Long-term Outcome of Total Femur Replacement.

Introduction: Total femur replacement is an option instead of amputation for extensive bone tumour or after revision surgery with a massive bone loss. Over a long period of time the patients may need revision surgery, and this might affect the functional outcome. We reviewed all consecutive total femur replacements done for primary and revision surgery of primary bone tumours in our centre to evaluate the long-term functional outcome and survival. Materials and methods: All patients who had total femur resection and reconstruction with modular endoprosthesis replacement in our centre from June 1997 to May 2022 were reviewed. The respondents were surveyed through WhatsApp using google form which was translated into Bahasa Malaysia based on the Musculoskeletal Tumour Society Scoring System (MSTS). The data were presented as descriptive data on the final survival of the limb and prosthesis. Results: Ten patients underwent total femur replacement. There were eight osteosarcoma, one giant cell tumour and one chondromyxoid fibroma. Three patients with osteosarcoma succumbed to pulmonary metastases; all had good early post-operative functional outcomes without local recurrence. Seven patients were available for long term evaluation of function with a mean follow-up of 17.6 years (ranged 10-25 years). Four patients with total femur replacement had good functional outcomes (60-80%) without revision with 10-25 years follow-up. Three patients experienced acetabulum erosion and chronic pain that required early hip replacements. Two of them were complicated with superior erosions and bone loss and subsequently were managed with massive reconstruction using cemented acetabulum cage reconstruction. The other has diabetes mellitus with chronic infection following revision of distal femur endoprosthesis to total femur replacement and subsequently underwent limited hemipelvectomy after 14 years. Conclusion: Total femur replacement offers a good long term functional outcome and prosthesis survival and is a favourable option for limb salvage surgery.

Study of Deep Vein Thrombosis Screening by using Ultrasound Doppler in Patients with Pelvic and Acetabulum Fractures Requiring Operative Intervention.

Introduction: Pelvic and acetabulum fractures are commonly caused by high impact injuries, increasing the risk of patients developing thromboembolic diseases such as deep vein thrombosis (DVT) and pulmonary embolism (PE). Therefore, this study was performed to determine the incidence of lower extremity DVT in patients with pelvic and acetabulum fractures and the importance of preoperative screening with Doppler ultrasound prior to surgical intervention. Materials and methods: This retrospective study involved 78 patients with pelvic and acetabulum fractures requiring surgical intervention from January 2015 until December 2019. Patients who underwent surgical interventions were screened pre-operatively with Doppler ultrasound to detect lower limb DVT and later compared with the incidence of lower limb DVT post-operatively. Descriptive statistical analysis was performed using IBM SPSS Statistics Version 24. Results: The participants of this study consisted of 30.8% females and 69.2% males. Pre-operative screening with Doppler ultrasound showed that three patients (3.8%) were diagnosed with lower limb DVT, whereas one of them (1.3%) was symptomatic and diagnosed with PE. Postoperatively, one patient developed DVT, and one patient developed PE. Both patients were negative for DVT preoperatively. Conclusion: The incidence of DVT in patients with pelvic and acetabulum fractures requiring operative intervention was significant despite the initiation of mechanical and pharmacological thromboprophylaxis upon admission. Despite the low incidence of DVT in our study, it has a high impact on patients' morbidity and mortality; thus, preoperative screening is important for early detection and the subsequent reduction of the risk of developing PE. The compulsory use of Doppler ultrasound of bilateral lower limbs as a part of pre-operative screening is highly recommended because it is cost-effective, efficient and readily available in most tertiary hospitals nationwide.

Femoral Neck Non-union Treated using Compression Screw with or without Gluteus Medius Trochanteric Flap: A Case Series of Ten patients.

Non-union is a challenging complication following a femoral neck fracture. Inability to achieve anatomical reduction and compression over the fracture leads to non-union. We reported a 10-case series of femoral neck non-union treated with sliding compression screw and anti-rotational screw with or without gluteus medius local trochanteric flap. When compression could not be achieved and a gap was present over the non-union site, a gluteus medius trochanteric flap was used to enhance the union. Surgeries were performed as a single-stage procedure through the Watson Jones approach. The initial implants were removed, followed by fracture reduction, during which the varus deformity was corrected, and the neck length was preserved as much as possible. Patients were advised for strict non-weight bearing until the presence of trabecular bone crossing the fracture on the radiographs. Union was achieved at three months in all cases. Patients undergoing surgery without trochanteric flap had normal abduction strength, and the neck length was maintained. All cases had no significant loss of function. Patients with trochanteric myo-osseous flap had neck shortening with weak abductors with MRC grade 4. Two out of 10 cases developed avascular necrosis of the femoral head before intervention. One case progressed to collapse of the femoral head requiring implant removal. This and the femoral neck shortening, caused this patient to have weak abductors and a positive Trendelenburg gait. We observed that delayed surgery leads to neck shortening and fracture gap requiring trochanteric myo-osseous flap to achieve union.

Three-year follow-up of a Traumatic Hemipelvectomy Survivor: A Case Report.

The management of a patient with traumatic hemipelvectomy is complex. We report the acute management and rehabilitation of a 21-year-old patient as well as her prosthesis modification. She was able to return to society as a K3 level ambulator.

Functional Outcome of Surgical Stabilisation of Acetabular Fractures.

INTRODUCTION: Approach to the management of displaced acetabular fractures has evolved from conservative to operative management after the work of Judet and Letournel. Various surgical methods have been explored and described by authors to address this type of fracture, leading to improved clinical outcome. This study aimed to evaluate functional outcome of surgically treated displaced acetabular fractures in the Malaysian context. MATERIALS AND METHODS: We analysed 43 patients with isolated acetabular fractures who were treated operatively with a minimum of three years follow-up. Anthropometric data, Judet-Letournel fracture pattern, surgical approach and complications were recorded. Post-operative Matta radiological outcome were evaluated for joint congruency and hip functional outcome was evaluated using Merle d'Aubgine-Postel and Harris Hip Score (HHS). All statistical analyses were analysed using SPSS version 24.0. RESULTS: The most frequent elementary fracture type was posterior wall (30.2%) while associated type was both columns (23.3%). Mean functional outcome of Merle d'Aubigné-Postel was 15.77 and HHS was 86.6. Thirty-three (76.7%) patients achieved satisfactory functional outcome, 19 (44.1%) patients achieved anatomic reduction (<2 mm step-off) based on Matta classification while 24 (55.8%) did not achieve the desired outcome. Fracture pattern exhibited strong association with post-operative Matta radiological outcome (p-value 0.001). However both fracture pattern and Matta radiological outcome did not exhibit association with the functional outcome group. The mean time for surgical interventions was 10.8 days and there was no significant association with final functional outcome score. CONCLUSION: Fracture pattern is a strong contributing factor towards post-operative Matta radiological outcome. However, achieving the perfect anatomical reduction is not of utmost important factor to predict the good functional outcome.

Assessment of Extra-Cortical Bone Bridge Interface in Cemented Mega Endoprosthesis for Limb Salvage Surgery.

INTRODUCTION: Mega endoprosthesis replacement for resection of primary malignant bone tumour requires immediate and long-term stability, particularly in the young and active patient. Extracortical bone bridge interface (EBBI) is a technique whereby autograft is wrapped around the interface junction of bone and porous-coated implant to induce and enhance bone formation for biological incorporation. This procedure increases the mean torsional stiffness and the mean maximum torque, which eventually improves the implant's long-term survival. MATERIAL AND METHODS: The extracortical bone bridge interface's radiological parameter was evaluated at the prosthesis bone junction two years after surgery utilising a picture archiving and communication system (PACS). The radiograph's anteroposterior and lateral view was analysed for both thickness and length in all four cortices. The analysis was done in SPSS Version 24 using One-Way ANOVA and independent T-Test. Results were presented as mean and standard deviation and considered significant when the p-value was < 0.05. RESULTS: The mean average thickness was 2.2293mm (SD 1.829), and the mean average length was 31.95% (SD 24.55). We observed that the thickness and length of EBBI were superior in the young patient or patients with giant cell tumour that did not receive chemotherapy, compared to patients treated for osteosarcoma. The distal femur also had better EBBI compared to the proximal tibia. However, the final multivariable statistical analysis showed no significant difference in all variables. EBBI thickness was significantly and positively correlated with EBBI Length (p<0.001). We conclude that, for each 1mm increase in EBBI thickness, the length will increase by 0.06% on average. About 17.2% of patients out of the 29 showed no radiological evidence of EBBI. CONCLUSION: From our study, there were no factors that significantly contributed to the formation and incorporation of EBBI.

Multicentric Giant Cell Tumor of Bone: Metachronous Presentation-a Case Report.

Giant cell tumors (GCT) of bone are a benign aggressive tumor with features of frequent local recurrence. It has the potential for metastasis and malignant transformation. GCT of bone represents about 4-9.5% of primary bone tumors. Metachronous GCT happen in less than 1% while metastatic spread in these lesions is very uncommon. Furthermore, reports of multicentric metachronous GCT are very rare in literature. We present a case of a 35-year-old male patient, who suffered from multicentric metachronous GCT, which involved the radius, humerus, femur, and pelvic with pulmonary metastasis. Local control by multiple resections of the tumor and chemotherapy for pulmonary metastases was able to control the disease with long-term survival and good functional outcome. These tumors had a typical radiological appearance and the diagnosis was confirmed on histopathology. Long follow-up needed in this case in view the illness occurs for long period.

Combined Techniques of Non-invasive 99mTc-Besilesomab/99mTc-Sulfur Colloid with Hybrid SPECT/CT Imaging in Characterising Cellulitis from Symptomatic Perimegaprosthetic Infection: A Case Report.

Megaprosthesis is used to restore the form and function of massive skeletal defects, but it is accompanied by risks of failure, mainly due to perimegaprosthetic infection (PMI). In practice, the diagnosis of infected megaprosthesis among patients with a high index of clinical suspicion, elevated serological markers, and multiple negative or inconclusive imaging can be very challenging and poses a diagnostic conundrum to many orthopaedic surgeons. We present the case of a symptomatic 26-year-old female with large B-cell lymphoma who developed cellulitis with suspected complication of PMI 15 months post-implantation. The combination of advanced nuclear medicine imaging strategies, i.e., 99mTc-besilesomab/99mTc-sulfur colloid scintigraphy with hybrid single-photon emission computed tomography/computed tomography (SPECT/CT) scanning helps to characterise and delineate both infections. Invasive procedures such as joint aspiration and biopsy were avoided, and the patient was successfully treated with antibiotics. Hence, we report a case where advanced imaging modalities were decisive in the investigation of PMI.

Iliac Telangiectatic Osteosarcoma - A Rare Presentation and Diagnostic Pitfall: A Case Report.

Telangiectatic osteosarcoma is a rare variant of osteosarcoma and can be easily misdiagnosed as aneurysmal bone cyst. We report an atypical case of iliac telangiectatic osteosarcoma in a young healthy female, who presents with painful slow growing expansile lytic septate lesion in the left hemipelvis, which is initially treated as aneurysmal bone cyst. The diagnosis of aneurysmal bone cyst is made after histopathological examination of core needle biopsy. Her condition became unstable and massive bleeding is noted at the lesion site after sclerosant injection. She undergoes emergency hemipelvectomy and eventually the biopsy turns up to be telangiectatic osteosarcoma. Our case highlights that core needle biopsy is not useful in making diagnosis for iliac telangiectatic carcinoma. Hence, an open biopsy should be carried out in our case. This case also emphasises on careful evaluation for malignancy which is mandatory because bleeding from pelvis after an unsuitable treatment can be grave, to the extent that major amputation hemipelvectomy is an option. Even though telangiectatic osteosarcoma has the same prognosis and treatment with conventional osteosarcoma, the outcome of delayed treatment for telangiectatic osteosarcoma is not good due to the dilemma in establishing an early correct diagnosis.

A Single Posterolateral Scapular Approach to Drain Post-Traumatic Intramuscular Scapular and Axillary Abscess in an Adolescent: A Case Report.

Scapular abscess is a rare clinical diagnosis. This is a report of an atypical case of extensive intramuscular scapular abscess involving the anterior and posterior aspects of the scapula with extension into the axillary region following minor trauma in a young healthy adolescent, describing a single posterolateral approach to the scapula to evacuate the abscess. Following surgical drainage and antibiotic treatment, patient recovered without any complication.

Functional Outcome after Treatment of Aggressive Tumours in the Distal Radius: Comparison between Reconstruction using Proximal Fibular Graft and Wrist Fusion.

Introduction: Restoration of a functional hand is the ultimate goal following a distal radius tumour resection. The early outcomes of mobile wrist reconstruction are satisfactory; however, long-term results are unpredictable due to late wrist instability and degenerative arthritis. Our aim is to compare mobile wrist reconstruction with wrist fusion (pan-carpal fusion) in our cohort of patients. Materials and Methods: A retrospective cohort study was performed for functional outcomes of all patients who underwent resection for distal radius tumour and treated with either fusion or reconstruction of the wrist in a single institution from years 2000-2013 with a minimum of three years follow-up. Results: Eleven patients were included in the study, six of whom had wrist reconstruction with proximal fibula graft and the remaining five wrist fusion, with a mean follow-up of 6.3 years. The mean Musculoskeletal Tumour Society (MSTS) score was 82.78%, ranging from 70% to 93.3%. Average grip strength compared to the normal contralateral hand was 60.0% for total wrist fusion, which was better than wrist reconstruction with 58.07%. There was no difference in the functional outcome between fusion and mobile reconstruction in our study. Osteoarthritis changes and subluxation of the wrist joint were the most common findings in the long-term follow-up for this group. Conclusion: There was no difference in the functional outcome of the long-term follow-up between the two groups.

Early Vessels Exploration of Pink Pulseless Hand in Gartland III Supracondylar Fracture Humerus in Children: Facts and Controversies.

The management of pink pulseless limbs in supracondylar fractures has remained controversial, especially with regards to the indication for exploration in a clinically well-perfused hand. We reviewed a series of seven patients who underwent surgical exploration of the brachial artery following supracondylar fracture. All patients had a non-palpable radial artery, which was confirmed by Doppler ultrasound. CT angiography revealed complete blockage of the artery with good collateral and distal run-off. Two patients were more complicated with peripheral nerve injuries, one median nerve and one ulnar nerve. Only one patient had persistent arterial constriction which required reverse saphenous graft. The brachial arteries were found to be compressed by fracture fragments, but were in continuity. The vessels were patent after the release of obstruction and the stabilization of the fracture. There was no transection of major nerves. The radial pulse was persistently present after 12 weeks, and the nerve activity returned to full function.

Immediate Revascularization of A Traumatic Limb Vascular Injury associated with Major Pelvic Injuries.

High velocity pelvic injury with limb vascular injury poses difficulties as immediate surgery for limb reperfusion is indicated. However immediate vascular intervention deviates from conventional principles of damage control following major injuries. We present two cases of this rare combination of injuries. In both cases, early limb revascularization is possible despite presented with multiple injuries and pelvic fracture.

Resection and reconstruction of malignant tumor involving sternum.

We present a series of four cases of chest wall tumor, which underwent sternum resection. The methods of resection and reconstruction chest wall defect are discussed and the final outcome highlighted.

Soft tissue reconstruction following hemipelvectomy: eight-year experience and literature review.

BACKGROUND AND OBJECTIVES: Hemipelvectomy is a major surgical procedure that associates with significant morbidity, functional impairment, and psychological and body image problem. Reconstruction of the defect is a challenged since a large amount of composite tissues are needed. We would like to share our eight-year experience with massive pelvic resection and reconstruction. METHODS: A retrospective analysis of all cases of hemipelvectomy was conducted in our institution over eight-year period with particular attention given to the reconstruction choices and associated complications. RESULTS: Thirteen patients were included with median age of 39 years (range 13-78) of which all had advanced tumour with stage IIb (54%) and Stage III (46%). External hemipelvectomy was performed in all cases, and resultant defects were reconstructed with variety type of flaps. These include fillet thigh flaps, regional pedicle flaps of different designs, and free flap. CONCLUSIONS: Massive pelvic tumour is rarely encountered in our population but can be seen across all age groups and usually due to late presentation. The defects should be reconstructed using local or regional flaps, incorporating the muscle component to enhance flap perfusion. The tissue should be harvested from the amputated limb, as it can limit the donor site morbidity.

Tumour volume and lung metastasis in patients with osteosarcoma.

PURPOSE: To assess the association between tumour volume and occurrence of lung metastasis in patients with osteosarcoma and to determine the cut-off value. METHODS: Records of 70 patients with histopathologically confirmed primary osteosarcoma in the extremities who had magnetic resonance imaging and computed tomography of the thorax less than one month before treatment were reviewed, with reference to the official report of tumour dimensions and lung metastasis by radiologists. The status of lung metastasis was assessed. Tumour volume was measured using the formula for an ellipsoidal mass. RESULTS: Of the 70 patients with osteosarcoma, 33 (47%) had evidence of lung metastasis. Tumour volume was directly associated with occurrence of lung metastasis (p=0.048). The proportion having lung metastasis when the primary tumour volume exceeded 371 cm3 was 69%, compared to 34% in those with smaller tumours. CONCLUSION: Larger tumours are more likely to correlate with lung metastasis. Both features are predictive of patient survival and prognosis.

Sliding compression screw fixation for delayed union/non-union of femoral neck fracture: is it a viable option.

Femoral neck fracture non-unions often present with significant difficult treatment decision as regards to surgical options and the risk of complication. We present three cases of femoral neck non-union treated with double screw stabilization technique using sliding compression hip screw and anti-rotational screw. The rationale for opting to these simple implants in our setting is discussed.

Forequarter amputation of the upper extremity for musculoskeletal tumors: posterior approach revisited.

Forequarter amputation entails surgical removal of entire upper extremity, scapula and clavicle. Several techniques of forequarter amputation have been described. The anterior approach has been the preferred technique of exploration of axillary vessels and brachial plexus. The posterior approach has been condemned to be unreliable and dangerous for most large tumor of the scapula and suprascapular area. We describe a surgical technique using posterior approach of exploration of major vessels for forequarter amputation of upper extremity in eight patients who presented with humeral-scapular tumor. There were six patients with osteosarcoma: three with tumor recurrent and three chemotherapy recalcitrant tumors with vessels involvement. One patient had massive fungating squamous cell carcinoma and another had recurrent rhabdomyosarcoma. Four patients had fungating ulcer and six patients had multiple pulmonary metastases at the time of surgery. The mean estimated blood transfusion was 900 ml (range 0-1600 ml) and two patients did not require transfusion. The duration of surgery ranged 2.5-6.0 hours (mean 3.8 hours). Two patients with known pulmonary metastases required post-operative intensive care monitoring. The mean duration of survival was 5.8 months. The posterior approach of exploring major vessels for forequarter amputation of upper extremity with musculoskeletal tumor is safe and reliable.

Aggressive giant cell tumour of bone.

INTRODUCTION: The surgical treatment of Stage III or aggressive giant cell tumour of the bone, whether to perform intralesional or en-bloc resection, remains controversial. The aim of this study is to identify the effectiveness of en-bloc resection for local control and final oncological outcome of the disease. METHODS: The data of 20 consecutive patients with Stage III giant cell tumour were retrospectively reviewed to determine the local control and oncological outcome after treatment with wide resection. RESULTS: The majority of the patients presented late with mean duration of symptoms of 24 months, and four patients presented with recurrences. All patients were treated with wide resection except for two patients who underwent ablative surgery due to major neurovascular involvement. Ten patients required free vascularised tissue transfer to cover massive soft tissue defect. Local recurrence occurred in one patient who was again treated with wide resection and vascularised flap. Six patients had pulmonary metastases. Two patients with resectable disease were treated with thoracoscopic surgery and they remained disease-free 36 months after surgery. Two patients with multiple lung metastases were treated with chemotherapy and the disease remained non-progressive. The remaining two patients who refused chemotherapy showed radiological progression, and one succumbed to the disease with massive haemoptysis. CONCLUSION: Aggressive giant cell tumour of bone should be treated with wide resection for better local control, and treatment of pulmonary metastases is mandatory for overall prognosis.

Femoral overgrowth following plate fixation of the fractured femur in children.

INTRODUCTION: The purpose of this study is to determine the overgrowth phenomenon of the affected femur following plate fixation of femoral fractures in children. METHODS: 15 patients (aged between eight and 14 years old), who underwent open reduction and plate fixation for fractures of the femur, were assessed at two years postoperation for limb length discrepancy. Measurements were made using a computed tomography (CT) scanogram. Its association with age, limb dominancy and site of fracture were analysed. RESULTS: There were 12 boys and three girls. All children had femoral overgrowth of the injured femur, ranging from 0.1 cm to 2.0 cm with a mean of 1.15 cm. There was a significant correlation between age and bone overgrowth. Limb dominancy and site of fracture had no significant influence on femoral overgrowth. CONCLUSION: The amount of femoral overgrowth following fracture stabilisation with plate in children was minimal. It could still occur even without fracture overlapping during the healing process. The overgrowth was less in older subjects.