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Introduction: Flexor tendon repair is challenging mainly due to the need to balance between a strong repair technique, ease of tendon gliding and early mobilisation to prevent adhesions while preventing tendon rupture. While different countries have different preferences in repair techniques, core sutures and suture types, there is still no study in Malaysia regarding our preference and whether we are following the current evidence. Materials and methods: We performed a survey with a standard questionnaire distributed during our annual national orthopaedic meeting in 2019. The standard questionnaire consisted of 24-objective multiple-choice questions concerning the treatment of flexor tendon injury were distributed with consent. A total of 290 questionnaires that were filled out correctly were included in this study. Results: The majority of respondents preferred the Modified Kessler technique (n=96, 33.1%) followed by the Adelaide technique (n=81, 27.9%) and Double Modified Kessler (n=45, 15.5%). However, for the number of core strands in the repair, the majority utilised the 4-strand (n=203, 70%), followed by 2-strand (n=34, 11.7%) and 6-strand (n=21, 7.2%). The majority utilised Prolene sutures (n=259, 89.3%) with a suture size of 4/0 (n=157, 54.1%). For rehabilitation, 56.9% (n=165) preferred early passive motion, 27.6% (n=80) early active motion and 14.8% (n=43) would strictly immobilise. Conclusion: There is still no consensus as to the best technique; however, the aim of tendon repairs is still the same around the world. It would be helpful to know our preferences to improve our current practice and outcomes following these common flexor tendon injuries in hand.
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Acrometastasis is rare with a very low incidence of all bone metastasis. It can present with swelling, pain and warmth with erythema that may mimic an infection especially in the distal phalanx. Due to its rarity and subtle clinical presentation, it can be misdiagnosed as an infection causing the treatment to be delayed. We report a 42-year-old female with an acrometastasis to the distal phalanx of the left middle finger which we mistook as an infection thus delaying her treatment. It was a terminal presentation of her endocervical adenosquamous carcinoma. We would like to highlight that acrometastasis has an indistinct presentation and in cases where the lesion does not respond to treatment, acrometastasis should be included as one of the differential diagnoses. Thus, physicians need to have a high level of suspicion in patients with a primary malignant tumour.
ABSTRACT
@#Acrometastasis is rare with a very low incidence of all bone metastasis. It can present with swelling, pain and warmth with erythema that may mimic an infection especially in the distal phalanx. Due to its rarity and subtle clinical presentation, it can be misdiagnosed as an infection causing the treatment to be delayed. We report a 42-year-old female with an acrometastasis to the distal phalanx of the left middle finger which we mistook as an infection thus delaying her treatment. It was a terminal presentation of her endocervical adenosquamous carcinoma. We would like to highlight that acrometastasis has an indistinct presentation and in cases where the lesion does not respond to treatment, acrometastasis should be included as one of the differential diagnoses. Thus, physicians need to have a high level of suspicion in patients with a primary malignant tumour.
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@#We report a case of a 59-year-old gentleman with complete left brachial plexus injury. He presented with chronic pain over the dorsum of his left hand since the injury eight years ago. Medical treatment had been optimized but the pain still persists. End-to-side nerve transfer was done involving superficial sensory radial nerve and median nerve to alleviate the pain. The surgery was considered successful as the patient claimed that the pain score had reduced a few weeks postoperatively. However, there was no sensory recovery and functionally no improvement was observed
ABSTRACT
Splinting of the wrist after carpal tunnel release (CTR) has been practised by many surgeons especially in North America. The main reason was to prevent possible adverse events of bowstringing of flexor tendons and the median nerve, pillar pain, entrapment of the median nerve in scar tissue and wound dehiscence. Studies on the effect of splinting after standard CTR have had dismal results. The duration of splinting in standard CTR has been either too long (for 2-4 weeks) or too short (48 hours only). The aim of our study was to compare the effects of post-operative splinting for a duration of one week with no splinting. METHODS: All 30 of our patients underwent a standardized limited open CTR by a designated surgeon. Post operatively, they were randomized into a splinted (n=16) and a nonsplinted (n=14) group. The splint was kept for a week. Patients were reviewed at regular intervals of one week, two months and six months. At each follow up, these patients were clinically assessed for the following outcome measures: VAS (visual analogue score), 2PD (two-point discrimination), pinch grip, grip, Abductor Pollicis Brevis (APB)) power and completion of the Boston questionnaire. RESULTS: All patients presented with significant improvement in the postoperative evaluation in the analyzed parameters within each group. However, there was no significant difference between the two groups for any of the outcome measurements at sequential and at final follow-up. CONCLUSION: We conclude that wrist splinting in the immediate post-operative period has no advantage when compared with the unsplinted wrist after a limited open carpal tunnel release.
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Brachial plexus injuries with intact yet flail limb presents with problems of persistent neuropathic pain and recurrent shoulder dislocations, that render the flail limb a damn nuisance. As treating surgeons, we are faced with the dilemma of offering treatment options, bearing in mind the patient's functional status and expectations. We present a case of a 55-year old housewife with complete brachial plexus injury begging for surgical amputation of her flail limb, 6 years post-injury. Here we discuss the outcome of transhumeral amputation and the possibility of offering early rather than delayed amputations in this group of patients.
ABSTRACT
Brachial plexus injuries with intact yet flail limb presents with problems of persistent neuropathic pain and recurrent shoulder dislocations, that render the flail limb a damn nuisance. As treating surgeons, we are faced with the dilemma of offering treatment options, bearing in mind the patient’s functional status and expectations. We present a case of a 55-year old housewife with complete brachial plexus injury begging for surgical amputation of her flail limb, 6 years post-injury. Here we discuss the outcome of transhumeral amputation and the possibility of offering early rather than delayed amputations in this group of patients.
Subject(s)
Brachial PlexusABSTRACT
OBJECTIVE: To evaluate the Philippine Obstetrical and Gynecological Society Clinical Practice Guidelines (POGS-CPG) and the International Association of Diabetes and Pregnancy Study Group (IADPSG) diagnostic criteria for gestational diabetes mellitus (GDM) against pregnancy outcomes.METHODS: This is a randomized controlled trial which enlisted patients attending the Out-patient clinic of our institution. All women included in the study were requested to take a 2-hour 75-gram oral glucose tolerance test (OGTT) between estimated 24th and 28th gestational weeks. In order to diagnose GDM, POGS-CPG consensus required a fasting plasma glucose of >92 mg/dl (5.1 mmol/L) or a 2-hour post-glucose load of >140 mg/dl (7.8 mmol/ml) while lADPSG criteria required 92 mg/dL (5.1 mmol/L) for fasting plasma glucose, 180 mg/dL (10 mmol/L)1-hour post-glucose load, or 153 mg/dL (8.5 mmol/L) 2-hour post-glucose load. Only 1 abnormal value on the OGTT is needed on both criteria to diagnose GDM. Women with diabetes antedating pregnancy were excluded in this study. Based on the 75-g OGTT result, the patients were divided into 4 groups and were followed through delivery. Pregnancy out-comes of the 4 groups were then compared.RESULTS: Among the 389 patients studied, POGS-CPG group had a GDM prevalence rate of 29% whereas the IADPSG group had 16%. Trends have shown that in patients diagnosed with GDM under IADSGP and POGS criteria, no significant differences in the birth-weight status (p=0.156), mode of delivery (p=1.000), indication of cesarean section (p=1.000), and other complications (p=1.000) were noted. The 75 g OGTT values of patients in both groups were not significant predictors of APGAR scores. However, the 1-hour post-glucose load value was shown to be a significantpredictor of birth weight. Yet, the regression models of FBS parameters in predicting APGAR scores and birth weight were still weak.CONCLUSION: There was no significant difference noted between the IADPSG group versus the POGS-CPG group in terms of maternal neonatal outcome.
Subject(s)
Humans , Female , Adult , Pregnancy , Glucose Tolerance Test , Diabetes, Gestational , Pregnancy Outcome , Blood Glucose , Birth Weight , Glucose , Cesarean Section , Pregnancy in DiabeticsABSTRACT
BACKGROUND AND AIM: Synthetic nerve conduits have been sought for repair of nerve defects as the autologous nerve grafts causes donor site morbidity and possess other drawbacks. Many strategies have been investigated to improve nerve regeneration through synthetic nerve guided conduits. Olfactory ensheathing cells (OECs) that share both Schwann cell and astrocytic characteristics have been shown to promote axonal regeneration after transplantation. The present study was driven by the hypothesis that tissue-engineered poly(lactic-co-glycolic acid) (PLGA) seeded with OECs would improve peripheral nerve regeneration in a long sciatic nerve defect. MATERIALS AND METHODS: Sciatic nerve gap of 15 mm was created in six adult female Sprague-Dawley rats and implanted with PLGA seeded with OECs. The nerve regeneration was assessed electrophysiologically at 2, 4 and 6 weeks following implantation. Histopathological examination, scanning electron microscopic (SEM) examination and immunohistochemical analysis were performed at the end of the study. RESULTS: Nerve conduction studies revealed a significant improvement of nerve conduction velocities whereby the mean nerve conduction velocity increases from 4.2 Î 0.4 m/s at week 2 to 27.3 Î 5.7 m/s at week 6 post-implantation (P < 0.0001). Histological analysis revealed presence of spindle-shaped cells. Immunohistochemical analysis further demonstrated the expression of S100 protein in both cell nucleus and the cytoplasm in these cells, hence confirming their Schwann-cell-like property. Under SEM, these cells were found to be actively secreting extracellular matrix. CONCLUSION: Tissue-engineered PLGA conduit seeded with OECs provided a permissive environment to facilitate nerve regeneration in a small animal model.
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Bone marrow derived Mesenchymal stem cells (MSCs) were evaluated as an alternative source for tissue engineering of peripheral nerves. Human MSCs were subjected to a series of treatment with a reducing agent, retinoic acid and a combination of trophic factors. This treated MSCs differentiated into Schwann cells were characterized in vitro via flow cytometry analysis and immunocytochemically. In contrast to untreated MSCs, differentiated MSCs expressed Schwann cell markers in vitro, as we confirmed by flow cytometry analysis and immunocytochemically. These results suggest that human MSCs can be induced to be a substitute for Schwann cells that may be applied for nerve regeneration since it is difficult to grow Schwann cells in vitro.
Subject(s)
Bone Marrow Transplantation , Bone Marrow/pathology , Mesenchymal Stem Cell Transplantation , Nerve Regeneration/physiology , Neural Tube/physiology , Peripheral Nerves/pathology , Schwann Cells/transplantation , Tissue Engineering , Cell Culture Techniques , Cell Differentiation , Flow Cytometry , Humans , Immunohistochemistry , TretinoinABSTRACT
Bone marrow derived Mesenchymal stem cells (MSCs) were evaluated as an alternative source for tissue engineering of peripheral nerves. Human MSCs were subjected to a series of treatment with a reducing agent, retinoic acid and a combination of trophic factors. This treated MSCs differentiated into Schwann cells were characterized in vitro via flow cytometry analysis and immunocytochemically. In contrast to untreated MSCs, differentiated MSCs expressed Schwann cell markers in vitro, as we confirmed by flow cytometry analysis and immunocytochemically. These results suggest that human MSCs can be induced to be a substitute for Schwann cells that may be applied for nerve regeneration since it is difficult to grow Schwann cells in vitro.
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A Malaysian family with congenital insensitivity to pain with anhydrosis was diagnosed based on clinical symptoms of chronic ulcers, joint deformities, malunited fractures, anhydrosis, and learning disabilities. We detected a compound heterozygous mutation in exon 16: V709L from the mother and G718S from the father. Two novel mutations were identified: at amino acid 709, a change of G to C at nucleotide 2209 (approximately 2209G to C) causing a valine to leucine substitution (V709L), and at amino acid 718, a change of G to A at nucleotide 2236 (approximately 2236G to A) causing a glycine to serine substitution (G718S). Polymorphisms identified were at nucleotides approximately 2113G to C and approximately 2176T to C.
Subject(s)
Hypohidrosis/genetics , Pain Insensitivity, Congenital/genetics , Adolescent , Asian People , Female , Humans , Hypohidrosis/ethnology , Malaysia , Male , Pain Insensitivity, Congenital/ethnology , Pedigree , Polymorphism, GeneticABSTRACT
Palmaris longus is a dispensable muscle with a long tendon which is very useful in reconstructive surgery. It is absent 2.8 to 24% of the population depending on the race/ethnicity studied. Four hundred and fifty healthy subjects (equally distributed among Malaysias 3 major ethnic groups) were clinically examined for the presence or absence of palmaris longus. This tendon was found to be absent unilaterally in 6.4% of study subjects, and bilaterally in 2.9% of study participants. Malays have a high preval
