.

ConclusionPoor fl exion following TKA, we conclude, is not associated with abnormal kinematics in the setting of well-aligned, well-fi xed implants. The results of this study should add to the knowledge base of knee kinematics to further our understanding about TKA performance and hopefully help infl uence TKA design.


List ofExhibitorsList ofList ofList of Exhibitors


LIST OF TRADE EXHIBITORS

Company Name Room / Booth No

Stryker S’pore Pte Ltd Amber1 Maritime Square #10-39 Harbourfront CentreSingapore 099253

Zimmer Pte Ltd Topaz 315 Alexandra Road #03-03Performance centreSingapore 159944

Depuy, a Johnson & Johnson Company Opal2 International Business Park#07-01 Tower OneThe StrategySingapore 609930

BrainLAB Ltd BG1 390 Havelock Road #05-02 King’s CenterSingapore 169662

Sanofi -Aventis Singapore Pte Ltd BG2 76 Raffl es Quay#18-00Singapore 048580

KCI Medical Asia Pte Ltd BG3 50 Ubi Crescent #01-01Singapore 408568

B Braun Singapore Pte Ltd BG4600 North Bridge Road#15-02/05 Parkview SquareSingapore 188788

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Synthes Singapore Pte Ltd BG52 Kallang Pudding Rd #05-11Mactech BuildingSingapore 349307

Servier (S) Pte Ltd BG8510 Thomson Road #09-02 SLF BuildingSingapore 298135

Smith & Nephew Pte Ltd SM11 Jalan Kilang Timor #03-05Pacifi c Tech CentreSingapore 159303

Genzyme Singapore Pte Ltd SM2 6 Temasek Boulevard #21-01 Suntec City Tower 4Singapore 038986

Opto System (S) Pte Ltd SM3Blk 30 Kallang Place #06-06,Singapore 339159

Pfi zer Pte Ltd SM4152 Beach Road #29-00Gateway east Singapore 189721

Merck Sharp & Dohme (I.A) Corp SM5 300 Beach Road The Concourse #13-02Singapore 199555

Heraeus Medical GMBH SM685 Genting Lane#07-02 Guan Hua Warehouse BuildingSingapore 349569


PT Medindo Inovasi SM7Kawasan Industri Jatake, Jl. Industri 2 Blok F No. 8 Pcode 15135, Tangerang, Indonesia

Trufi t Limbs Centre SM8Blk 1001 Jalan Bukit Merah #05-14 Redhill Industrial Estate Singapore 159455

Rottapharm Singapore SM9 & SM10151 Chin Swee Road #15-05 Manhattan HouseSingapore 169876

Tyco Healthcare Pte Ltd SM11 No. 26 Ang Mo KioIndustrial Park 2 #04-01Singapore 569507

Medical Plus Pte Ltd SM12 Blk 1090 Lower Delta Road#05-15/16Singapore 169201

Australian Wine Index SM13 3 Pickering Street#01-66 Nankin RowChina Square CentralSingapore 048660

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