Officialjournalofthe · Supplement F December 2004 ISSN 0300-5283 PP 2121/11/04 MITA(P) 124/1/91. Volume 59 SupplementF December2004 Editor JohnT Aroklasamy Members Victor K E Lim

Official journal of theMalaysian Medical Association

Orthopaedic Supplement

Volume 59

Supplement F

December 2004

ISSN 0300-5283 PP 2121/11/04 MITA(P) 124/1/91

Volume 59 Supplement F December 2004

EditorJohn T Aroklasamy

Members

Victor K E Lim

Lim Kean Ghee

Mahendra Raj

Khalid Yusoff

Kannan Kutty

PP 2121/11/04

Members

Abdul Hamid

Azhar Md Zain

Khoo KahLin

Ex-officioMastura Ismail

MCI (PI 124/1/91

Members

Mohd Akhtar Qureshi

Balwant Singh Gendeh

Rusli Nordin

Sivallngam Nalliah

Abdul Rashid

ISSN 0300-5283

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ii

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Med JMalaysia Vol 59 Supplement F December 2004

EDITOR'S NOTE

EDITOR'S NOTES Sengupta

INVITED EDITORIAL

NEW HIPS FOR OLD! LESSONS FROM THE ARABIAN NIGHTSS Harwant

ORIGINAL ARTICLES

2

EARLY RESULTS OF METAL ON METAL ARTICULATION TOTAL HIP ARTHROPLASTY 3IN YOUNG PATIENTSJ A Mohamad, M K Kwan, AM Merican, A A Abbas, Z H Komori, M K HisatZ Ismai!, R M Idrus

2

3

4

5

6

OBJECTIVE TRICEPS MUSCLE STRENGTH MEASUREMENT USING COMPUTERIZEDADAPTATIONA Ama!ourde, P Vinayaga, N Noveed, S K Choon, 0 Za!eha,

CORONAL PLANE AND APICAL VERTEBRAL ROTATION CORRECTION OFADOLESCENT IDIOPATHIC SCOLIOSIS WITH MULTISEGMENTED HOOK-RODSYSTEM - A RETROSPECTIVE REVIEWM K Kwant W K Chooi, H H Lim

THE EPIDEMIOLOGY OF SHOULDER DISLOCATIONS IN MALAYSIAJ S Yeap, DJ K Lee, M Fazir, TA Muhd Borbat», B A Kareem

OSTEOSARCOMA: THE OUTCOME OF LIMB SALVAGE SURGERYW I Fcushot», W Zu!mi, A S Ha!im, B M Biswo], S S Mutum

EARLY COMPLICATION FOLLOWING LONG BONE RECONSTRUCTION USINGVASCULARISED FIBULA GRAFTY 1mrant W Zu!mit A S Ha!im

8

14

19

24

35

INNOVATION ARTICLES

1- 1

iv

TREATMENT FOR FLEXION CONTRACTURE OF THE KNEE DURING ILiZAROVRECONSTRUCTION OF TIBIA WITH PASSIVE KNEE EXTENSION SPLINTM K Kwant R Penafort, A Saw

39

INVITED EDITORIAL

New Hips for Old!

S Harwant, FRCS, PhD

Lessons from the Arabian Nights

Consultant Orthopaedic Surgeon, Hospital Seremban, Seremban, Negeri Sembilan

In the Arabian Nights, Princess Shahrazad tells us ofAladdin whose old, ditty, magical lamp (and genie),was accidentally exchanged for a new shiny one'.While not directly apparent, the moral of thatchildhood fable is that we should not abandonsomething useful until and unless the newer device orpractice has been proven to be superior. Therefore,very stringent peer review is mandatory, but sometimesnot always available. Sometimes what was requiredwas just plain single mindedness in the face ofadversary. Such is the fascinating story of the metal onmetal articulation in total hip arthroplasty. The firstattempts in hip arthroplasty in 1938 by Philip Wileswere metal on metal articulations. Little is knownabout the outcome of these patients, but subsequentprosthesis designs failed because of bone resorptionand loosening" Later, Kenneth McKee (Wiles' SeniorRegistrar) popularised the McKee-Farrar metal on metalarticulation which had long term survivorship ofbetween 80% to 90% at 10 years in the 1970's 3. Theseare good results.

1. H Haddawy: The Arabian Nights. Translated from theSyrian manuscript by Muhsin Mahdi. W\Yf Norton & Co,New York, 1990.

2. Scales JT. Arthroplasty of the hip using foreign materials:A History. Symposium on lubrication and wear in livingand artificial human joints. London, Inst of Mech Eng1967; 63-84.

2

Why were they abandoned? The answer is probablybecause of the excellent early results achieved by SirJohn Charnley using metal on polyethylene bearingwith the 27mm head; and the fact that Charnley initiallyonly allowed personally selected surgeons to use theprosthesis. By this, he effectively ensured good resultsby well-trained surgeons who understood what wasbeing done. Another concern was the frictional torqueissue; the larger McKee implants had greater frictionaltorque, and were shown to seize up in Charnley'spendulum comparator (without lubrication). Therewere also concerns about carcinogens and metalsensitivity, and an early infection rate of 8 to 11%'.

The metal on polyethylene arthroplasty is a successstory, but polyethylene wear debris remains theultimate cause of most total hip arthroplasty failurestoday'. Does this signal a comeback for metal on metalarticulations? The jury is out on this. In this issue youwill read of one group's early experience of metal onmetal articulation for total hip arthroplasty in youngpatients. So, new 'metal on metal hips' for old 'metalon plastic hips'; you decide!

3. HC Amstutz, P Grigoris. Metal on metal bearings in hiparthroplasty. Clin Orthop. 1996; 329S, pp Sl1-S34.

4. T Visuri. Long term results and survivorship of theMcKee-Farrar total hip prosthesis. Arch Orthop. 1982;106: 368-74.

5. HC Amstutz. Editorial Comment. Clin Orthop. 1996; 329S,pp S2-S3.

Med j Malaysia Vol 59 Supplement F December 2004

ORIGINAL ARTICLE

Early Results of Metal on Metal Articulation Total HipArthroplasty in Young Patients

J A Mohamad, MS (Ortho)", M K Kwan, MS (Ortho)", AM Meriean, MS (Ortho)", A A Abbas, MD*, Z HKamari, MS (Ortho)", M K Hisa, MS (Ortho)?', Z Ismail, MS {Ortho)***, R M Idrus, MS {Ortho)****

"Department of Orthopaedic Surgery, University Malaya Medical Centre, Kuala Lumpur, *Hospital Sultanah Aminah, johor Bahru, johor,"Hospital Melaka, Melaka, ***Hospital Kuala Lumpur, Kuala Lumpur, ****Damansara Specialist Hospital, Kuala Lumpur

Introduction

Metal on metal arthroplasty was first introduced in theyear 1938 by Philip Wiles'. He performed the operationon 6 patients, who suffered from Still's disease.Unfortunately, the entire data of his patients were lostduring the Second World War. In the 1950's and 1960's,the development of metal on metal articulationarthroplasty was associated with the names of KennethMckee, Peter Ring and John Seales'. These firstgeneration metal on metal prostheses e.g McKee-Farrarprosthesis, were commonly used for hip replacementuntil the mid 1970's, when metal on polyethyleneprosthesis became more favourable. The factors thatcontributed to the abandonment of the metal on metaltotal hip arthroplasty were; the early success of theCharnley prosthesis, the frictional torque issue,increased strain rates in the periprosthetic bone andfatigue fractures of the acetabular floor, carcinogenesisconcerns and metal sensitivity concerns 2. In addition,the long-term results of metal on metal prosthesis were

Submitted for publication: 23 September 2002

Med J Malaysia Vol 59 Supplement F December 2004

not encouraging 34. As a result, Kenneth Mckeestopped using the McKee-Farrar system in 1982 5

.

Inspired by the success of the Charnley prosthesis,research in the past two decades have been directed atimproving the design and implantation techniques ofthe metal on polyethylene prosthesis. The metal onpolyethylene prosthesis however has its limitationsespecially in young patients. In the early 1980's,osteolysis as a result of biological reaction topolyethylene wear debris was increasingly recognisedas a cause for aseptic loosening 678.9. Wear andosteolysis have become the primary concerns in metalon polethylene articulation total hip arthroplasty. Thishas led to the resurgence of second generation metalon metal articulation surface with a CoCr alloy 10. Themetal on metal prosthesis has been shown to produceless volumetric wear than the standard metal onpolyethylene articulation 1112. From this standpoint, thelongevity of this prosthesis should be superior. Thus,

3

Early Results of Metal on Metal Articulation Total HipArthroplasty in Young Patients

100

90 +---------80 -j----------70 +---------60 +-----,.",..-------

g 50(I'l 40

30

20

10

o

9389

This study.

Pre-op FinalFollow-up

Fig. 1: A comparative study on the average total Harris Hip Score between the present study andthe study published by Dorr et all 1996

Fig. 2: Radiograph illustrating a case ofdislocation of the implant at 3 monthspost surgery

Fig. 3: Radiograph illustrating a case ofinfected implant which required twostaged revision

Table I: The difference between the pre-eperefive and the totalHarris Hip Score at final follow up

Pre-operativeoo1 (5%)

19 (95%)

HARRIS HIP SCORE90 - 100 (Excellent)80 - 89 (Good)70 - 79 (Fair)

s 69 (Bad)

Final follow-up12 (60%)

4 (20%)3 (15%)1 (5%)

Med J Malaysia Vol 59 Supplement F December 2004 5

ORIGINAL ARTICLE

Obiective Triceps Muscle Strength MeasurementUsing Computerized Adaptation

A Amalourde, MS (Ortho)", P Vinayaga, MS (Ortho)*, N Naveed, MS (Ortho)", S K Choon, FRCS*,o Zaleha, FRCS**

"Department of Orthopaedic Surgery, **Department of Allied Medical Sciences, University of Malaya, Kuala Lumpur

Introduction

Objective muscle strength measurement has alwaysattracted keen interest among scientists from the earlypart of the nineteenth century, during the outbreak ofpoliomyelitis. Till today newer muscle testingmachines are still evolving.

Hislop and Perrine! introduced the concept ofisokinetic exercises. Mary Moffroid et aP conducted thefirst study on reliability and validity of is0 kineticexercise using Cybex I machine. However the concernis the cost-benefit ratio of these devices.

In our center subjective muscle strength measurementsand non-availability of computerized exercise machinelimits the monitoring of muscle strength rehabilitationprogrammes. Therefore it is our aim to measure triceps

Submitted for publication: 01 August 2002

8

muscle strength using computerized adaptation ofNORSK-Gym Machine with accelerometer andpositional transducer interfaces.

Materials and Methods

In order to achieve our objectives, we conducted thestudy in three parts.

Study INORSK-Gym exercise machine was first interfaced withan Accelerometer and Positional Transducers to acomputer. Validyne Data Acquisition System wasinstalled into a Pentium III computer that allowed datacollection, and processing. Special software was usedfor data tabulation, display and calibration. This datawas then tabulated using Microsoft Office 2000 (Excel).

Med j Malaysia Vol 59 Supplement F December 2004

Objective Triceps Muscle Strength Measurement Using Computerized Adaptation

Table III: Intra-individual reproducibility of Peak Force measurements for a Subject A

System Weight Peak Force(kg) Day Correlation

1 2 3 Mean Coefficient10 11.33 13.40 9.92 11.55 r=0.96615 17.65 19.18 17.04 17.9620 19.02 19.82 21.46 20.1025 33.92 29.37 31.53 31.6130 34.05 32.85 29.54 32.1535 35.39 34.61 34.68 34.89

Table IV: Intra-individual reproducibility of Peak Force measurements for all subjects

Subjects Correlation Coefficient1 0.9612 0.9573 0.9724 0.9495 0.9536 0.9297 0.9418 0.9359 0.96210 0.959

Fig. 2: Complete assembly of thecomputerized NORSK-Gym machinewith both transducers


ORIGINAL ARTICLE

40

30

Accelerometer20 Force

10

. Positional Force0

25 3015

-10

-20

-30

TIME (x 0.1 seconds)

Fig. 3: Peak Force measurements using the Positional & Accelerometer transducer for a weightplate of 25 kg

Discussion

Moffroid' and Mayhem & Rothstein' gave emphasis toissues of validity and reproducibility of measurementsobtained from new instruments used to measure muscleperformance.

We have successfully adapted the NORSK-Gym exercisemachine with accelerometer and positional transducerinterfaces to a computer to measure muscle strength.The positional transducer was first calibrated andshowed an excellent PCC (r=0.9999).

The validity of the test parameter (Peak Force) wasdetermined using the concept of criterion-referencedvalidity as defined by Johnstone et a15• It states that anew test parameter is considered valid if the readingscoincide with readings obtained from a gold standardtest for which the validity is known. For exampleTremblay et a16 had modified Hydra-Gym Equipment to

measure isokinetic strength and his results werecompared with a standard isokinetic dynamometer (KinCom) to validate the criterion-reference validity.Another definition for criterion-referenced validity iswhether two tests are comparable and the extent wasexpressed in relation to the other. We had used thisdefinition in our study to determine criterion-referencedvalidity. We found an excellent PCC with a r=0.940 forthe validity test.

12

The most frequently used test parameter in isokineticmeasurement in clinical and scientific work has beenPeak Torque':". It refers to the single highest torqueoutput of the joint produced by muscular contraction asthe limb moves through the range of motion at constantvelocity. Peak Torque is the equivalent to peak forcemultiplied by the lever arm distance. In our study as thisdistance is kept a constant thus the peak force and thepeak torque values are proportionate.

We studied the reproducibility of our adaptation usingknown masses as done by Moffroid-, Seger? andTremblay'. Reproducibility for known mass (m)showed excellent Correlation Coefficients (r) rangingfrom 0.982 to 0.998 for mass of 10 to 25kg. An excellentintra-individual reproducibility was demonstrated forthe 10 subjects with a correlation coefficient (r) = 0.9290.972.

Stabilization and positioning of the body are criticalfactors affecting reproducibility and validity of tests ofmuscular performance. Schmier" and Beasley" stressedthat the true strength of a muscle cannot be assessedunless its origin is sufficiently stabilized to allow it tocontract maximally against its insertion. johnson"identified testing measurement variation of up to 25%without restraining straps, We believe that we havestandardized this variable by a standard position for thesubjects as well as strapping as illustrated in Figure 1.


Objective Triceps Muscle Strength Measurement Using Computerized Adaptation

There are several factors that influenced thereproducibility of this machine. The motivation level ofthe subjects is an important variable, however it is themost difficult to standardize. All our subjects weregiven a standard instruction to minimize this bias. Theywere instructed to depress the handle of the gymmachine using the sling by exerting maximum force.They were allowed to familiarize themselves with themachine prior to the actual tests.

1. Hislop H, Perrine J: The isokinetic concept of exercise.Phys Ther, 1967; 47(2): 114-17.

2. Moffroid M, Whipple R, Hofkosh J et al: A study ofisokinetic exercise. Phys Ther, 1969; 49: 735-47.

3. Smidt GL, Blanpied PR, and White RW: Exploration ofmechanical and electromyographic responses of trunkmuscles to high-intensity resistive exercise. Spine, 1989;14: 8, 815-30.

4. Mayhew TP, Rothstein JM: Measurement of muscleperformance with instruments: Measurement in physicaltherapy. Churchill Livingstone Inc. publisher: 1985; 7: 146.

5. Johnstone MV, Keith RA, Hinderer SR: Measurementstandards for interdisciplinary medical rehabilitation. Archof Phys Med and Rehab, 1992; 73: S3-S23.

6. Tremblay MS, Lovely DF, McInnis MD, Sexsmith JR.:Adaptations to hydra-gym equipment provide forclinically useful strength measurements. J Ortho SportsPhys Ther, 1994; 19:4, 205-11.

7. Kannus P: Normality, variability and predictability ofwork, power and torque acceleration energy with respect


Conclusion

We have successfully adapted the NORSK-Gym exercisemachine with Accelerometer and Positional Transducerinterfaces to a computer to measure muscle strength.This computerized adaptation of the NORSK-Gymmachine produced an objective, valid and reproducibletriceps muscle strength measurement

to Peak Torque in isokinetic muscle testing. Int J SportsMed, 1992; 13: 249-56.

8. Sapega AA: Muscle performance evaluation inorthopaedic practice. J Bone Joint Surg, 1990; 72-A:1562-574.

9. Seger JY, Westing SH, Hanson M, Karlson E, Ekblom B: Anew dynamometer measuring concentric and eccentricmuscle strength in accelerated, decelerated or isokineticmovements. Validity and reproducibility. Eur J ApplPhysiol, 1988; 57: 5, 526-30.

10. Schmier AA: Research Work on a More Precise Method ofDetermining Muscle Strength in Poliomyelitis Patients. ANew Muscle Tester. J Bone and Joint Surg, 1945; 27: 31726.

11. Beasley WC: Quantitative muscle testing: Principles andapplications to research and clinical services. Arch PhysMed Rehab, 1961; 42: 398-425.

12. Jonson LR: Cybex II hip and trunk stabilization duringquadriceps/hamstring evaluation. J Orthop Sports PhysTher, 1981; 2(4): 191-93.

13

ORIGINAL ARIIQlE

Coronal Plane and Apical Vertebral Rotation Correctionof Adolescent Idiopathic Scoliosis with MultisegmentedHook-Rod System ... A Retrospective Review

M K Kwan, MS (Ortho), W K Chooi, MS (Ortho), H H Lim, FRCSE

Department of Orthopaedic Surgery, University Malaya Medical Centre, Kuala Lumpur

Introduction

Adolescent Idiopathic Scoliosis is a three dimensionaldeformity, represented by abnormal alignment in thefrontal, sagittal, and axial plane. The prevalence of thiscondition is approximately 2-3% for the coronal curvesgreater than 10 degrees. The risk of progression iscorrelated to the severity of the existing coronal curve,the patient's age, Risser's sign, and rate of the growth'.The risk of progression of a curve that is less than 20degrees is 25% for a 10-12 years old patient but it is rarefor a patient who has completed growth. However, therisk is approximately 100% when the curve is more than


14

60 degrees for a 10-12 year-old-patient and 70% for apatient who has completed growth".

Harrington distraction rod has been the maininstrumentation for the scoliosis surgery and has showngood long-term results 3.4.5. However, it does not correctthe sagittal plane deformity and axial rotation'.

Recently, the three dimensional concept of theidiopathic scoliosis has been recognized, and moresophisticated instruments; Multisegmented Hook-RodSystem, have been designed for the correction. The


ORIGINAL ARTICLE

preoperative Cobb's angle was 61 ± 11 degrees (range,44 degrees to 79 degrees). For those patients withanterior release and posterior instrumentation, themean preoperative Cobb's angle was 95 ± 14 degrees(range, 76 degrees to 122 degrees) (Table I).

The overall mean immediate postoperative Cobb'sangle was improved to 38 ± 18 degrees (p « 0.01), atotal reduction of 32 degrees (45.70/0). The meanimmediate postoperative Cobb's angle for the anteriorrelease and posterior instrumentation group was 58 ±17 degrees. On the other hand, the mean immediatepostoperative Cobb angle for the posteriorinstrumentation alone group was 31 ± 10 degrees(Table n.

At the latest follow up, the overall mean Cobb's angledeteriorated from 38 degrees to 42 degrees, animprovement of 400/0 as compared to the overall meanpreoperative Cobb's angle of 70 degrees (p « 0.01).For those patients with posterior surgery alone, themean Cobb's angle at the latest follow up was 36 ± 10degrees (range, 17 degrees to 60 degrees). For thosepatients with anterior release and posteriorinstrumentation, the mean Cobb's angle at the latestfollow up was 61 ± 17 degrees (range, 38 degrees to86 degrees) (Table D.

The mean preoperative apical vertebral rotation was 25degrees. It was improved by 10 degrees (40.00/0) to 15degrees after the operation. However, at final follow up,the mean apical vertebra rotation was 20 degrees (p > 0.05),

Fig. 1: Apical shift measurement on astanding posteroanterior radiograph

16

The head shift was analysed and the result reviewedthat the mean head shift before the operation was25mm from the CSL. The mean head shift improved to19mm after the operation. At the final follow up, themean head shift improved further to 16 mm from theCSL(p < 0.05). The trunk shift was also analysed fromthe radiograph, mean preoperative trunk shift was 27mm from the CSL. It improved to 15mm after theoperation. At the latest follow up, the trunk shift stillmaintains the same value (p < 0.05),

Pain assessment showed that two third (twentypatients) of the patients did not complain of painduring the final follow up. Nine patients experiencedoccasional pain but did not need to seek professionaladvice. Only one patient complained of frequent painthat needed professional advice.

All of the patients were able to participate in schoolactivities, non contact sports and work at the latestfollow up.

One patient developed superficial wound infection,which resolved with aggressive wound debridement.One bone graft site infection, which resolved withoutcomplication. One patient developed monoparesis ofher lower limb, which resolved with expectantmanagement for 6 months. At final follow up, one caseat of superior screw cut out was noted where the patientpresented with the complaint of prominent implant.Neither pseudoarthoses nor broken rod was noted. Nojunctional kyphosis or flatback was observed.

o

Fig. 2: Trunk shift measurement on a standingposteroanterior radiograph


Coronal Plane and Apical Vertebral Rotation Correction of Adolescent Idiopathic Scoliosis

L4L3L2L1TI2TIl

14J'r----------

12M----------lO.u-----------8.u--------'""'7'""....,....-

6

4

2

Ol-f----'""'T'''"'--

OtberCDMoss MiamiIsola

Fig. 3: Types of Multisegmented Hook-RodSystem used

Fig. 4: The lowest vertebra instrumented

Table I: The average Cobb's angle values

Preoperative Postoperative Follow upAnterior release and posterior instrumentation 95° 58° 61°Posterior instrumentation 61 ° 310 36°Overall 70° 38° 42°

Discussion

Harrington rod instrumentation has been a standardsurgical technique for correction of scoliosis deformity.Willers et al ' reported a mean follow up 10.8 years ofthirty three patients who were treated with Harrington'srod. Their study showed that the mean Cobb's angleimproved by 23.7 degrees (40%); from 59.9 degreespreoperatively to 36.2 degrees at final follow up.However, this system provides correction that is limitedonly to coronal plane and requires a postoperativeexternal bracing.

With the introduction of Multisegmented Hook-RodSystem, in the mid 1980's, this system has gained muchpopularity. It is now becoming the new "goldstandard" for the spinal instrumentation 9. This systemis used to perform multiplanar correction of scoliosis.Besides that, it can also be employed to stabilise thespine sufficiently to obviate the use of external bracing.Guidera KJ et al 9 reported a mean follow up 22.8months of fifty two patients with Cotrel-DuboussetInstrumentation. The mean Cobb's angle improved by52.1 % postoperatively (from 60.6 degrees to 29degrees) and 45.5% at final follow up (from 60.6degrees to 33 degrees). Cotrel et al " reported a 60%correction in the frontal plane with 40% correction ofrotation. Subsequently Ecker et all! also noted a 24%improvement of rotation with Cotrel-Dubousset

Instrumentation based on Computer Tomographystudies.

In our series, we were able to achieve 40% (from 70degrees to 42 degrees) of coronal correction and 20%(from 25 degrees to 20 degrees) of apical vertebralrotation correction at the final follow up.

The mean operating time and amount of blood loss forthe posterior instrumentation alone were 270 minutesand 2.2 litres respectively. These results arecomparable with the results reported by Gurr andMcAfee 10 whose findings revealed an average operatingtime of 285 minutes and average blood loss of 1600mls.

All of the cases of anterior release and posteriorinstrumentation were performed under the sameanaesthesia on the same day for severe rigid curve.Shufflebarger et al 12 have shown that continuousanterior release and posterior instrumentation has thefollowing advantages; (1) continuous procedure isfaster than staged procedure; (2) there is less bloodloss; (3) fewer days are spent in the hospital; and (4)better correction of spinal deformity is achieved. In ourseries, the mean operating time and amount of bloodloss for the anterior release and posteriorinstrumentation were 522 minutes and 3.3 litresrespectively.


ORIGINAL ARTICLE

Efforts should be made to preserve the motion of thelower vertebrae as much as possible. Preservation oflower vertebra not only preserves motion but alsoprovides pain relief by aligning the load distributionand stress transfer. As noted in this series, 96.6%(twenty nine cases) of the lowest vertebra fused was L3and above (Figure 4). Only one case where the fusionneeds to be performed to the L4 level. However thispatient was free of complications during her lastassessment.

Thompson et al" stated that spinal imbalance is arecognized complication of Cotrel-DuboussetInstrumentation. Truncal imbalance could bemanifested by the translation of occiput, thorax, 11, andshoulder elevation. In our series, we assessed thetruncal balance radiologically by head shift and trunkshift distance. The head shift improved 36% (p<O.OS),from 2Smm to 16mm at final follow up. The trunk shiftimproved 44% (p<O.OS), from 27mm pre operatively tolSmm at final follow up.

1. William P. Bunnell. The natural history of IdiopathicScoliosis. Clin Orthop. 1988; N 229: 20-25.

2. Weinstein SL. Adolescent Idiopathic Scoliosis-Prevalence,Natural History, Treatment Indications. Chicago, ScoliosisResearch Society, 1985.

3. Dickson ], Erwin W, Rossi D. Harrington Instrumentationand arthroses for idiopathic scoliosis: A twenty-one-yearfollow-up. J Bone Joint Surg. 1990; 72A: 678-83.

4. Fitch R, Turi M, Bowman B, Hardaker W. Comparison ofCotrel-Dubousset and Harrington rod instrumentation onidiopathic scoliosis. J. Pediatric Orthopaedic. 1990; 10: 4447.

5. Harrington PR, Dickson J. An eleven -year clinicalinvestigation of Harrington instrumentation: a preliminaryreport 578 cases. Clin Orthop. 1973; N93: 113-30.

6. WillersU, Hedlund R, Normelli H, and Westman 1. Longterm results of Harrington Instrumentation in IdiopathicScoliosis. Spine. 1993; V18, N6: 713-17.

7. King HA, Moe JH, Bradfort DS, and Winter RB. Theselection of fusion levels in thoracic idiopathic scoliosis,

J. Bone Joint Surg. 1983; 65A: 1302-313.

18

Complications playa significant part in the risk-benefitratio and must be evaluated and discussed with eachpatient before surgery. A slightly higher incidence ofneurological injury has been noted with these systemscompared with Harrington rod instrumentation, andsome have speculated that this is due to the de rotationof the vertebrae, which leads to the kinking of theneural elements 14. In our series, there was one case ofneurological injury, which fortunately improved after 6months of observation.

Conclusion

In conclusion, the Multisegmented Hook-Rod Systemsappear to be a good system for correction of IdiopathicScoliosis in our hands. We are able to achieve anaverage of 46.7% of coronal correction and 40.0% ofapical rotation correction immediate post operativelyand 40.0% and 20.0% correction respectively after amean of 22.3 months of follow up.

8. Simmons ED, KowalskiJM, and Simmons EH. The resultsof surgical treatment for adult scoliosis. Spine.1993; V18,N6: 718-24.

9. Guidera KJ, Hooten J, Weatherly W, Highhouse M,Castellvi A, Ogden JA, Pugh L, Cook S. Cotrel-DuboussetInstrumentation, Results in 52 patients. Spine. 1993; V18,N4: 427-31.

10. Gurr KR. McAfee PC. Cotrel-Dubousset Instrumentationin adults: A preliminary report. Spine. 1988; V13: 510-20.

11. Ecker ML, Betz RR, Trent PS, et al. Computer Tomographyevaluation of Cotrel-Dubousset Instrumentation inidiopathic scoliosis. Spine. 1988; V13: 1141-144.

12. Shufflebarger HL, Grimm JO, Bui V, and Thompson JD.Anterior and posterior spinal fusion. Staged versus sameday surgery. Spine. 1991; v16, N1: 930-33.

13. Thompson JP, Transfelt EE, Bradfort DS, Ogilvie JW,Boachie-adjei, O. Decompensation after CotrelDubousset Instrumentation of Idiopathic Scoliosis. Spine.1990; V15: 927-31.

14. Gray JM, Smith BW, Ashley RK, Lagrone MO, Mall, J.Spine. 1991; V16, N8: S391-93.


ORIGINAL ARTICLE

The Epidemiology of Shoulder Dislocations inMalaysia

J S Yeap, FRCS*, D J K Lee, BScMed**, M Fazir, MS (Ortho)***, T A Muhd Borhan, FRCS***, B A Kareem,MS (Ortho)"

'Department of Orthopaedics, International Medical University, Seremban, Negeri Sembilan, "Faculty of Medicine, Universiti PutraMalaysia, Kuala Lumpur, "'Institute of Orthopaedics and Traumatology, Hospital Kuala Lumpur, Kuala Lumpur

Introduction

The shoulder is the most common major joint todislocate, accounting for 45% of all dislocations', Firsttime shoulder dislocations were found to represent 17%of all major injuries of the shoulder girdle in adults'.The prevalence of a history of shoulder dislocation inSwedish population has been estimated as 1.7%3. As inthe Western population, it is also a commonly seeninjury in Malaysia. Despite this, there has not been anypublished paper on this common injury in Malaysia.This retrospective study was performed to improve theunderstanding of the epidemiology of shoulderdislocations in Malaysia, to obtain an overview of thepresent management, and also to provide comparativedata for future studies.

Submitted for publication: 18 December 2002



All shoulder dislocations treated in a 2-year periodbetween October 1998 and September 2000 at theInstitute of Orthopaedics and Traumatology, HospitalKuala Lumpur was included in this retrospective crosssectional study. Of the 143 shoulder dislocationsidentified from the census book, only 117 dislocationscould be reviewed as 26 case notes were incomplete.

From the case notes, the patients' demographic data, themechanisms of injury and treatment were recorded ontoa proforma. Recurrent dislocation was defined as threeor more dislocations. All the radiographs in each casenotes were reviewed independently and thedislocations classified based on the direction of

19

ORIGINAL ARTICLE

35

30

~ 25

] 20~

'"'"C 15

~ 10

o<21 21-30 31-40 41-50 51-60 61-70 71-80 >80

Age group (years)

Fig. 1: Age and sex distribution

45

40

35

30

~ 25

~ 20

~is

10

directblowor fullon theshoulder

MvA Sports injury

Type of mechanism

Fig. 2

Discussion

It is obviously not possible to report the incidence ofshoulder dislocation in a study of this nature but it ispossible to compare the findings with other studiesbased on the percentage of the patients in each study.Seventy five percent of the patients in this study weremales. Kr0ner et al6 reported only a slightpreponderance of male patients (53%) ~n Aa~hus,Denmark. In first time anterior shoulder dislocations,the male:female ratio found in this study (3:1) washigher than that reported by Simonet et af in OlmstedCounty, Minnesota (2:1).

The age distribution of the male patients in this studyshowed that the highest number was in the 21-30 yearsgroup, followed by those below 20 years. This wassimilar to that found by Simonet et al'. Kr0ner et a~

reported the greatest number in those aged below 20years followed by those aged between 20-29 years.The female patients were evenly distributed in each agegroup in this study whereas Kr0ner et a~ found thehighest number in patients aged below 20 years but thehighest incidence in the 61-80 years group. 20-25% ofprimary dislocations occur in patients over 60 years ofage'", and the female:male ratio in this age gro:rp w~s14:4 in Gumima and Postacchini's study". Patients In

this age group represented 13% of the dislocations, andthe female:male ratio was 9:4. Therefore, it appearsthat there are relatively more male patients than femalepatients in each group compared to Westernpopulation. One of the reasons may be the role oftraffic accidents as the causative factor in this injury.This accounted for 22% of the dislocations in this studybut only 3% in Simonet et at's study', and more ofteninvolved males than females.

22

This study has several limitations, one of which is thatwe were not able report the rate of recurrentdislocation in our population due to the large numberof patients who were lost to follow-up.

However, the severity of the initial trauma may alsoaffect the recurrence rate; the greater the initial trauma,the lower the recurrence rate but higher thecomplication rate'"". Therefore, the incidence ofrecurrence may be lower in our population.

The recurrence rate in athletes was reported to behigher than in non-athletes by Simonet and Cofield".However, using age-adjusted logistic regressionanalysis, Kralinger et aP3 reported that the correlationbetween sports and recurrence rate was false and thatthe only factor associated with recurrence was agebetween 21 and 30 years. Dislocations sustainedduring sporting activity accounted for only 5.3% of thepatients in this study, considerably lower than the 25%reported by Hovelius' and 47% reported by Simonet etal'. This difference is likely to be due to the lack ofand the types of sports popular in differentpopulations. The small number of sports relatedshoulder dislocations is thus unlikely to affect therecurrence rate in our patients significantly.

Fractures of the greater tuberosity was not found in anypatients who had recurrent dislocat~ons a~d th~ssupports Rowe's observation" that patients with thisassociated fracture have a lesser risk of recurrence. Inour study, the incidence of this fracture was highest inthe age-group 41-50 years. Hovelius et aP4 reportedthat these fractures were found in 30% of patients agedbetween 34-40 years and only 3% in patients between20-22 years.


In our study, the number of dislocations successfullyreduced without a general anaesthesia (95%) was veryhigh. Though it was 8% in Kr0ner et al's study' andSimonet et at reported that 4.5% of their patients fromwithin their cO\lnty and 15% of their referral patientsrequired a general anaesthesia, Vermeiren et aP5 on theother hand found that 43% of their non-recurrent groupand 26% of their recurrent group required a generalanaesthesia and it was 93.5% in patients aged over 60years in Gumima and Postacchini's study".

A disproportionate number of our patients hadassociated injuries and are likely to have continualdifficulties following their injury. Their outcome istherefore not representative of the series as a wholeand no conclusions can be drawn on the generaloutcome of shoulder dislocations.

Thirty-five percent of the patients in Vermeiren et at'sstudy" did not find it necessary or wished to havesurgery. Only two out of the 26 patients with recurrentdislocations seen during the study period agreed tohave a (Bristow's) stabilisation procedure performedand the rest declined surgery giving reasons such as

1. Kazar B, Relovszky E. Prognosis of primary dislocation ofthe shoulder. Acta Orthop Scand 1969; 40: 216-24.

2. Nordqvist A, Petersson C]. Incidence and causes ofshoulder girdle injuries in an urban population. J ShoulElbow Surg 1995; 4: 107-12.

3. Hovelius 1. Incidence of shoulder dislocation in Sweden.Clin Orthop 1982; 166: 127-31.

4. Rowe CR, Patel D, Southmayd WW. The BankartProcedure: A long term end-result study. J Bone JointSurg 1978; 63-A: 1-16.

5. Constant CR, Murley AGH. A clinical method offunctional assessment of the shoulder. Clin Orthop 1987:214: 160-4.

6. Kr0ner K, Lind T,Jensen]. The epidemiology of shoulderdislocations. Arch Orthop Trauma Surg 1989; 108: 288-90.

7. Simonet \VT, Melton JL, Cofield RH, Ilstrup DM. Incidenceof anterior shoulder dislocation in Olmsted County,Minnesota. Clin Orthop 1984; 186: 186-91.

8. Rowe CR. Prognosis in dislocations of the shoulder. JBone Joint Surg 1956; 38-A: 957-77.


The Epidemiology of Shoulder Dislocations in Malaysia

minimal discomfort or disability, financial constraints ornot being able to take time off from their work beingmostly self employed. Thus, it is the patient'ssubjective symptoms, of which pain is often the mostimportant factor to the patient, rather than the numberof dislocations, which will ultimately decide the needfor surgery.'

Conclusion

Shoulder dislocation is a common injury, which is seenmuch more often in males, especially in the 21-30 yearsage group. Male patients also tend to be younger thanfemales. Ninety eight percent of the dislocations wereanterior dislocations. Although the most commonmechanism of injury is a direct blow or fall onto theshoulder, motor vehicle accidents are a much moreimportant causative factor compared to the Westernpopulation. Almost all dislocations were reducedwithout a general anaesthesia with body strappingbeing the most common method of immobilisation.Few operations were performed for recurrent instabilityand surgery does not appear to be well accepted bymost of our patients.

9. Gumina S, Postacchini F. Anterior dislocation of theshoulder in elderly patients. J Bone Joint Surg 1997; 79-B:540-43.

10. Rowe CR, Sakellarides HT. Factors related to recurrencesof anterior dislocations of the shoulder. Clin Orthop 1961;20: 40-8.

11. Kiviluoto 0, Pasila M, Jaroma H, Sundholm A.Immobilization after primary dislocation of the shoulder.Acta Orthop Scand 1980; 51: 915-19.

12. Simonet Wf, Cofield RH. Prognosis in anterior shoulderdislocation. Am J Sports Med 1984; 12: 19-24.

13. Kralinger FS, Golser K, Wischatta R, Wambacher M,Sperner G. Predicting recurrence after primary anteriorshoulder dislocation. AmJ Sports Med 2002; 30: 116-20.

14. Hovelius L, Eriksson K, Fredin H, Hagberg G, HusseniusA, Lind B, Thorling J, Weckstrom]. Recurrences of initialdislocation of the shoulder: Results of a prospective studyof treatment. J Bone Joint Surg 1983; 65-A: 343-9.

23

ORIGINAL ARTICLE

Osteosarcoma: The Outcome of Limb SalvageSurgery

WI Faisham, M Med (Ortho), W Zulrni, MS (Ortho), A S Halim, FCCP, B M Biswal, MD (AIIMS) DNB,S S Mutum, MD (Path)

Musculoskeletal Oncology Unit, School of Medical Science, Universiti Sains Malaysia, Kubang Kerian, Kelantan

Introduction

Osteosarcoma is a primary malignant tumour derivedfrom primitive bone forming mesenchymal tissuewhich is characterized by the production of osteoid orimmature bone by the malignant proliferating spindlecells. Osteosarcoma is highly malignant and has atendency to metastasize to the lung. Osteosarcomamost commonly affects the adolescent and childhoodage group preferably around the knee region. Before1975, the treatment of osteosarcoma consisted mainlyof amputation with fewer than 20% of patientssurviving beyond five years". Majority of these patientsdeveloped distant metastases within the first 2 years oftreatmentw. The dramatic improvement in survival inthe last two decades had been mainly contributed bythe efficient chemotherapy to combat micro-metastases.The modern treatment programme is multimodal in

Submitted for publication: 01 May 2003

24

natures which include neoadjuvant chemotherapy,surgery to control local disease and other adjuvanttreatment". The five-year survival rate withmultidisciplinary approach varies from 60_70%4,13,15.

Multidisciplinary management of osteosarcoma hasbeen practiced in musculoskeletal oncology unit,HUSM since 1997, We would like to present our resultsof treatment of osteosarcoma affecting extremities, andprovide yet another perspective of the literature in theSouth-east Asia.


Twenty-three patients with histologically provenosteosarcoma were seen at our institution during aperiod of five years between June 1997 and January


Osteosarcoma: The Outcome of Limb Salvage Surgery

(Figure Ie, b) Distal femur osteosarcoma at presentation

(Figure 1(, d) Radiographs after three courses of neoadjuvant chemotherapy

Distal femur osteosarcoma with radiographic evidence of response toneoadjuvant chemotherapy. Mineralisation of soft tissue extension withcontainment and dear radiographic margin


ORIGINAL ARTIClE

28

Fig. 2: Patient with distal femur endepresthesis, he has full extension and 90°knee flexion and ambulating pain free. At present he survives for 3 yearswithout disease.


ORIGINAL ARTICLE

Survival Function1.1 ...-------------------,

1.0 '

.9'

.8'

.7

+

.6

+ Survival Functior

+ ++1+

10 20 30 40

months

Fig. 4: Actuarial Survival of 23 Patients with Osteosarcoma

Survival Functions1.2...--------------------,

1.0 '

.8'

.6'

.4 Operative

o s.2

+ S-censored

0.0 A

+ A-censored

70605040302010

-.2 -~-__._-~~-...__-~-__._--.,L

o

months

Fig. 5: Actuarial Survival of 23 Patients with Osteosarcoma Stratified by Treatment Group ofAmputation Versus Limb Salvage

30 Med J Malaysia Vol 59 Supplement F December 2004

Age Site STAGE Reconstruction Resection Necrosis Functional oukome Survival Status(Enneking) Method length Cm (%) &Complication (Months)

9 Distal Femur III AlloQraft 27 90 16 CDF25 Distal Femur liB Distal Femur Endoprosthesis & 26 90 30 CDF

Free lattismus dorsi Rap15 Proximal Humerus liB Total Humeral Endoprosthesis & 24 22 CDF

Rotational lattismus dorsi flap15 Distal Femur liB Total Femur Endoprosthesis & 10 62 CDF

Free lattismus dorsi flap15 Proximal Tibia III Proximal Tibia Endoprosthesis 17 34 CDF14 Proximal Humerus liB Allograft Prosthetic Composite & 13 90 9 DOD

Rotational lattismus dorsi flap PM17 Proximal Tibia liB Proximal Tibia Endoprosthesis 19 20 Recurrence at 15 months 18 DOD

PM17 Proximal Humerus liB Vascularised Fibular waft 15 50 30 CDF34 Distal Humerus liB Distal Humeral Endoprosthesis 17 70 30 CDF13 Distal Tibia liB Allograft vascularised fibula 90 24 DOD

composite PM18 Proximal Tibia liB Proximal Tibia Endoprosthesis 90 Metal allergic and 54 CDF

recurrence infection36 Illium liB Type II resection & Arthrodesis hip 16 38 CDF

to remcininq acetabulum23 Distal Femur liB Distal Femur Endoprosthesis 21 10 37 CDF16 Proximal Tibia liB Proximal Tibia Endoprosthesis 90 60 CDF16 Distal Humerus liB Allograft total elbow composite & 17 Allograft fracture- convert 36 CDF

Rotational latissmus dorsi flap to allofibular composites22 Proximal Tibia liB Proximal Tibia Endoprosthesis 20 10 20 DOD

PM

Table I: Limb Salvage in Osteosarcoma with Method of Reconstruction

oCDoCD30-~IVo~

CDF: Continuous disease free DOD: Died of disease PM: Pulmonary metastases

o~~no3o-l:::rCD

occ=ro3CD

Q..r-

3"0-

g'(§

coCDC/>c

cOCD

-.<

ORIGINAL ARTICLE

1. Bacci G, Picci P, Ferrari S, Avella M, Prever BA, RuggeieriP, Casadei R, Lari S, Manti C, Cazzola A. Neoadjuvantchemotherapy for non-metastastatic osteosarcoma of theextremities: the recent experience at the Rizzoli Institute.Cancer Treat. Res. 1993; 62: 299-308.

2. Bramwell VH, Burgers M, Sneath R, Souhami R, VanOosteron AT, Voute PA, Rouesse ], Spooner D, Craft AW,Somers R. A comparison of two short intensivechemotherapy regimens in osteosarcoma of limb inchildren and young adult: The study of the EuropeanOsteosarcoma Intergroup. J. Clin. Oncol. 1992; 10: 1579

91.

3. Cordiero PG, Neves RI, Hidalgo DA. The role of freetissue transfer following oncologic resection in the lowerextremity. Ann. Plast. Surg. 1994; 33: 9-16.

4. Chang HC, Pho RWH, Kumar VP, Kour AK. Extremityosteosarcoma - A Southeast Asian Experience. Ann. Acad.Med. Singapore 2002; 31: 598-606.

5. Enneking WF, Spanier SS, Goodman MA. A system for thesurgical staging of musculoskeletal sarcoma. Clin. Orthop.1980; 153: 106-120.

6. Huvos AG, Rosen G, Marcove RC. Primary osteogenicsarcoma, Pathological aspect in 20 patients aftertreatment with chemotherapy, en-bloc resection andprosthetic bone replacement. Arch. Pathol, Lab. Med.1977; 101: 14-18.

7. Kaplan EL, Meier P. Non-parametric estimation fromincomplete observations. J. Am. Stat. Assoc. 1958; 53:457-81.

8. Krag DN, Klein H, Schnider PD, Goodnight .IE. Compositetissue transfer in limb-salvage surgery. Arch. Surg. 1991.126: 639-41.

9. Link MP, Goorin AM, Miser AW, Green Ai"., Pratt CB,Belasca JB, Pritchard .I, Malpos .IS, Baker AR, Kirk PatrickJA. The effect of adjuvant chemotherapy on relapse freesurvival in patients with osteosarcoma of the extremity.N. Eng.]. Med. 1986; 314(25): 1600-6.

10. Ma LD. Magnetic resonance imaging of musculoskeletaltumours skeletal and soft tissue masses. Curr. Probl.Diagn. Radiol 1999; 28: 29-62.

34

11. Mankin H]. Gebhardt 1v[C, Jennings LS, Springfield DS,Tomford W"\X!. term results of allograft replacementin the management of bone tumours. Clin. Orthop. 1996;324: 86-97.

12. Mastorakos D. Athanasian E, Boland P, Healey ]H,Cordeiro PG. Soft tissue flap coverage maximizes limb

after bone extremity reconstruction. PlastReconstr Surg 2002; 109(5): 1567-73.

13. Ogihara Y, Sudo A, Fujinami S, Sato K, Miura T. Currentmanagement, local management and survival statistic of

osteosarcoma. Experience in Japan. Clin.; 270: 72-78.

14. Rosen G, B, Huvos AG, Koslott C, Nirenberg A,Cacavia A, Marcove RC, Lane .TM, Mehta B, Urban C.Preoperative chemotherapy for osteogenic sarcoma:selection of adjuvant chemotherapy basedon the response of the tumour to preoperativechemotherapy. Cancer 1982; 49: 1221-1230.

15. BT. Simon MA., Kneisl]S, Greenberg DB, MankinH]. Limb treatment compared with amputationfor osteosarcoma of the distal end of the femur. A Longterm oncological, functional, and quality-of-life study. ].Bone Surg. 76A: 649-56.

16. Shin D. Choong PFM, Choa EY, Sim FH. Large tumourand extracortical bone bridging: 28

patients followed 10-20 years. Acta Orthop. Scand. 2000;71: 305-11.

17. Simon MA, Aschliman MA, Thomas N, Mankin H]. Limbtreatment versus amputation for osteosarcoma of

the distal femur J. Bone Joint Surg. 1986; 68A: 1331-37.

18. Souhami RL, Craft AW, Van cler Eijken .TW, Nooij M,Spooner D, Bromwell Wierzbicki R, Malcom AJ,Kirkpatrick A, Vsoinska BM, Van Glabbeke M, Machin D.Randomised trial of two regimens of chemotherapy inoperable osteosarcoma. A study of the EuropeanOsteosarcoma Intergroup. Lancet 1997; 350: 900-901.

19. Sweetnam R, Knowelden .I, Seddon H. Bone sarcoma:treatment irradiation amputation, or a combination ofthe two. Br. Med. J. 1971; 2(758): 363-67.

20. KMH, Leung PC, Kurnta SM. Osteosarcoma in HongKong. Clin. Orthop. 1996; 323: 49-59.


ORIGINAL ARTICLE

Early Complication Following Long Bone ReconstructionUsing Vascularised Fibula Graft

Y Imran, MD, M Med (Ortho)", W Zulmi, MBBS, MS (Ortho)", A S Halim, MD, FCCP**

*Department of Orthopaedics, *'Department of Surgery, School of Medical Science, Universiti Sains Malaysia, Kubang Kerian, Kelantan

Introduction

Skeletal defects following trauma or bone tumourresections may be successfully treated by conventionalbone grafting or bone transport. However for massivedefect following reconstruction may be morechallenging. Taylor first reported the successful use ofvascularized fibular graft for the reconstruction of atibial defect in 19751

• This is followed by other reportsdealing with various indicationsv-'-'. In Malaysia, theuse of vascularized fibular grafting for the managementof massive bone loss has not been reported. In thisstudy, we reviewed a total number of thirteen patientsinvolved in the reconstruction of the limbs using thisrelatively new technique and identified the earlycomplications encountered.


This is a retrospective study of thirteen patients whohad undergone long bone reconstruction usingvascularized fibula graft in our hospital following

Submitted for publication: May 2003


massive resection of diseased bones. The patients wereoperated between January 1997 to May 2000 (period of29 months). They were followed up for at least 6months for the evaluation of early complications.Indications for skeletal reconstruction are summarizedin Table I.

Surgical techniqueWe followed technique for harvesting free vascularizedfibular grafting described by Weiland6. The procedurewas performed with the patient supine, donor kneeflexed approximately 135 degrees under tourniquetcontrol. A straight lateral skin incision made along thefibula extending from the neck distally down to thefascia overlying the peroneus longus muscle.

The interval between the peroneus longus and soleusmuscles identified and the deep fascia was incisedalong this interval. Then, the peroneus longus andsoleus muscles are reflected from the fibular diaphysis.Perforating vessels to the skin lying immediatelyposterior to the fascia and overlying the soleus musclewere preserved in our patients.

35

ORIGINAL ARTICLE

procedure. Review of our early series suggest thatvascularized fibula grafting is relatively safe and

1. Taylor GI. The free vascularized bone graft. A clinicalextension of microvascular techniques. Plast ReconstrSurg 1975; 55: 533-44.

2. Weiland AJ, Moore JR, Daniel K. Vascularized boneautografts. Experience with 41 cases. Clin Orthop 1983;174: 87-95.

3. Harrison DH . The osteo cutaneous free fibular graft. JBone Joint Surg Br 1986; 68: 804-7.

4. Jupiter JB, Gerhard HJ, Guerrero J, Nunley JA, Levin LS.Treatment of segmental defects of the radius with use ofthe vascularized osteocutaneous fibular autogenous graft.J Bone Joint Surg Am 1997; 79: 542-50.

5. De Boer HH, Wood MB. Bone changes in thevascularized fibular graft. J Bone Joint Surg Br 1989; 71:374-78.

6. Weiland AJ. Vascularized free bone transplants. J BoneJoint Surg Am 1981; 63: 166-69.

38

effective to treat various common orthopaedicconditions especially massive musculoskeletal tumor.

7. Mankin HJ, Doppelt S, Tomford W. Clinical experiencewith allograft implantation. The first ten years. ClinOrthop 1983; 174: 69-86.

8. Moore JR, Weiland AJ. Free vascularized bone and muscleflaps for osteomyelitis. Orthopedics 1986; 9: 819-24.

9. Brooks JSJ, Freeman M, Enterline HT. Malignant "triton"tumors.Natural history and immunohistochemistry of ninenew cases with literature review. Cancer 1985; 55: 2543-49.

10. Lee EH, Goh CJH, Helm R, Pho RWH. Donor sitemorbidity following resection of the fibula. J Bone JointSurg Br 1990; 72: 129-31.

11. Robbins S, Bailey BN. Correspondence. Resection of thefibula. J Bone Joint Surg Br 1989; 73: 352.

12. Hsu RWW, Wood MB, Sim FH, Chao EYS. Freevascularized fibular grafting for reconstruction after tumorresection. J Bone Joint Surg Br 1997; 79: 36-42.


INNOVATION ARTICLE

Treatment for Flexion Contracture of the KneeDuring lIizarov Reconstruction of Tibia with PassiveKnee Extension Splint

M K Kwan, MS (Ortho), R Penafort, MS (Ortho), A Saw, FRCS

Department of Orthopaedic Surgery, University Malaya Medical Center, Kuala Lumpur

Introduction

Ilizarov method is one of the most widely usedprocedures for bone lengthening since its worldwideintroduction in 1981. This procedure has improved theability to treat complex deformities that previouslywere either impossible or difficult to correct. However,it has a steep learning curve! and is associated with arather high rate of various complications 1,2,3,4. Jointcontractures may develop due to excessive muscle pullor joint capsular contracture 3,4. Intensive physiotherapyis essential to prevent joint contracture but occasionallyit is not performed adequately due to problems relatedto lack of facilities, transportation or cost.

We encountered 4 paediatric patients who developedflexion contractures of their knees during treatment forcongenital abnormalities of tibia with Ilizarov external

Submitted for publication: 31 January 2003


fixator. They stayed far from our institution with nolocal facility of physiotherapy available. In view of thislimitation, we developed a splint from components ofIlizarov external fixator that can be attached to theexisting fixator frame. A posterior support for the thighwas connected to the tibia frame with two hinges thatallowed knee movement at its axis of rotation (Figure1). A handle was extended anteriorly from the existingtibia frame to allow manipulation of the knee joint(Figure 2). With this device, patients themselves wereencouraged to passively extend the knee joint bypulling the handle. They were asked to immobilize thesplint with the knee in extension during the night. Weare reporting the positive outcome of this procedureand would also like to recommend its use for treatmentor prevention of this complication.

39

INNOVATION ARTICLE

Case Summary

CaselTTS, a 4-year-old Chinese boy with left fibularhemimelia was treated for 6cm tibial shortening andequinus deformity of the ankle. Ilizarov externalfixator was applied over the left leg extending acrossthe ankle joint. Gradual distraction was completed 4months after initiation of treatment with 8.4cm increasein tibial length. The knee however, developed fixedflexion deformity of 65°. The passive extension splintwas applied with the instruction to exercise the knee 4times a day and to keep the knee as straight as possibleduring the night. After 6 weeks, the flexion deformitywas reduced to 20°. The Ilizarov rings were removedafter a total duration of 10 months.

Case 2AHA, an 8-year-old Malay boy with neurofibromatosiswas referred for pseudoarthrosis of right tibia resultingfrom a fracture 3 months earlier. Resection of thepseudoarthrosis with acute docking, fibular osteotomyand lengthening of proximal tibial segment wasperformed with Ilizarov external fixator. After 2months of distraction, a 4.8cm lengthening wasachieved. At this stage, unfortunately, the knee wasfound to have developed 35° of flexion deformity. Thepassive knee extension splint was applied and 7 weekslater the affected knee can be extended fully. TheIlizarov frame was eventually removed after a totalduration of 7 months

Case 3WHY, a 7-year-old Chinese girl with neurofibromatosis,was presented with pseudoarthrosis of left tibia. Shewas treated with non-vascularized fibula grafting 3years earlier without success. Excision ofpseudoarthrosis and bone transport were performed,followed by lengthening of the affected bone. 9.8 cmof total lengthening was achieved after 5 months anddistraction was stopped. Patient did not attendphysiotherapy regularly. The knee developed severestiffness allowing only 65° to 1200 of motion. Thepassive extension knee splint was applied at that stageand contracture gradually improved. The frame waseventually removed 12 months after application withonly 20 degrees of flexion contracture remaining.

Case 4MM is a 5-year-old Indian girl, also withpseudoarthrosis of tibia due to neurofibromatosis. Shewas treated with Ilizarov external fixation at the age of3 but failed to achieve union. On the secondoperation, she underwent resection of pseudoarthrosisand bone transport followed by lengthening of her lefttibia. 7.5cm of lengthening was achieved butdeveloped 55° of fixed flexion contracture. Passiveknee extension splint was applied and contractureimproved to 20° after 6 weeks of treatment. The framewas removed 10 months after application with fullextension of the affected knee.

Fig. 1:

40

The 'Passive Knee Extension Splint' wasmounted on the existing IIizarovexternal fixator of the tibia through twohinged joints. The extension handle wasseen projecting in front and theposterior support was noted over theposterior aspect of the thigh

Fig. 2: The patient was performing exerciseby pressing on the extension handle


Treatment for Flexion Contracture of the Knee During lIizarov Reconstruction of Tibia with Passive Knee Extension Splint

Discussion

Knee t1exion contracture develops as a result ofimbalance in the tension generated by thigh and calfmuscles. The soleus-gastrocnemius-archiles complexoffers the greatest resistance to lengthening of the tibiadue to the large muscle bulk, causing t1exion of theknee and plantart1exion of the ankle 3. Connectivetissues around a joint also tend to shorten if they arenot stretched regularly, resulting in restricted range ofjoint movement. In addition to the above property, thecollagenous connective tissue shows features ofplasticity - it slowly elongates under moderate tension 5.

Stretching methods are best when they incorporate lowlevels of force over longer periods; a mild stretch forthroughout the day is more effective than five minutesof heavy stretching. The longest period of low forcestretch produces the greatest amount of permanentelongation, with least amount of trauma and structuralweakening of the connective tissue 5,6.

The passive knee extension splint allows the patients ortheir parents to determine the exact force to be applied.They were advised to adhere to the minimal frequencyand duration of the exercise at home, graduallyincreasing the frequency and duration when pain wasmore tolerable. In most patients, an average correctionof more than 30° knee t1exion was achieved after about

1. Dahl MT, Gulli B. Berg T. Complications of limblengthening. A learning curve. Clinical Orthopaedics andRelated Research. 1994; 301: 10-18.

2. Wagner. H. Operative lengthening of the femur. ClinicalOrthopaedics and Related Research. 1978; 136: 125.

3. Paley D. Problems, obstacles, and complications of limblengthening by the Ilizarov technique. ClinicalOrthopaedics and Related Research. 1990; 250: 181-104.

4. Coleman 55, Scott SM. The present attitude toward thebiology and technology of limb lengthening. ClinicalOrthopaedics and Related Research. 1991; 264: 76-83.

5. Hepburn GR. Case studies: Contracture and stiff jointmanagement with Dynasplint. The Journal ofOrthopaedic and Sports Physical Therapy. 1987; 8: 498504.


6 weeks of manipulation. Although completecorrection was not achieved in three out of the fourpatients at the end of 6 weeks, we noticed that thedeformity will further improve over a period of time byapplying the passive knee extension splint. At the endof an average of 6 months of application of this splint,a complete correction was achieved in three cases.Only the third case still had 20 degrees of t1exioncontracture but full correction was eventually achievedafter removal of the frame.

Knee contracture during Ilizarov bone lengtheningprocedures can be prevented or corrected by extendingthe frame across the joint, but this involves fixation ofunaffected femur and restricting the mobility of theaffected the knee joint". Dynasplint' is an orthosis thatcan produce extension force for the knee joint, but thisapparatus requires accurate setting and is ratherexpensive.

Passive Knee Extension Splint is an effective mode oftreatment for patients who develop significant t1exioncontractures of the knee during lengthening of the tibia.It should also be considered as a prophylactic measurefor patients who do not have easy access to facilities ofphysical therapy. Physical therapy is still the main stayfor the prevention of the contracture deformity duringthe Ilizarov reconstruction of the tibia.

6. Kottke FJ, Pauley DL, Ptak RA. The rationale forprolonged stretching for correction of shortening ofconnective tissue. Archieves of Physical, Medicine &

Rehabilitation. 1996: 345-52.

7. Lehman WB, Grant AD, Atar D. Preventing andovercoming equines contractures during lengthening ofthe tibia. Orthopaedic Clinics of North America. 1991; 22:633-41.

8. Van Roermund PM, van Valburg AA, Duivemann E, vanMelkebeek J, Lafeber FPJG, Bijilsma JWJ, Verbout A].Function of stiff joints may be restored by Ilizarov jointdistraction. Clinical Orthopaedics and Related Research.1998; 348: 220-27.

41

INNOVATION ARTICLE

Versatility of the Latissimus Dorsi Flap in Upper LimbSalvage Tumour Surgery

A A Dorai, MBBS, A S Halim, FCCP, W Zulmi, M Med (Ortho)

Reconstructive Sciences Unit, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan

Introduction

The latissimus dorsi flap was first introduced by Tansiniin 1896. It can be used either as a pedicle or a freeflap. Bostwick et al has clearly demonstrated thevarious arcs of rotation of the latissimus dorsi flap',With the wide anterior arc of rotation, coverage of thelower lateral abdominal wall, chest wall, axilla, neckand lower half of the face can be accomplished. Theposterior arc of rotation allows coverage of the entirespine, shoulder region and posterior part of the neck.The third arc of rotation is the lateral arc of rotation,when defects of the upper limb can be covered bytunneling the latissimus dorsi muscle or themusculocutaneous unit through a subcutaneous tunnelcreated in the axilla. Hence coverage of the shoulder,upper arm, elbow and the proximal part of the forearmcan be accomplished. It also has the advantage ofbeing used as a functional muscle transfer wherebyelbow flexion and extension can be achieved".


42


Between 1998 and 2002, eleven patients underwentreconstructive surgery using the latissimus dorsimyocutaneous flap for upper limb salvage tumoursurgery. They were divided into two groups accordingto the type of transfer either pedicle or free transfer. Allpatients had an open biopsy to confirm the type oftumour. Pre -operative MRI was done to assess theextent and spread of the tumour. CT scan of the chestand bone scan was done to check for any evidence ofdistant metastasis.

Group 1:Eight patients underwent pedicled latissimus dorsimyocutaneous flaps after wide resection of the tumour(Table I). The mean age at time of operation was 27.1 year (range 12-54 years). This group of patients hadsignificant soft tissue deficiency after wide tumourresection over the upper arm and elbow region. Fourpatients had osteosarcoma, two had chondrosarcoma,


INNOVATION ARTICLE

1. Bostwick J 3rd, Nahai F, Wallace JG, Vasconez LO. Sixtylatissimus dorsi flaps. Plast Reconstr Surg 1979; 63(1): 3141.

2. O'Connor M, Jacksonville F, Sim F H, Chao E y'S,Rochester M. Limb salvage for neoplasms of the shouldergirdle. Immediate reconstructive and functional results. JBone Joint Surgery (Am) 1996; 78-A (12): 1872-88.

3. Minami A, Ogino T, Ohnishi N, Itoga H. The latissimusdorsi musculocutaneous flap for extremity reconstructionin orthopedic surgery. Clin Ortho 1990; (260): 201-6.

4. Elliot LF, Raffel B, Wade J. Segmental latissimus dorsi freeflap: clinical applications. Ann Plast Surg 1989; 23(3): 2318.

46

5. Mordick TG 2nd, Britton EN, Brantigan C. Pedicledlatissimus dorsi transfer for immediate soft tissue

COjf. .rage and elbow flexion. Plast Reconstr Surg 1997;99(b) : 1742-4.

6. Chang LD, Goldberg NH, Chang B, SpenceR. Elbowdefect coverage with a one staged, tunneled latissimusdorsi transposition flap. Ann Plast Surg 1994; 32(5): 496502.

7. Heiner J, Rao V, Mott W. Immediate free tissue transfer fordistal musculoskeletal neoplasms. Ann Plast Surg 1993;30(2): 140-6.

8. Germann G, Bickert B, Steinau H.D, Wagner H, SauerbierM. Versatility and Reliability of Combined Flaps of theScapular System. Plast Reconstr Surg 1999; 103(5): 1386

99.


INNOVATION ARTICLE

A Modified Method of Traction for Young Childrenwith Congenital Dislocation of the Hip as aPreliminary to Reduction

K L Pan, FRCS, H Rasit, MS (Ortho)

Department of Orthopaedics, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Sarawak General Hospital,Kuching

Case Report

A six-month old female infant presented with congenitaldislocation of the right hip. She was admitted to thepaediatric orthopaedic ward for initial traction, using asplit Russell's traction. However, with this traction, itwas difficult for the child to maintain her position. Shewould often be pulled to the end of the bed or turnherself into a prone position, causing the ropes to beentangled. She was generally irritable and had difficultyin sleeping. Her mother had to remove parts of thetraction in order to "hand-rock" her to sleep or to feedher until the mother took it on herself to lie the baby ona rocker-bed with a soft netting, with the tractionapparatus still on (Fig 1). It was found that this solvedthe problems faced previously to a considerable extent.Baby was able to complete two weeks of tractionfollowed by reduction, arthrogram and castimmobilisation under general anaesthesia.

Discussion

The use of preliminary traction for the management ofneglected developmental dislocation of hip is

Submitted for publication: 26 June 2002


Fig 1: Modified traction on a rocker bed

controversial. In a recently published paper byLangenskiold' a study was made on prereductiontraction as a single variable during closed treatment ofdevelopmental dislocation of the hip in children aged6-48 months. Thirty-three hips were reduced withoutpreliminary traction and 65 hips after traction. At amean follow-up of 11 years, it was found that the group

47

INNOVATION ARTICLE

with traction had significantly better results statisticallyin relation to the incidence of avascular necrosis of thefemoral head.

Various methods of traction have been used. It may bein the form of overhead Bryant's traction, split Russell'straction with the hip in semiflexion, straight Buck'sunilateral traction, or skeletal traction with a threadedpin through the distal femur, depending on the age ofthe child.

Split Russell's traction, with the hips flexed 30 to 60degrees and the knees flexed 20 to 30 degrees, is thetype recommended by Tachdjian-. Traction with thehips in complete extension will cause compression ofthe hip capsule by the taut iliopsoas tendon and,therefore, may interfere with the blood supply to thefemoral head. The purpose of traction is to elongate theshortened pelvifemoral muscles; traction applied withthe hips in 90 degrees of flexion will not stretch the hipflexors (especially the iliopsoas) and the hip adductors.It is thus recommended that the hips should be insemiflexed position of 45 degrees (with a range from 30to 60 degrees) and gradually abducted.

In this patient, we have added on a rocker bed to thesplit Russell's traction. It prevents the patient from

1. Langenskiold A, Paavilainen T. The effect of prereductiontraction on the results of closed reduction ofdevelopmental dislocation of the hip. J Pediatr Orthop,2000; 20(4): 471-74.

48

being pulled down and makes it more difficult for himor her to turn over into a prone position. Parents areable to "rock" the child at any time without having toremove the traction. We have found that this simplemodification has reduced the child's irritability andincreased the compliance to longer periods of traction.This rocker bed is easily available up to 2 years of ageand culturally acceptable in this part of the world.

Editor's Note: Editor agrees with the reviewer thatalthough innovative, the method of traction describedis of limited value due to:1. Rocker bed can only accommodate a small toddler

up to about two years of age.2. The amount of traction on a rocker bed may be

difficult to quantify and vary when rocked.3. It will be important to ensure at all times that the

child's buttock is not resting on the bed.4. As the rocker bed cannot be tilted, no counter

traction is available. Limb cannot be graduallyabducted.

5. Finally, child's initial irritability or reluctance is nota problem in traditional skin traction. Being adynamic traction, desirable force is constantlyapplied across the joint and twisting and turning inbed does not matter.

2. Tachdjian MO. Pediatric Orthopedics (2nd ed.) W.B.Saunders Company, 1990; 342-3.


CASE REPORT

Ossifying Fibromyxoid Tumour in a Child

C A Aminudin, MS (Ortho)", I Sharaf, FRCS**, A H Hamzaini, MBBCh***, A Salmi, MBBS****, M A SitiAishah, DCP****

"Department of Orthopaedics, Traumatology & Rehabilitation, Kulliyyah of Medicine, International Islamic University of Malaysia,Kuantan, Pahang, **Department of Orthopaedics and Traumatology, ***Depaltment of Radiology, *'*'Department of Pathology,Hospital Universiti Kebangsaan Malaysia, Kuala Lumpur

Case Report

A five-year-old girl presented in August 2001 with apainless, gradually enlarging mass in the right thigh forone year. It had progressively enlarged from a verysmall swelling to the size of a tennis ball by the time ofher first visit to our clinic. The mass did not disturb herdaily activities. Physical examination revealed a firm tohard mass at the anterior aspect of the right upperthigh, measuring approximately LOcm in diameter. Itwas well demarcated, mobile with a lobulated surface.The mass was not attached to the overlying skin.

On plain radiograph, there was an irregular "pop-corn"soft tissue calcification overlying the proximal part ofthe right femur. The underlying bone and adjacent hipjoint were normal and there was no periosteal reaction(Figure 1). Axial computed tomography (CT) scanshowed a well-defined mass with centrally locateddense calcification. The mass did not appear to arisefrom either the muscles or the neurovascular bundlebut it displaced these structures medially. Theunderlying bone and joint space were normal. Themass was isointense to the surrounding muscles withlow signal areas of mineralization in the centre on T1weighted Magnetic Resonance (MR) images,gadolinium-enhanced images showed considerableperipheral enhancement. The T2 weighted axial MRimages showed an inhomogenous high signal intensity



mass which was surrounded by a low signal capsule(Figure 2).

A tru-cut biopsy revealed a benign fibrous lesion. Themass was excised subsequently and sent for biopsy.The mass was located between the vastus lateralis andrectus femoris, deep to the sartorius muscle. Thefemoral neurovascular bundle was displaced medially.On gross examination, the lesion measured 10 x 7cm.It was well circumscribed, well encapsulated and firmto hard in consistency. Cut section showed a diffusewhitish whorled-like appearance with calcifiedmaterial. The tumour was found to be encapsulatedwith a fibrous capsule on histological examination.There were extensive areas of ossification with lobulesof mvxoid degeneration (Figure 3). The tumour cellswere' arranged in interlacing fascicles and hadeosinophilic cytoplasm with indistinct margins. Thecells within the myxoid areas were stellate in shape.Scattered mast cells were present. There was noevidence of malignancy. Immunohistochemically,these cells were positive for 5-100 protein, vimentinand desmin, but negative for smooth muscle actin.These findings suggested the diagnosis of an ossifyingfibromyxoid tumour of soft tissues.

At one year after surgery, our patient had no evidenceof recurrence, but longer period of follow up isawaited.

49

CASE REPORT

Fig 1: The plain radiograph shows "popcern" soft tissue calcification (arrow)

50

Fig 2: T2 weighted axial Magnetic Resonance(MR) image shows inhomogenous highsignal intensity mass which issurrounded by a thin low signalfibrous capsule (arrow)

Fig 3: Ossification centers with surroundingspindle cells (Haematoxylin & Eosin X20)

Med J Malaysia 59 Supplement F December 2004

Discussion

Ossifying fibromyxoid tumour is a rare tumour of softtissue. This lesion was first described by Enzinger et. al.'in 1989. In his review of 59 patients, this tumour almostexclusively affected adults (ranging from 14 to 79 yearsof age) and had a male predominance. To the best ofour knowledge, this patient is the youngest case ofOFMT reported in the English literature. Essentially abenign condition it usually occurs as a small, painless,well circumscribed mass in subcutaneous tissue ormuscle, mainly in the extremities (68%), and lessfrequently elsewhere.

Matsumoto et. al.' described OFMT as wellcircumscribed lesion, with thick collagenous fibrouscapsules composed of uniform-sized fusiform cells witheosinophilic cytoplasm and a round or oval nucleus ina myxoid matrix. In addition, an incomplete shell ofmature bone with lamellar structure was also observed.The proliferating cells in the tumour positively stainedfor vimentin, S-100 protein, neuron specific enolase andsynaptophysin. Although the histogenesis is uncertain,cartilaginous or neural origin seems to be most likely.

1. Enzinger FM, Weiss SW, Liang Cy' Ossifying fibrornyxoidtumor of soft parts: a clinicopathological analysis of 59cases. Am J Surg Pathol 1989; 13: 817-27.

2. Matsumoto K, Yamamoto T, Min W, Yamada N, Asano G,Moriyama M, Matsumo T. Ossifying fibromyxoid tumor ofsoft part: clinicopathological, immunohistochemical andultrastructural study of four cases. Pathol International1999; 49(8): 742-46.


Ossifying Fibromyxoid Tumour in a Child

Kilpatrick et. al.' however highlighted the presence ofcentrally placed osteoid, increased cellularity andincreased mitotic activity as the atypical and malignantvariant of this tumour. \Ve consider our case as theatypical variant in view of the centrally placed osteoid.While considered benign, local recurrence after excisionis common and this tumour should be excised with aclear margin to prevent recurrence. Follow up of 41 outof 59 cases in Enzinger's series, 11 patients (27%) hadone or more recurrences.

Acknowledgements

We would like to thank the experts from TelepathologyConsultation Center, Union Internationale Contre LeCancer (DICC), Geneva, Switzerland for their expertopinion; and Dr. Mohd Azlan Aziz and Mr. Rosli Nasir ofUniversiti Kebangsaan Malaysia for the preparation ofthe photographs.

3. Kilpatrick SE, Ward WG, Mozes M, Miettinen M,Fukunaga M, Fletcher CDM. Atypical and MalignantVariants of Ossifying Fibromyxoid Tumour. Am J Surg.Pathol 1995; 19(9): 1039-46.

51

CASE REPORT

Sleeve Fracture of the Patella in a Child

A H Rasit, MS (Ortho)", I Sharaf, MS (Ortho)**, K L Pan, MS (Ortho)"

"Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Kuching, Sarawak, **Department of Orthopaedics andTraumatology, Universiti Kebangsaan Malaysia, Kuala Lumpur

Case Report

An eleven-year-old boy presented with a history of afall while playing football and landed on his knee. Hewas brought to a nearby hospital and treated as a rightknee haemarthrosis before being seen in our hospitalsix weeks later.

Local examination showed on examination the rightknee was found to be held in extension with only 10degrees of passive flexion possible. There was atrophyof the quadriceps muscle with a large gap palpable atthe lower end of the patella. Radiographs showedpatella positioned proximally with a large patch ofossification at the inferior pole of the patella. Thisappeared as an avulsion fracture of the tibial tuberosity.(Figure 1)

At surgery, it was noted that a large portion of thecartilage of the lower pole of the patella together witha small fragment of bone were avulsed. The gap wasfilled with fibrous and ossified tissue. Afterdebridement, the avulsed fragment was reduced andfixed with a tension band and circumferential wire. Asthe avulsed fragment was small, fixation wasinadequate; a cylinder cast was applied with the kneein full extension. Static quadriceps and straight legraising exercises were gradually introduced. Fiveweeks later the cast was removed and active kneeflexion was started. (Figure 2)


52

Eight weeks post-surgery, he had regained full range ofmotion of his knee and had good quadriceps power.He was able to walk normally at four months. Theimplants were removed after ten months when healinghad been achieved.

Fig. 1


Fig. 2

Discussion

Sleeve fracture of the patella is defined as an extensivesleeve of cartilage that is pulled off the main body ofthe bony patella, together with a bony fragment fromthe distal pole. This is an uncommon type of fracturein children. Because of its rarity, sleeve fracture of thepatella has received little attention and very few reportshave been found in the literature 1,2.

Sleeve fractures are classified as superior, inferior,medial or lateral. A sleeve fracture of the inferior poleof the patella results from an indirect injury: powerfulcontraction of the quadriceps muscle while the knee isflexed.

Houghton and Ackroyd 2 described the relationshipbetween high jumping and lower pole sleeve fractureswith the same mechanism of injury. This uncommonfracture usually occurs in children who participate in

!IIII

1. Heckman ]D, Alkire CC: Distal patellar pole fractures, aproposed common mechanism of injury. Am] Sports Med1984; 12: 424-28.

2. Houghton GR, Ackroyd CE: Sleeve fractures of the patellain children.] Bone Joint Surg 1979; 61B: 165-68.


Sleeve Fracture of the Patella in a Child

sports activities that require forceful extension of theknee; with the quadriceps contracting againstresistance.

The diagnosis of an avulsion or a sleeve fracture of thepatella is suggested by a history of sudden pain andgiving-way of the knee and difficulty in bearing weighton the extremity. The knee is usually swollen andtender and there is haemarthrosis. Active extension ofthe knee may be difficult or impossible, especiallyagainst resistance. The patella may be displacedproximally and a gap in the extensor mechanism maybe palpable 23.

The diagnosis may be missed or delayed because of thepainful swelling and tense haernarthrosis, masking thegap in the extensor mechanism. The fragment ofavulsed bone is also often too small to be detectedradiologically in the younger child.

The avulsed patellar fragment always includes animportant "sleeve" of cartilage and this must beaccurately reduced in order to re-establish the articularsurface of the patella. Accurate reduction, along withrigid internal fixation and repair of the extensorapparatus, is the key to regaining a properlyfunctioning knee. Conservative management, alongwith splinting the knee in full extension, could lead torestoration of the extensor mechanism, but may alsoresult in irregularity of the patellar articular surface anda limited range of motion. In our patient, activemovement was encouraged immediately after removingthe cast and full range of movement of the knee wasrestored after two months.

Acknowledgements

We are grateful to thank Mr Zamri Bujang forpreparation of the illustrations.

3. Grogan, D. P.; Carey, T. P.; Leffers, D.; and Ogden, J. A.:

Avulsion fractures of the patella. J. Pediat. Orthop 1990;10: 721-30.

53

CASE REPORT

The Rusty Knee .... Pigmented Villonodular Synovitis

o Samsudin, MS (Ortho), K K Leong, FRCS, M H Shukur, MS (Ortho), K K Tan, MS (Ortho), S Ismail, MBBS

Department of Orthopaedics and Traumatology, Hospital Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

Case Report

A 36 year-old lady presented with history of recurrentright knee swelling and pain preceding a fall sustainedfive years earlier. She was initially presumed to have asimple hemarthrosis as preliminary radiograph failed todepict any bony lesion, and arthrocentesis of the kneemerely confirmed the presence of what was describedas hemarthrosis by a junior house officer. Her progresshowever, was complicated with episodic flare-ups ofswelling and pain affecting the same knee. Each flareup responded well to brief rest and NSAID therapy butpersisted over the last 6 months. She had neitherhistory of contact with patients with tuberculosis normultiple joint pains associated with morning stiffness.Her general health was not altered. There was nohistory of bleeding tendency in her family.

Examination revealed a grossly swollen right knee andquadriceps wasting. Fullness of both suprapatellarpouch and popliteal fossa was obvious. There wasmoderate effusion of the affected knee with finecrepitus felt over the suprapatellar pouch. Allligaments and both menisci of the knee were clinicallyintact. Active and passive range of motions of the kneewas almost full.

Laboratory investigations including TWC, ESR, and C reactive protein were essentially normal. Rheumatoid


54

Factor was negative. Radiographs of the right kneeshowed normal bony anatomy and joint spaces withoutperiarticular osteopenia or erosion. There wasdisplacement of capsular shadow caused by distensiondue to either soft tissue mass or effusion in the anteriorcompartment of the knee. MRI displayed low Signalintensity masses in the joint with effusion on both Tland T2 weighted images (Figure 1). On performing adiagnostic arthroscopy; the synovial fluid was noted tobe rusty brownish-red in colour. The synovium wascharacterized by clusters of rusty brownish lookingplump synovial villi (Figure 2) and encapsulatednodular lesions. The articular cartilage and menisciwere otherwise normal. Synovial biopsy was taken anda preliminary diagnosis of diffuse PVNS washistopathologically confirmed by evidences of clustersof hyperplastic synovial villi and subsynovialproliferation of mononuclear fibroblasts and histiocyteswith occasional multinucleated giant cells displayed ashemosiderin-ladden macrophages and fat-laden foamcells, and abundant collagen deposition.

Arthroscopic-assisted synovectomy using Ogilvie-Harris6-portal technique was performed under spinalanaesthesia and exsanguinous tourniquet. Thetechnique allows thorough excision of synovial tissuein the suprapatellar pouch, anterior and posteriorcompartments of the knee. By using PCA (patientcontrolled analgesia) to alleviate pain, early active


CASE REPORT

pathologic lesion appears as poorly delineated clustersof plump synovial villi and small encapsulated nodules.Brownish and yellowish pigmentation depends on theamount of hemosiderin deposition from microscopichaemorrhages and the number of foam cells (lipidladen macrophages) respectively. The hallmarkshistopathological features of PVNS include subsynovialcircumscribed nodule consisting polyclonalproliferation of fibroblasts and histiocytes interminglingwith variable number of multinucleated giant cells.

The treatment of PVNS is surgical synovectomy.Unfortunately the disease tends to recur in up to 33%of cases 1 in nodular type and up to 45% in diffusetypes'. Arthroscopic-assisted synovectomy using 6portal technique of Ogilvie-Harris' has made totalsynovectomy possible, but recurrent rate of 50%following arthroscopic synovectomy has been

reported', Total synovectomy is commonly associatedwith post-operative joint stiffness. This is true in casewhere open synovectomy is performed. Witharthroscopic-assisted total synovectomy, earlyrehabilitation is possible and operative stiffness is nolonger a problem.

Conclusion

Despite its rarity and diagnostic difficulty, PVNS is nowa well-recognised entity representing a spectrum ofbenign polyclonal proliferative synovial disease withpropensity to recur after inadequate resection. PVNSshould be considered in the differential diagnosis ofyoung patients with insidious onset of unexplainedpain, stiffness or recurrent effusion affecting a singlemajor joint.

II II If! I J IIi! Ii IIIIIIII

1. Granowitz SP, Mankin HJ. Localized pigmentedvillododular synovitis. Report of five cases. J. Bone JointSurg. 1967; 49-A (1): 122-8.

2. Flandry F, HughstonJC, McCann SB. Diagnostic Featuresof diffuse pigmented villionodular synovitis of the knee.Clin. Orthop. 1994; 298: 212-

3. Ogilvie-Harris DJ, McLean J, Zarnett ME. PigmentedNodular Synoviitis of the knee. J. Bone Joint Surg 1992;74-A (1): 119-23.


CASE REPORT

Symptomatic Intra-Articular Ganglion Cyst of theKnee

C A Aminudin, MS (Ortho)", 0 C Samsudin, MS (Ortho)**, M Y Hyzan, MS (Ortho)**, A H Hamzaini,MBBCh***, M Zahiah, M Med Rad***

'Department of Orthopaedics, Traumatology & Rehabilitation, Kulliyyah of Medicine, International Islamic University of Malaysia,Kuantan, Pahang, **Depaltment of Orthopaedics & Traumatology, ***Department of Radiology, Hospital Universiti KebangsaanMalaysia, Kuala Lumpur

Introduction

Ganglia or ganglion cysts are common and may befound in a variety of locations, such as tendon sheathsand muscles, and occasionally in joints. Very few MRfindings in intra-articular ganglia of the knee have beenreported previously. We present a case with interestingMR findings.

Case Report

A 19-year-old man presented with a history of graduallyincreasing anterior knee pain and inability to fullyextend the right knee following a fall while playingfootball a year ago. Pain was intermittent especially onsquatting and climbing stairs. He had also experienceda few episodes of locking of the knee.

Examination of the right knee showed mild effusion.There was fullness of the antero-lateral aspect of theknee just lateral to the patellar tendon and tendernessat the anterior aspect of the knee was aggravated bypassive flexion and fifteen degrees of extension lag.Anterior drawer test and Lachman's test were positivewith grade 2 laxity. There were no features ofpatellofemoral joint pathology.



Plain radiographs were normal. Magnetic resonance(MR) imaging of the right knee showed a lobulatedcystic lesion within the deeper part of the infrapatellarfat pad (Figure 1) and extending to the lateralcompartment (Figure 2). It was hyperintense in T2Spin Echo (SE) and T1 Fat Saturation (FS) images.These features were in keeping with a fluid filled cyst,suggestive of ganglion cyst.

Arthroscopic examination revealed a cystic swelling inthe infrapatellar fat pad, anterior to the insertion ofanterior cruciate ligament. The cyst measured12x15x20 mm in size and was noted to be compressingthe lateral tibial articular surface. The anterior cruciateligament was partially attenuated, meniscus appearednormal and posterior cruciate ligament was intact. Thepatellofemoral joint appeared normal. Delivery of thecyst arthroscopically failed and had to be removedthrough a mini-open technique by extending theantero-lateral portal incision.

Post operative recovery was uneventful. Histopathologyexamination confirmed the mass to be a ganglion.During follow up at 4 weeks, patient had nocomplaints, full extension of the knee was restored andhe had resumed full activity.

57

CASE REPORT

Proton density sagittal MR image, thelobulated cyst shows intermediatesignal intensity

Fig 2:Inversion recovery axial MR images ofthe knee shows the cyst with presentof internal septation

Fig 1:

Discussion

Brown et al' reported that the majority of intra-articularganglion cysts were associated with the cruciateligaments and rarely are intra-articular ganglion cystsassociated with the infrapatellar fat pad. Furthermore,our patient presented with symptoms of pain andlimitation of knee extension. Most ganglion cysts wereincidental findings during arthroscopic examination.

Clinical presentation of symptomatic intra-articularganglion cysts are variable. The commonest complaintare pain over the joint line. Some patients may havemechanical locking with definite blocking of knee

~extension. The symptoms may be similar to those of aninternal derangement of the knee and should beincluded in the differential diagnosis of a meniscallesion. On the other hand, Kang et aF found thatganglion cysts do not have specific symptoms.

diameter with an average diameter of 2.3cm. Most ofthese lesions were multiloculated similar to our patient.Only eight out of the 20 patients underwent arthroscopyfor aspiration or debridement of the cysts, others wereremoved by arthrotomy.

This study' also suggested that all ganglion cysts havetypical Magnetic Resonance (MR) appearance of a cysticlesion, exhibiting homogeneously high signal intensityin relation to skeletal muscle on T2-weighted Spin Echo(SE), T2*-weighted Gradient Echo (GRE), T2-weightedTurbo Spin Echo (TSE) and fat-suppressed TSE images.On Tl-weighted Spin Echo images, the cysts wereslightly hypo or isointense to skeletal muscle. Fatsuppressed contrast-enhanced MR imaging could beuseful. A thin, rim-enhancing feature of cyst allows it tobe distinguished from synovial haemangioma andsynovial sarcoma.

Kim et al' in their clinical and MR Imaging studies of 20patients in whom evidence of intra-articular ganglioncvst were seen, found five of the cysts to be in thei~frapatellar fat pad, three of which had a palpablemass. The duration of pain was from 20 days to 7 years,with a mean duration of 9.8 months. All the ganglioncysts were solitary, ranging from 1.5 to 4.5cm in

The lesion can be removed successfully througharthroscopy'>, Other options are percutaneousaspiration under ultrasound or CT scan guidance orexcision using a mini-open technique, as was done inthis patient. Although recurrence rate for ganglion ishigh elsewhere, such as wrists, none of the patientsdescribed from previous studies had any recurrences.


CASE REPORT

A Rare Case of Chondrosarcoma of the Clavicle

A Amalourde, MS (Ortho)", P Vinayaga, MS (Ortho)", N Naveed, MS (Ortho)", A Jamal, MS (Ortho)**,L M Looi, FRCPath*, S Sengupta, FRCS*

"University of Malaya, *·Selangor Medical Centre

Introduction

Chondrosarcomas are malignant tumours whose cellsproduce cartilage matrix. They can either arise de novoor from a prexisting benign cartilaginous tumour suchas enchondromas and osteochondromas. Theycontribute to 17% of primary malignant bone tumours'.It occurs most frequently in the middle to elderly agegroup with a peak incidence between 30-60 years.Patients present usually with a dull ache or with agradually enlarging mass.

The common sites are the pelvis, scapula, proximalfemur and humerus. Although it has been reported inall the bones in the body it is extremely rare in theclavicle. In their review of 11087 cases ofmuskuloskeletal tumours, Dahlin (996) found 900cases of chondrosarcomas of which only five werefrom the clavicle". Of these, three were primary andtwo were arising from underlying osteochondromas inpatients with multiple exostosis. From our review ofthe literature, we could find only five other cases ofchondrosarcoma of the claviclev>.

Case Report

A 56-year-old lady presented with a 5-year history ofprogressively enlarging mass at the medial end of the


60

left clavicle. The mass was painless initially but itbecame painful 3 months prior to presentation. Atpresentation she also had loss of appetite and loss ofweight.

Examination revealed an ill defined swelling arising atthe medial end of the left clavicle measuring 3 x 4 cm.It was firm in consistency, non-tender and fixed to thebone. The overlying skin was uninvolved. There wasno neurovascular deficit. General examination did notreveal any evidence of other bone abnormalities.

Plain radiographs showed an expansile lesion at themedial end of the clavicle. There was evidence ofcortical destruction with an ill-defined margin andspeckled calcification without periosteal reaction. TheCT scan (Figure 1) confirmed an expansile lytic lesionwith specks of calcifications within it. The left sternoclavicular joint was not involved. No lung metastaseswere detected. Magnetic resonance imaging showedthat the great vessels were not involved. A clinicaldiagnosis of chondrosarcoma was made and thetumour was resected en bloc with 7cm of the clavicletogether with the sternal end of the first rib. At surgery,the tumour was greyish, lobulated and wellencapsulated by fibrous tissue.

Microscopic examination confirmed the diagnosis ofchondrosarcoma. There was a chondroid background


and the tumour cells showed enlarged hyperchromaticnuclei with occasional binucleated cells (Figure 2). Thesurgical margins were clear.

The patient recovered well post-operatively. She wasnot given any adjuvant therapy. Currently, at five yearspost-surgery, she is disease free and doing well withoutany restriction of shoulder movements at the time ofthis publication.

DiscussionOur patient presented with a typical history of a primarychondrosarcoma although the site is very uncommon.The protracted history renders the diagnosis of ametastatic lesion unlikely. Furthermore there is nohistory or physical finding to suggest a primary tumourat an alternative site. Benign conditions likeosteochondromas and bone cysts are also not likely asshe presented with history of weight loss and loss ofappetite. The possibility of an underlyingosteochondroma that underwent malignant change is tobe considered. Although osteochondromas are rare inthe clavicle, they are, however the most commonbenign clavicular lesion'. If this patient had anunderlying osteochondroma she should have had thisswelling before the age of 20, during the time of

Fig. 1: CT Scan showing an expansile lesion ofthe medial end of the left clavicle


A Rare Case of Chondrosarcoma of the Clavicle

maximal growth of the bone. However, it would beunlikely that the swelling could have been undetectedas the clavicle is a subcutaneous bone.

In this patient a biopsy should ideally have been doneprior to the surgical resection. This was not done as itwas felt that the history and the radiographic finding,particularly that of a lytic lesion with an ill definedmargin associated with speckled calcification, were verysuggestive of a chondrosarcoma.

The chondrosarcomas are of low-grade malignancy andthe surgical margins in this case were clear. Theseindicate good prognosis. Chondrosarcomas have ahigher rate of recurrences even after five years than domost other sarcomas. The use of chemotherapy andradiotherapy has not been shown to increase thesurvival of patients with chondrosarcomas.

Conclusion

The clavicle is a rare site for tumour and tumour-likelesions. Primary chondrosarcoma of the clavicle is anextremely rare condition. To the best of our knowledgethis is the first reported case of chondrosarcoma of theclavicle in Malaysia.

Fig. 2: Microscopic examination revealedtumour cells showing enlargedhyperchromatic nuclei with occasionalbinucleated cells with a chondroidbackground

61

CASE REPORT

1. Springfield, Dempsey S, Gebhardt, Mark C, McGuire,Michael H: Chondrosarcomas: Instructional CourseLectures. J. Bone and Joint Surg. 1996: 78(A): 141-49.

2. Dahlin DC. Bone Tumours: General aspects and data on11087 cases. (5th Ed.) Lippincott-Raven, 1996: 71-75.

3. Rankin KC, Cobb JR: Removal of a giant chondrosarcomain the clavicular region. Surg. Edin. 1983; 28: 340-48.

62

4. Aprin H, Joseph C, Rabia M, jea YL: Radiation-inducedchondrosarcoma of the clavicle complicating Hodgkin'sDisease. Clin. Ortho. 1986; 209: 189-93.

5. Smith J, Yuppa F, Watson RC: Primary tumour andtumourlike lesions of the clavicle. Skel. Radiol. 1988;17(4): 235-46.


CASE REPORT

Unicameral Bone Cyst of the Calcaneum

C H Wan Hazmy, MD, MS (Ortho)

Department of Orthopaedics and Traumatology, Seremban Hospital, Seremban, Negeri Sembilan

Introduction

Unicameral bone cysts are not seen commonly in thecalcaneum. However, because of the concentration offorces through the heel, such solitary bone cysts areusually symptomatic, depending on the proximity tothe joint and the size of the cyst, although some ofthese lesions are detected as incidental findings'.

Case Report

Mr ZT, a 38 years old Malay man, first presented to uswith chronic painful left heel of two years duration.The pain was continuous in character and worsened onprolonged standing and walking. There was noprevious history of trauma or infection around theaffected region. Physical examination revealed asignificant tenderness on deep palpation of the leftheel. There was no obvious deformity noted and therange of motion of the ankle and foot was normal.There was also no evidence of ligamentous laxity.

Plain radiograph showed a large cystic lesion in the leftcalcaneum (Figure 1). The cortical shell was still intact.Computer tomograph-scan was also suggestive ofsolitary bone cyst of the calcaneum. Curettage andbone grafting of the lesion was performed. Intraoperatively, a large cyst was noted containing strawcoloured fluid and autogenous bone graft taken from

Submitted for publication: 23 January 2003


the left iliac crest was inserted via a lateral corticalwindow. The patient was discharged two days after theoperation and he was advised not to weight bear untilevidence of sufficient new bone formation.

Histopathological results confirmed the presence of afibrous cyst wall, hyperdense surrounding bonyfragment and scattered haemosiderin-ladenmacrophages. The findings were consistent withsolitary bone cyst of the calcaneum. The patientshowed significant clinical recovery after the operationand a radiograph five months after surgery revealedbony consolidation (Figure 2). He was able to fullyweight bear four months after the surgery and wasdischarged from the clinic at seven months.

Fig. 1: Lateral radiograph ofboth feet showinga cystic lesion in left calcaneus

63

CASE REPORT

Fig. 2: Radiograph of the patient five monthsafter currettage and bonegraft

Discussion

Unicameral bone cyst is a benign lesion of the bone.Bone tumours and tumour like conditions in the boneconstitutes approximately 7% of all tumours, of which1.5% are malignant. Unicameral bone cysts arerelatively common in humerus, femur and tibia and arefound mostly in children but uncommon in calcaneum.Only a few cases have been reported'>. The naturalhistory of unicameral bone cyst in the calcaneum isunknown. The majority of the cases are detected asincidental findings while others presented as heel pain.

1. Seip GU, Thiele H. Die solitaire juvenile ferseinbeinzyste;Falldarstellung und literaturubersicht. Unfallchirurg 1999;102: 576- 9.

2. Reig-Boix V, Guinot-Tormo J, Risent Martinez F, AparisiRodriquez F, Ferer-Jimenez R. Computed tomography ofintraosseous lipoma of os calcis.Clin Orthop 1987; 221:286-91.

Pathological fracture has been reported and thesymptoms that are believed to increase the likelihood ofa pathological fracture are a history of progressive pain,following increased activity level of the patient.

The radiological differential diagnosis includes intraosseous lipoma of the os calcis and intra-osseousganglions. Computer tomography scan is helpful toestablish the differential diagnosis in the absence of aMRI scan. Exact histological diagnosis is of particularimportance. Our histopathological report confirmedour clinical suspicion.

A variety of treatment has been suggested forunicameral bone cysts. For asymptomatic, nonexpansile and small cysts a non-operative treatmentwith watchful negligence has been recommendedwhereas for painful expansile large cysts treatment withmethyl-prednisolone acetate injection or currettage andbone grafting has been suggested. Glaser et a1 3 foundthat steroid injection treatment, although useful in otherlocation, may not be the best options for themanagement of unicameral bone cysts in thecalcaneum. Though invasive, curettage and bonegrafting yielded uniformly good results. Our patient hasshown a good radiological consolidation andencouraging clinical outcome following curettage andbone grafting.

In conclusion, despite the rarity of bone cyst in thecalcaneum, it can be a cause for chronic heel pain withfavourable outcome if treated accordingly.

3. Glaser DL, Dormans JP, Stanton RP, Davidson RS.Surgical management of calcaneal unicameral bone cysts.Clin Orthop 1999; 360: 231-7.

64 Med j Malaysia Vol 59 Supplement F December 2004

CASE REPORT

An Unusual Radiographic Presentation of PosteriorCruciate Ligament Avulsion Fracture

M N Mohd Nizlan, MBBS, A Suhail, MD, 0 C Samsudin, MD, 0 Masbah, MBBS

Department of Orthopaedics and Traumatology, Hospital Universiti Kebangsaan Malaysia, Kuala Lumpur

Case Report

A 14-year old male pillion rider was involved in amotorcycle accident when the motorcycle was hit frombehind by a car. He was thrown off the motorcycle andfell on to the road. Upon admission to the casualtydepartment, he exhibited swelling of the right kneewith tenderness along the right fibular head, rightlateral femoral condyle and posterior part of the rightknee joint. Anteroposterior and lateral radiographs ofthe right knee joint showed a PCL avulsion fracturewith a possible tibial spine fracture (Figure 1).

CT scan of the right knee showed avulsion fracture ofthe tibial spine at the attachment of the ACL, fracture atthe attachment of the PCL with avulsion of theposterolateral margin of the lateral femoral condyle(Figure 2).

A diagnostic arthroscopy revealed that the patientactually had a tibial PCL detachment and the big bonyfragment had actually been displaced into the anteriorcompartment of the knee (Figure 3).

The menisci, ACL and tibial spine were noted to beintact. Examination done under anaesthesia alsorevealed mild lateral collateral laxity. An openreduction and screw fixation for the bony fragment wasperformed. Post-operatively the right knee was put on



a Plaster-of-Paris backslab and he was discharged onthe second post-operative day.

On follow-up at 3 months, the patient was able to walkwithout pain; however, he complained of occasionalinstability of his right knee on brisk walking andrunning. Clinically the posterior drawer test was stillpositive with Grade 2 posterior sagging of the tibia onthe femur. The radiograph showed that the screw wasin place and the fragment was well reduced. He wasencouraged to continue with quadriceps-strengtheningexercise which was started at 6 weeks post-op.

Discussion

Posterior cruciate ligament (PCL) injury is uncommon'>.However, when it occurs, it is often associated withinjuries to other ligamentous structures of the kneejoint, especially the posterolateral corner structures(namely the lateral collateral ligament (LCL), popliteus,popliteofibular ligament, posterolateral joint capsuleand iliotibial band) 3. Isolated PCL avulsion fractures areoften undiagnosed and its incidence is probably muchhigher than expected 4.

The most common cause of PCL avulsion injuries ismotorcycle accidents, followed by automobileaccidents and fall from heights . There are two basic

65

CASE REPORT

Fig. 1: AP and lateral radiographs of the right knee showing PCl avulsion fracture with apossible tibial spine fracture (arrows)

Fig. 2: CT scan of the right knee showing a free fragment in the joint


CASE REPORT

stability of the cruciate ligaments is not essential for anormal functioning knee, provided that the collateralsare intact and the quadriceps strength is maintainedadequately 67. One series found out that small andundisplaced fragments can be managed conservativelywith good results 1. However, most authors agree thatisolated PCL avulsion fracture should be managedsurgically, as some conservatively-treated patients maylater show complications such as chronic kneeinstability, patello-femoral degenerative disease andpain 1,4.6. Methods of fixation vary: large fragments canbe fixed with screws, smaller or cartilaginous fragmentscan be fixed by means of staplers or pull-throughsutures 1,4.6 •

1. Torisu T Isolated avulsion fracture of the tibialattachment of the posterior cruciate ligament. ]. BoneJoint Surg. 1977; 59(A): 68-72.

2. Ho T, Fang D. Posterior cruciate avulsion fractureassociated with a large inverted medial tibialosteochondral fragment.]. Trauma. 1995; 38(4): 653-7.

3. Fanelli G.c., Edson C.]. Posterior cruciate ligamentinjuries in trauma patients: Part II. Arthroscopy 1995;11(5): 526-9.

4. Meyers M.H. Isolated avulsion of the tibial attachment ofthe posterior cruciate ligament of the knee. ]. Bone JointSurg. 1975; 57(A): 669-72.

68

Reviewer's Note

In retrospect, the plain films showed normal tibialspines and therefore the avulsion of ACL insertion wasunlikely. The plain film lateral view showed thefragment to be posteriorly placed and the only onefragment was evident and not two fragment andtherefore ACL insertion avulsion is not likely.

Also when evaluating CT reformatting it is importantnot to look just at the position of the fragment but alsofor the corresponding defect from which the bone hasavulsed from. No defect was noted at the tibial spinestop suggest an ACL avulsion on CT.

5. Allen c.R., Kaplan L.D., Fluhme D.]., et al, Posteriorcruciate ligament injuries. Curl'. Opin. Rheumatology2002; 14(2): 142-9.

6. Covey D.C., Sapega A.A. Current concepts review:Injuries of the posterior cruciate ligament. ]. Bone JointSurg. 1993; 75(A): 1376-86.

7. Parolie ].M., Bergfeld ].A. Long-term results ofnonoperative treatment of isolated posterior cruciateligament injuries in the athlete. Am. J. Sports Med. 1986;14: 35-8.


CASE REPORT

Tarsal Tunnel Syndrome Caused by Ganglion

W M Ng, MS (Ortho)", K Y Chan, FRCS**

'Orthopaedic Surgery Unit, Department of Surgery, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, Kuala Lumpur,"Orthopaedic Sports Surgery Unit, Department of Orthopaedic Surgery, University Malaya Medical Centre, Kuala Lumpur

Introduction

Keck and Lam in 1962 defined tarsal tunnel syndromeas a compressive neuropathy of the posterior tibialnerve and its branches in the tarsal tunnel. This tunnelis located distal to the medial malleolus. The roof isformed by the flexor retinaculum whereas thecalcaneus, tibia and the posterior process of the talusform the bony floor. The structures crossing the tunnelare the posterior tibial nerve, tibial artery and vein,tibialis posterior, flexor digitorum longus and flexorhallucis longus tendons. Ganglions were reported as acommon cause of tarsal tunnel syndrome in severalstudies 12. Most of the ganglia originate from the talocalcaneal joint and it is often associated with tarsalcoalition 3.

Case Report

A forty four year old nurse complained of left anklepain for seven years that had progressively worsenedover one month before presentation. It was associatedwith a burning sensation and numbness on the lateralplantar aspect of left foot. It became worse especiallyafter walking and standing for long duration. Recently,she noticed a diffuse swelling posterior to the medialmalleolus that progressively increased in size.



A needle aspiration was done under local anesthetic inthe Accidents and Emergency Department but thisyielded only blood. However, her symptoms improvedand a MRI reported a ruptured ganglion. As hersymptoms were improving, she was referred forphysiotherapy.

Six months later, her symptoms recurred anddeteriorated to the extent that she was unable to work.The burning sensation on the plantar aspect of her solewas so severe that she was not able to tolerate bedsheets covering her toes at night. For pain relief sherelied constantly on analgesics. The swelling measured2 x 3cm posterior to the medial malleolus. It was firmand non-tender on deep palpation. However, therewas a positive Tinel's sign just posterior to the medialmalleolus that reproduced the tingling distally in thesole of her foot. There was no dystrophic changes orintrinsic muscle wasting. The range of movement to allher joints in the foot was normal. MRI showed aswelling consistent with a ganglion (Figure 1) betweenthe medial and lateral plantar nerves bifurcation.

At surgery, a curvilinear incision was made followingthe course of the tibialis posterior nerve behind themedial malleolus. The superficial fascia and flexorretinaculum was divided and the posterior tibial nerve

69

CASE REPORT

was identified. A ganglion was found pushing outbetween the medial and lateral plantar nervebifurcation. The lateral branch of the plantar nerve wasseverely compressed and was wafer thin while themedial plantar branch appeared thinner than normal(Figure 2). The lobulated ganglion was dissected andtraced down to its origin at the talo-calcaneal joint andremoved along with a part of the joint capsule.

Twelve months after surgery, her symptoms havemarkedly improved especially the burning sensation.She is now able to tolerate bed-sheet covering her toesat night. However, she still has aches around her ankleand foot at the end of a long working shift standing onher feet. The scar was hypertrophic but non-tendernon-sensitive. She could wear normal shoes and ableto go for long walks.

Discussion

Clinical presentation of tarsal tunnel syndrome includeslocalized pain or burning sensation posterior to themedial malleolus, radiating to the sole in thedistribution of the planter nerves that sometimes radiateupwards to the medial aspect of the calf. Classically,pain is aggravated with activity and is relieved by rest.Frequently, it is associated with night pain, alteredsensation and dysaesthetic pain along the distributionof the plantar nerve. There may be tenderness behindthe medial malleolus and a positive Tinel's sign. Thereis usually no atrophy of the abductor hallucis muscle orweakness of intrinsic muscles of the foot.

Causes of nerve compression vary but the presence ofa palpable mass behind the medial malleolus maysuggest a space occupying lesion contributing to thecompression. Benign lesions like synovial cyst,

Intrinsic

Extrinsic

Idiopathic

Table I: Aetiology of tarsal tunnel syndrome

TumourBenign: Ganglion, Neuroma, Synovial cysts

Vessels: Anomalies, Venous thrombosis, Varicose vein

Inflammation: Tenosynovitis

Bony prominence: Tarsal coalition

Tight shoes, tight castHyperlaxity of joints and excessive pronation

Systemic illness: Rheumatoid arthritis, Diabetes Mellitus, Hypothyroidism

Drugs:Chlorothiazine, Nitrofurantoin

Fig 1: MRI showing ganglion

70

Fig 2: Operative viewofganglion and medialand lateral plantar nerves


neuroma or ganglion are other causes, but as reportedin the literature, ganglion remains the most commontumour causing tunnel compression (Table D.

In our patient, the numbness and the sensation ofparaesthesia were more marked on the lateral planteraspect which suggests that the compression was on thelateral planter nerve as seen intra-operatively.However, Nagoaka and Satou 3 reported that the medialplantar nerve was more often involved. Nerveconduction test is the gold standard in the diagnosis ofcompressive neuropathy. It is a superior objective testfor tarsal tunnel syndrome but the sensitivity variesbetween 40-80%. It was not performed in this casebecause the clinical presentation was conclusive.Although ultrasound imaging is useful to localize andassess the size of the ganglia, especially occult ganglia.A MRI is more informative as in addition to size, siteand the origin, it can exclude the presence of tarsalcoalition.

The presence of a swelling posterior to the medialmalleolus suggests a ganglion as a possible cause fornerve compression. We agree with Nagoaka and Satou 3

that needle aspiration for diagnosis and decompressionis not recommended. The risk of puncturing a nerveand consequent neuroma formation may worsen thesymptoms.

1. Takakura, Y., Kitada, c., Sugimoto, K., Tanaka, Y., Tarnai,S. Tarsal tunnel syndrome: Causes and results of theoperative treatment. J Bone Joint Surg, 1991. 73-B: 12528.

Tarsal Tunnel Syndrome Caused byGanglion

Intra-operatively, the lateral plantar nerve was found tobe severely flattened and stretched to form a'hammock' over the ganglion. It was not surprising asshe had symptoms for more than 7 years. Similar tomost reports 2. 3, the ganglion arose from the talocalcaneal joint and extended to the bifurcation of theinferior branch of the posterior tibial nerve moretoward the lateral plantar nerve.

A complete excision of the ganglion in general has amore predictable and better outcome compared toother causes of tarsal tunnel syndrome!. However, herprognosis is guarded because of the long history andsignificant flattening and fibrosis of the nerve fromchronic compression. The burning sensation wascompletely resolved at her last follow up, however themild residual paraesthesia persists.

Conclusion

Tarsal tunnel syndrome is a common presentation ofaltered sensation in the foot that is frequentlymismanaged due to lack of awareness. Ganglion is acommon cause of tarsal tunnel syndrome and theoutcome is favorable if it is recognized and adequatelytreated early.

2. Takakura, Y., Kumai,T., Takoaka,T., Tarnai,S., Tarsaltunnel syndrome caused by coalition associated with aganglion. J Bone Joint Surg, 1998. 80-B: 130-33.

3. Nagaoka, M., Satou,K., Tarsal tunnel syndrome caused byganglia. J Bone Joint Surg, 1999. 81-B: 607-10.


CASE REPORT

Close Fracture Complicated by Acute HaematogenousOsteomyelitis

S Baskaran", T Nahulan", A Siva Kumar**

'Department of Orthopaedic Surgery, Hospital Queen Elizabeth, Kota Kinabalu, Sabah, "Department of Orthopaedic Surgery, Facultyof Medicine, University Malaya Medical Centre, Kuala Lumpur

Introduction

It is rare for osteomyelitis to develop at the site of aclosed fracture. Nonetheless the awareness of such acondition is necessary considering that the nature andoutcome of the subsequent surgery may changesignificantly. The aim of this case report is to increaseawareness of this peculiar finding among the practisingsurgeon.

Case Report

Madam NS, a 38 year old housewife was referred to usfrom a district hospital on the 1st of January 2001 afterbeing involved in a motor-vehicle accident the previousday. On admission she was stable and was found tohave sustained a closed fracture of the parasymphysisof the right mandible with a sublingual haematoma,and a closed fracture of the right femur.

The attending dental team treated her with intravenousMetronidazole 500mg 8 hourly for 5 days from the dayof admission. She was planned for lockedintramedullary nailing of the right femur and wiring ofthe mandible on the next available operative list. Sheremained afebrile in the ward. On 16th January 2001she underwent nailing of her femur fracture. Uponintroducing the guide wire into the fracture site, pus

Submitted for publication: 15 July 2004

72

began oozing out of the proximal entry wound. Thefracture site was immediately opened through a lateralapproach and a large collection of pus was drained.Commercially-available gentamicin-impregnatedcement beads were inserted after thorough wounddebridement. The fracture was stabilized in anexternal-fixator (Figure 1)'and the wound was leftopen. She was immediately started on intravenousCloxacillin 500 mg 6 hourly. The mandible fracturewas stabilized with wire fixation on the 17th january.This surgery was otherwise unremarkable.

The tissue culture grew coagulase positiveStaphylococcus Aureus sensitive to Methicillin. Shewas treated with 3 weeks of intravenous Cloxacillinand a further 3 weeks of oral antibiotics. After 2months, patient developed pin-tract infection and theexternal fixator was removed and a functional castbrace applied. At that time the fracture was not stableand there was some loss of reduction on follow-up.Swab from the pin tract grew Pseudomonas Aeruginosaand this responded well to intravenous antibiotics. Shewas then discharged and was on follow-up.

Partial weight bearing was allowed at 18 weeks afterclinical and radiological signs of union was evident(Figure 2). In October 2001 she was allowed fullweight bearing. Her last review was on 21st October


Close Fracture Complicated by Acute Haematogenous Osteomyelitis

2002 where she complained of slight shortening of herright lower limb. There was no pain or discharge fromthe wound. The range of motion of her right knee andhip was full. Her right lower limb measured 77cmcompared to 79cm on the left. X ray showed that thefracture had healed well.

Discussion

Our search for osteomyelitis occurring at the site of aclosed fracture in the available literature yielded onlythree papers with a total of 5 cases. Considering thehundreds of thousands of fractures occurring orpossibly being treated daily around the world, this isindeed a rare finding. Our patient did not even displayany clinical evidence of infection. However most of theother reported cases seem to have prior evidence ofinfection':",

Patients who develop this unusual complication seemto have delayed union, as seen in this case and in othercase reports': 2, 3.

A study of the available literature reveals that thiscomplication can generally occur in 2 group ofpatients'. The first group is patients who sustain a

Fig 1: Post-operative x-raYI on externalfixator


closed fracture who then subsequently develop aremote infection which later spreads via thehematogenous route to the fracture site. This is morecommon in children and the prognosis seems to begood. The primary focus is often from the upperrespiratory tract, urinary tract or skin. The diagnosisshould be suspected when a child who has had aclosed fracture later develops increasing pain andswelling at the fracture site with systemic signs ofinfection.

The second group is in adults, who generally have apoorer outcome'. This group of patients often isimmuno compromised and has reduced resistance toinfection due to diabetes or prolonged steroid use!.Treatment in this group of patients is often moredifficult and the outcome may not be as good as in theprevious group.

In summary, osteomyelitis complicating closedfractures is very rare, nonetheless it can occur and oneshould exercise a high index of suspicion when certaintelltale signs or symptoms surface. This is especially soin a time when the immunosuppression in AIDS hasmade common, conditions which just two decades agomay have been considered bizarre.

Fig 2: Fracture united at 18 weeks

73

CASE REPORT

1. A.E Hardy, R.O. Nicoll. Close Fractures Complicated byAcute Haematogenous Osteomyelitis ClinicalOrthopedic and Related Research, 1985; 201: 190-95.

2. S.T. Canale, James Puhl. Acute Osteomyelitis followingClose Fractures - Journal of Bone and Joint Surgery; 1975;57: 415-17.

3. L.N. Cozen. Four unusual cases of Osteomyelitis inAdults. - Journal of Bone and Joint Surgery; 1957; 39: 454.

74 Med JMalaysia Vol 59 Supplement F December 2004

CASE REPORT

Resection and Reconstruction of RetroperitonealSarcoma of Spinal Roots

Y Imran, M Med (Ortho)", W Zulmi, MS (Ortho)**, WI Faisham, M Med (Ortho)**, M Zainal, MD,M Med (Surg)***

'Spine Unit, "Oncology & Reconstructive Unit, Department of Orthopaedics, "'Department of Surgery, School of Medical Science,Universiti Sains Malaysia, Kubang Kerian, Kelantan

Introduction

An eighteen year old man presented with three monthshistory of a gradually enlarging painful swelling in leftiliac fossa associated with left lower limb numbness.There was significant weight loss. He had noticedweakness of the left lower limb for a month and hadbeen unable to walk for a week.

On admission he was found to be cachexic. A 5 x 14cmfirm mass was palpable at the left lower quadrant of theabdomen. No organomegaly or ascites were noted. Hisleft lower limb was weak with power grade 3.

CT abdomen showed (Fig 1) a massive soft tissue massin the retroperitoneal region extending from the leftiliac fossa to left subcostal region. It extended from thespinal canal at L4L5 vertebra exiting into paravertebralregion via L4L5 exit foramen, infiltrating psoas anderector spinae muscles, without causing cordcompression. L4L5 vertebral bodies, pedicles andtransverse process were also eroded. Bone scan did notshow any other metastasis.

Biopsy revealed evidence of PNET and he received 6cycles of Ifosphamide, Mesna and Adriamycin.Clinically the mass significantly reduced in size and hisneurological deficit improved. Post chemotherapy CTscan confirmed reduction of the tumor mass to 3 x 4cm.The bony destruction remained unchanged. Howevertwo lung nodules were noted.

He underwent wide resection of the tumor, whichincluded hemi resection of L4L5 vertebral bodies andexcision of left erector-spinae and psoas muscles



followed by interbody fusion with fibula strut graftaugmented with posterior instrumentation. L3 and L4nerve roots were also resected since they were encasedby the tumor mass.

Histologically, the resected tumor mass was a spindlecell tumor, with extensive necrosis following preoperative chemotherapy. The final diagnosis wasMalignant Peripheral Nerve Sheath Tumor.

Radiotherapy of 50CGy to the tumor bed was given.Follow up CT scan of the abdomen and thorax showedevidence of resolving lung metastasis. However hepresented again after 18 months with systemicmetastasis and finally succumbed to the disease.

Fig 1: Axial CT scan of the aHected regionshows Lt sided soft tissue mass and thevertebra involvement, sparing thespinal cord

75

CASE REPORT

Fig 2: Spinal stabilization achieved with strutfibular graft and pedicle screwinstrumentation

Discussion

Malignant Peripheral Nerve Sheath Tumor (MPNST) isalso known as malignant schwannoma and malignantneurilemoma. It is a malignancy of peripheral nerveSchwann cells. Malignant change in benignschwannoma is rare! but has been reported 2. Manyother tumors like metastatic malignant melanoma' andsynovial sarcoma' may resemble MPNST. It is difficult todifferentiate between MPNST from Peripheral NeuroEctodermal Tumour (PNET)5. MPNST has a very highassociation with Neurofibromatosis and usually foundin the lower extremities, head and neck region.

Extraperitoneal tumor is rare. The natural history ofretroperitoneal and pelvic sidewall sarcoma differsignificantly from common abdominal and pelvicadenosarcoma or visceral sarcoma. Unique featuresinclude their large size at the time of diagnosis and itoften pushes rather than invades into surrounding

76

structures 6. Their deep location within the bodyprecludes palpation of the tumor mass early in thecourse of the disease and consequently after reaching alarge size prior to the diagnosis patients present latewith symptoms of weakness and large retroperitonealmass. Metastatic neurofibromatosis to the spine is notcommon. Keat-White had observed and reviewed fourreported cases of the condition", Spine secondaries inthese cases originated from neurofibrosarcomas in thethigh (sciatic nerve and femoral nerve). They werenoted between 10 months to two years after wideresection of the primary sarcoma.

The treatment results with extremity soft tissuesarcomas have improved dramatically. Themultimodality approach which includes meticulouslocal staging, aggressive surgery and local DXT and/orsystemic chemotherapy has improved survival andquality of life. Surgical removal of the primary tumor, itspseudocapsule and involved adjacent organ with aclear margin is a treatment option indicated for allabdominal and pelvic sarcomas as aggressivechemotherapy or radiotherapy has not demonstratedsurvival benefits 8.

This patient had wide resection of the tumor whichinclude hemi resection of the vertebral body resultingin massive soft tissue loss and unstable vertebralsegment. Reconstruction with prolene mesh to augmentposterolateral corner of the abdominal cavity, fibulastrut graft for segmental fusion (and posterior pediclescrew fixation) was important to achieve early stabilityfor patient's rehabilitation.

Local recurrence is common and haematogenousmetastasis occurs very fast. Local control by wideexcision and radiotherapy is usually feasible butsystemic metastasis is very difficult to control even withchemotherapy. In this case the secondaries to the lungsshowed a good response to the given chemotherapyinitially. However, he succumbed to the disease after 18months with distant metastases. Spinal sarcoma haspoor prognosis as most patients die within 2 years afterdiagnosis 7.


CASE REPORT

Pulmonary Metastases of Giant Cell Tumour of theBone

WI Faisham, M Med (Ortho), W Zulmi, MS (Ortho), A H Mat Saim, FRCS, B M Biswal, DNB

Musculoskeletal Oncology Unit, School of Medical Science, University Sains Malaysia, Kubang Kerian, Kelantan

Introduction

The clinical presentation and behaviour of giant celltumour of bone vary 1,2, This tumour has the unusualtendencies of local aggressiveness, local recurrence andoccasional distant metastases 1,2,3,4,5, The awareness ofmetastatic potential is important to allow treatment withless morbidity and greater success 6,7, Despite overallprognosis of giant cell tumour being favourable,pulmonary metastases will carry significant morbidityand mortality,

Methodology and Results

Forty-three patients with giant cell tumour of the bonewere treated at this centre from 1998-2002, Pulmonarymetastases was diagnosed in six patients, The ageranged between twenty to sixty-two years old, Therewere four males and two females, Location of theprimary tumours was distal femur in one case, proximaltibia in two cases, one distal radius, one fibula and onemetachronous giant cell tumour of distal end femur andradius. All patients presented with local aggressive

Submitted for publication: May 2003

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lesions with soft tissues involvement (stage IIICampanacci classification) during presentations,

Four of the six patients also presented with localrecurrence. Two patients had intralesional resection offibula and distal end radius, one had curettage andmetametylcrylate bone cement reconstruction of distalfemur and one had wide resection followed byendoprosthesis reconstruction. Two patients presentedlate, one patient refused primary surgery, remaineddormant and finally presented with massive soft tissueinvolvement and pulmonary metastases ten years later.Another patient presented after one year with thedisease and primary ablative surgery has to beperformed due to massive tissue involvement.Pulmonary metastases occurred 2 years later withmetachronous tumour to distal end radius,

The diagnosis of pulmonary metastases was based fromcomputed tomography scan findings. Two patients hadsurgical resections of the metastasis, and the histologywere the same as primary lesion without evidence ofmalignant transformation. We attempted limb salvage


CASE REPORT

Comparison Computed Tomography Scan at presentation and after three years

Case 2A 24 year-old patient presented with recurrence tumour of the distal radius, which was resected and reconstructedwith vascularised fibula graft. He also had multiple pulmonary metastases that preclude surgical resection. Hereceived six courses of adriamycin and cisplatin for six months. At present he is asymptomatic and pulmonarynodules remain static and some showed resolutions.

Discussion

Giant cell tumour of bone with pulmonary metastasesis rare. The cause of metastases is unclear. Intravascularextension or invasion of peritumoral blood vessels havebeen described, however this does not seem to

correlate with increase risk of metastases 2.5. The risk ofmetastases is also postulated to be the result ofiatrogenic seeding of tumour cells into the blood streamat the time of surgery for the primary lesion. However,pulmonary metastasis has been described

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simultaneously along with the primary lesion 3,4.

Aggressive primary tumour with massive soft tissueinfiltration and local recurrence as shown in all caseswas a risk for pulmonary metastases 6.

Most metastases are diagnosed within the first fewyears after the primary diagnosis, although they maypresent after ten years or more 7.4. Close follow-up ofall giant cell tumour patients with both clinical andradiological evaluations is essential. Baseline CT scanof the chest and bone scan should be performed at the


time of presentation and follow-up. It has been ourprotocol to performed CT scan chest and bone scan sixmonthly for two years and yearly for subsequent threeyears in all patients.

The natural history of metastatic lesion has beenunpredictable. Pulmonary metastases from giant celltumour have been treated in various ways. Completeexcision of pulmonary metastases excellent survival hasbeen reported. The majority of such patients have noevident of active disease on long term follow up 34,6.

However, complete excision of all lung metastases isoften not possible because of the extent of pulmonarydisease. Long term results with incomplete excisionhave also been reported, but because many of thesepatients have undergone adjuvant chemotherapy orradiotherapy, the effect of incomplete excision alone isharder to ascertain 3,47. Report on treatment withchemotherapy and radiotherapy was scanty as theywere usually reserved for unresectable pulmonarylesions. In our series all surgically treated pulmonarymetastases remained disease free for two to three years,two patients that received chemotherapy showed noevidence of progression and patients who refused

1. Campanacci M, Baldini N, Boriani S, Sudanese A. Giantcell tumor of bone. J, Bone joint Surg. 1987; 69(A): 10614.

2. Dahlin DC, Cupps RE, johnson EW. Giant cell tumor ofthe bone. A study of 195 cases. Cancer 1970; 25: 1061-70.

3. Bertoni F, Present D, Enneking WE: Giant cell tumor ofbone with pulmonary metastases. J, Bone and joint Surg.1985; 57(A): 890-900.

4. Bertoni E, Present D., Sudanese A., Baldini N., BachinniP., Campanacci M.: Giant cell tumor of bone withpulmonary metastases. Six case reports and review of theliterature. Clin. Orthop. 1988; 237: 275.


Pulmonary Metastases of Giant Cell Tumour of the Bone

chemotherapy showed disease progression and onesuccumbs within six months

Total extirpation of the primary lesion should beattempted in order to avoid recurrences and furtheroperative interventions 12. We do not believe thatpulmonary metastases preclude limb salvage in thelocal treatment of giant cell tumour. Oncologicalclearance is mandatory as all patients with pulmonarymetastases in these series presented with localaggressive disease and massive soft tissue infiltration.Local recurrence after primary treatment also can betreated without ablative surgery provided goodoncological clearance can be achieved.

Conclusions

Aggressive treatment of primary disease and pulmonarynodule should be attempted in treatment of metastasesgiant cell tumour. The outcome has been favourable inpatients who had complete surgical resection ofpulmonary nodule or received chemotherapy.

5. Rock M.G., Pritchard D.l, Unni K.K.: Metastases fromhistologically benign giant cell tumour of bone. J, Bonejoint Surg. 1984; 66A: 269.

6. Maloney Wj, Vaughan LM, jones HH, Ross j, Nagel DA.Benign metastasizing Giant cell tumor of bone. Report ofthree cases and review of the literature. Clin. Orthop. ReI.Res. 1989; 243: 208-15.

7. Kay R.M., Eckardt j.j., Seeger L.L., Mirra J,M., Hak D. J,Pulmonary metastases of benign giant cell tumor of bone.Six histologically confirmed cases, including one ofspontaneous regression. Clin. Orthop. ReI. Res. 1994; 302:219-30.

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Officialjournalofthe · Supplement F December 2004 ISSN 0300-5283 PP 2121/11/04 MITA(P) 124/1/91. Volume 59 SupplementF December2004 Editor JohnT Aroklasamy Members Victor K E Lim

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