Medical services during the 24th summer universiade.

Background: International sports competitions are one of the mass gathering events which require a well-planned medical care system for large numbers of participants. The Universiade, the World University Games, is organized for university athletes every two years. Methods: The medical service organization was presented and the medical care for injuries and illnesses provided during the 24th Summer Universiade were described. Results: During 1 to 23 August 2007, a total of 5,641 patients aged 12-89 years (including 1,700 athletes) received medical care. There were 2,535 cases (44.9%) using the Athletes’ Village Polyclinic, 2,755 cases (48.8%) using the on-site medical units, and 351 cases (6.2%) using Thammasat Hospital. For the patients presented at the Athletes’ Village Polyclinic, muscle strain was the most common injury (n=287, 34.1%), and musculoskeletal system problems were the most common illnesses (n= 484, 27.33%). Nineteen patients required hospital admission at Thammasat Hospital. Conclusion: This information might be useful for planning medical services in international multi-sport competitions in the future.

The results of surgical management of bone metastasis involving the periacetabular area: Siriraj experience.

BACKGROUND: Periacetabular metastasis is a common site of bone metastasis and can cause major disability to the patients. Non-operative treatment including medication or radiation therapy is the first treatment modality. The operative treatment is indicated in patients with failed non-operative treatment or pathologic fracture. OBJECTIVE: To assess the functional results, quality of life, and complications after reconstruction of the periacetabular metastasis. MATERIAL AND METHOD: Fourteen patients underwent 16 intralesional excisions of tumor and cemented total hip arthroplasty reconstruction from 2002 to 2006. The primary tumors were breast carcinoma in five patients, thyroid carcinoma in three, kidney carcinoma in two, and one each of cervix carcinoma, urinary bladder carcinoma, lung carcinoma, and multiple myeloma. Type of periacetabular metastases by Harrington 's classification, age of patients, blood loss, unit of blood transfusion, and postoperative complication were reviewed. Pre- and Postoperative pain by the visual analogue scale was evaluated. RESULTS: The mean age of patients was 56years with a mean follow up time of 389 days (range 30-1,275 days). The mean time from diagnosis of primary tumor to periacetabular metastatic surgery was 32.5 months (range 0-84 months). By Harrington 's classification, seven patients were classified in class I, four patients were class II, and three patients were class III. The visual analogue scale was improved from more than 8/10 preoperatively to 2/10 postoperatively. All patients could ambulate and walk independently and two patients could walk without gait support. Four patients died of disease progression and 10 patients are still alive. Two patients had complications from postoperative hip dislocation and acetabular loosening which successfully treated by closed reduction and revision of the prosthesis respectively. CONCLUSION: With promising results, low rate of complication and improvement of quality of life could be achieved after total hip arthroplasty reconstruction in the appropriately selected patient with a periacetabular metastasis. Additional surgery may be required in the patient with longer survival or progression of the disease.

Endoprosthetic reconstruction for malignant bone and soft-tissue tumors.

BACKGROUND: Nowadays, the results of the management of malignant bone and soft-tissue tumors have been dramatically improved because of the advance in imaging, chemotherapy, radiation therapy, and surgical techniques. Patients can have longer survival times with limb-salvage surgery. Several techniques of reconstruction have been advocated and gained more popularity following malignant tumor resection by using allograft, tumor prostheses, composite allograft prosthesis, or arthrodesis. OBJECTIVE: To report the preliminary results of 32 endoprosthetic reconstructions following malignant bone and soft-tissue tumor resection. The oncologic results, functional outcomes, and complications from the surgery were assessed in the present study. MATERIAL AND METHOD: Since September 1988, the authors have performed 188 limb-salvage surgical operations for the treatment of musculoskeletal tumors at Siriraj Hospital. From March 1994 to July 2006, 32 endoprosthetic reconstructions were performed on 30 patients following malignant bone or soft-tissue tumor removal. There were 16 males and 14 females with a mean age of 28 years (range 10-73). The diagnosis was conventional osteosarcoma in 16 patients, parosteal osteosarcoma in two patients, chondrosarcoma in two patients, leiomyosarcoma in two patients, failed allograft in two patients and one patient each of periosteal osteosarcoma, Ewing's sarcoma, Gorham's disease, synovial sarcoma, malignant fibrous histiocytoma, metastatic renal cell carcinoma, and prosthetic loosening. Wide excision was performed with a mean length of 18.5 cm (range 10-41). Five proximal femurs, 17 distal femurs, 1 total femur 3 proximal tibias, 1 intercalary tibia, 4 proximal humerus and 1 distal humerus were used for reconstruction. Modular replacement systems (MRS, Stryker/Howmedica/Osteonics) were the most common prostheses used in the present series. RESULTS: The mean follow-up time was 26 months (range 6-128.7). Sixteen patients are continuously free of the disease, two are alive with the disease, two had no evidence of the disease, nine died of the disease, and one patient died from complication of hypertension. The mean Musculoskeletal Tumor Society functional analysis for upper extremity reconstruction was 93% (range 86.7-100) and for lower extremity was 89% (range 63.3-100). Two patients (6.7%) were determined to be a failure. Revision due to aseptic loosening was performed in one patient (3.3%) and one hip disarticulation was done related to local recurrence (3.3%). One patient with sciatic nerve palsy and two seromas was found and successfully treated in the present study. CONCLUSION: Endoprosthetic reconstruction could yield satisfactory results as a wide excision and limb-salvage for patients with malignant bone and soft-tissue tumors. Most patients in the present report had good to excellent functions following surgery and few complications occurred in the present report.

Falling can be a serious problem for the elderly.

We present the role of a multidisciplinary approach for the patient with a pathological fracture of the femur. A 56-year-old female complained of pain in the right hip from falling at home. After that she was sent for treatment without knowing her breast mass. For final diagnosis and treatment, the case was brought for discussion and made an appropriate treatment was made for her by the members of tumor board. With a multidisciplinary approach we saved not only her life but also the function of her leg.

Medical utilization review by indicators “ORTHOPAEDICS” in orthopaedic inpatients under universal coverage policy admitted to Siriraj Hospital.

Objective: Utilization review is very important especially in universal coverage policy. In Siriraj Hospital the utilization review began in 2002, and the Department of Orthopaedic Surgery developed the indicators “ORTHOPAEDICS” to assess the appropriateness of medical utilization. This study is designed to study the effectiveness of medical utilization review by using indicators “ORTHOPAEDICS” in orthopaedics, public inpatients under universal coverage policy in terms of expenses, the appropriateness, length of hospital stay and the satisfaction of the patients. Methods: 301 orthopaedic inpatients were divided in 2 groups: Group A included 149 patients, 100 men and 49 women. Their average age was 32.7 years old. From June 1, 2003 – May 31, 2004, each patient was prospectively reviewed regarding their daily utilization in terms of expenses, appropriateness of medical utilization by using indicators “ORTHOPAEDICS”. Their length of hospitalization was measured, as well as and their satisfaction evaluated. Group B was the control which included 152 patients, 98 men and 54 women. Their average age was 34.8 years old. No intervention was performed and the data was collected only in expenses and the length of hospital stay for each patient retrospectively from June 1, 2002– May 31, 2003. The expenses and the length of hospital stay of both groups were compared and analyzed. The appropriateness in Group A was studied by using indicators “ORTHOPAEDICS” which were: O = Operation; R = Relative weight rate; T = Type of treatment; H = Hospital stay; O = Occurrence of complication; P = procedures; A = admission; E = expenses; D = drugs; I = Investigation; C = Care map according to CPG of 12 diseases; S = Satisfactions score from 0-10 minimum to maximum, by asking the patients about the satisfaction in term of results of treatment. Results: The total expenses per patient in group A was 24,566.74 baht but in group B was 30,484.53 baht. The expense in group A was 5,917.79 baht reduction which was statistically significant difference (P<0.05). The average length of hospital stay in group A was 8.24 days, whereas in group B was 10.93 days. It reduced 2.69 days after utilization review was implemented. The appropriateness of utilization was found in the procedures, drugs and investigation without inappropriateness (0%). The inappropriateness in admission was 26.9% because the physician forgot to take blood examination and laboratory investigation before admission and it was done in the ward without any effect the treatment. And the average satisfaction score in group A was 9.6. Conclusion: “ORTHOPAEDICS” was useful and helpful indicator to significantly reduce the expense per patient and the length of hospitalization without reducing patient satisfaction and quality of treatment.

Deadly soft tissue sarcoma: Curable using a multidisciplinary approach.

We present the role of multidisciplinary approach to treat our patient with a soft tissue sarcoma at her thigh successfully. A 56-year-old female complained of a progressive enlarging soft tissue mass on her thigh before the diagnosis of malignant fibrous histiocytoma was confirmed by appropriate approach. With final diagnosis and staging of the disease, the appropriate treatment was decided from all members of Siriraj Musculoskeletal Tumor Board to save not only patient's life but also preserve her extremity and function.

Giant cell tumor of the bone : Radiographic evaluation.

Giant cell tumor is a relatively common skeletal tumor with radiographically characteristic appearance in a predictable location. Clinical data from 66 patients with radiographical and from 37 patients with pathological diagnosis of giant cell tumor of the bone in Siriraj Hospital were retrospectively reviewed from June 1995 - December 2001. Histological grading was classified as grade I 78%, grade II 19%, and grade III 3%. Female patients accounted for a alight majority (F : M = 1.54 : 1). Eighty percent of the tumors were in the expected locations at the end of long bone (femur, tibia, radius, and humerus), where as a few lesions were located at atypical sites such as sacrum, talus, ulna, rib, or scapula. One patient had pulmonary metastasis and one patient had multifocal lesions. The aggressiveness of radiographic findings was evaluated and based on the following criterias : breaking of cortex, soft tissue involvement, joint involvement and large tumor size in correlation with histological grading and tumor recurrence. Our study showed no correlation between tumor size and histological grading.