POA 74th Annual Congress Free Paper Abstracts

Outcomes of Stable Fixation in Long Bone Fracture Surgeries: Evaluating Union, Non-Union, Infection Rates, and Implant Failures at a Tertiary Hospital in Pangasinan, 2023

Nike Kier P. Perez, MD

Region 1 Medical Center

 

Background: The management of long bone fractures through stable fixation remains a critical focus in orthopedic surgery. This study aimed to evaluate the outcomes of stable fixation in long bone fractures, specifically examining bone union rates, non-union, infection, implant failures, and potential risk factors influencing these outcomes.

 

Methods: This retrospective cohort study analyzed data from 188 patients who underwent long bone fracture surgeries with stable fixation at a regional medical center between January 01 – December 31, 2023. Key outcomes included time to bone union, RUST scores, non-union incidence, infection rates, and implant failure rates. Correlation analysis was conducted to explore relationships between patient demographics, follow-up intervals, and surgical outcomes.

 

Results: The average time to bone union was 7.52 weeks, with a low non-union rate of 0.5%. The RUST score demonstrated a strong positive correlation with time to bone union (r = 0.897, p < 0.001), underscoring its reliability as a measure of healing progression. Implant failure and infection were rare, each occurring in 0.5% of cases. Correlation analysis revealed significant relationships between follow-up intervals and bone healing metrics, suggesting that personalized follow-up care may enhance patient outcomes.

 

Conclusion: The findings support the effectiveness of stable fixation in achieving high bone union rates with minimal complications. The low incidences of non-union, infection, and implant failure highlight the success of current surgical practices. The study emphasizes the importance of individualized follow-up care and radiographic monitoring to optimize patient outcomes. Future research should focus on refining surgical techniques and exploring additional risk factors to further improve long bone fracture management.

 

Keywords: Long bone fractures, stable fixation, bone union, non-union, infection, implant failure, RUST score, orthopedic surgery, follow-up care, retrospective study.

 

Tuberculous Osteomyelitis of the Hip in a Pediatric Patient Managed with a Customized, 3D-Printed Antibiotic Spacer: A Case Report

Miguel Gabriel C. Ocampo, MD

Region 1 Medical Center

 

Background: Osteomyelitis in the pediatric patent is an uncommon, albeit very damaging when left untreated, disease characterized by inflammation of the surrounding soft tissues of the infected bone secondary to bacterial infection. This is often associated with the presence of septic arthritis when the joint is involved. These disease processes are often treated with culture-guided antibiotic therapy, however, in severe cases, surgical intervention may be warranted to decrease the bacterial load at the foci of the infection. Tuberculosis (TB) of the hip accounts for nearly 15% of all osteoarticular tuberculosis, presenting with pain, loss of movement, and possibly pathologic dislocation. The treatment is primarily anti-TB regimens aided by surgery when warranted.

 

Case Presentation: A 3D printed antibiotic spacer was used to treat a severe case of TB osteomyelitis of the hip in an 11-year old female patient who was confined in our institution for 55 days, with delays caused by both patient and logistical factors. The patient underwent a Girdlestone procedure followed by implantation of a custom, 3D-printed antibiotic spacer before being discharged.

 

Conclusion: Noted improvement in the patient’s overall condition post-operatively provided

promising results for the use of this method in future patients.

 

Keywords: Tuberculous pediatric osteomyelitis, Antibiotic cement spacer, 3D printed

 

Clinical Outcomes of Tibia Fractures: A Retrospective Cross – Sectional Study between Open III Tibia Fractures managed with Definitive External Fixation and Staged Surgery

Nicole Escutin , MD

Region 1 Medical Center

 

Background: The most common form of treatment modality for open fractures is debridement of the open wound, along with application of a uniplanar external fixator. External fixators are the workhorse for skeletal stabilization in open fractures, being easily applied, provides stability, maintains bone length and does not add further periosteal stripping to remaining healthy bone. External fixators are also highly variable in their constructs, having a uniplanar, circle and hybrid variations, giving highly flexible treatment modalities dependent on the fracture location and degree of soft tissue injury.

 

Objective: To conduct a retrospective study regarding the clinical outcomes of patients with Open Tibia fractures treated with External Fixators as definitive management, with those treated with Staged Surgery

 

Methods: We reviewed patients 12 years old and above from the years 2022 – 2023 with Open Tibia Fractures who were managed with External Fixators. From that population, we grouped the patients on who used the external fixators as definitive management, with those who underwent Staged Surgery (who shifted into Ilizarov Fixators, Intramedullary Nails or Plating)

 

Results: The study involved 72 patients recruited, with 44% managed with definitive external fixation, 12% managed with Staged Surgery, and 43% excluded from the study. Out of the definitive external fixation group, 15% had complications, but all eventually underwent clinical and radiographic union. From the staged surgery group, the most common management used was plating (55%), followed by both Ilizarov Fixator application and Intramedullary Nailing (22%) Conclusion: External fixators can be a used as definitive management for those who had Open tibia fractures, but have to be monitored carefully with the incidence of complications. Further data is required to validate these findings and improve patient

management   

 

Local Infiltration Analgesia (LIA) in Skin Crease “Bikini Incision” Anterior Total Hip Arthroplasty (THA) for Neglected Femoral Neck Fractures: A Double-Blinded Randomized Control Trial (RCT)

Angelico Gabriel Lorena , MD

 

Introduction: The incidence of femoral neck fractures continues to increase along with the rise of the elderly population, and in the Philippines, a significant number becomes neglected. THA is the treatment of choice for previously healthy and active patients. LIA is a known adjunct for post-operative pain control, but its effects on THA via the “bikini incision” anterior approach are yet to be established.

 

Materials and Methods: 42 patients (21 per treatment arm) aged 50-80 years old who underwent THA via the said approach were included in a double-blinded RCT. Modified d’Aubigné-Postel score, pain control on Days 1 and 2 post-operative, and length of hospital stay were the measured outcomes. Independent Sample T-test, Mann-Whitney U test, and Fisher’s exact/Chi-square test were used to determine the difference of mean, rank, and frequency, respectively, between the two groups. Null hypotheses were rejected at 0.05α-level of significance.

 

Results: On Day 1 post-operative, LIA group had a higher Modified d’Aubigné-Postel median score compared to the placebo group (14 vs. 12, P-value 0.026). Day 1 median NRS of the LIA group was also slightly lower versus the placebo group (3 vs. 4, P-value 0.032). On Day 2 post-operative, NRS scores decreased for both groups, but the difference was not statistically significant (1 vs. 2, P-value 0.203). Number of rescue doses on both days and the length of hospital stay were not significantly different for both groups. No adverse effects to LIA were recorded.

 

Conclusion: LIA is effective in reducing pain only on Day 1 post-operatively, with the LIA group having statistically significant lower median NRS scores and a higher Modified d’Aubigné-Postel score. Since one of the goals of THA is to allow the patient to do immediate pain-free range of motion and ambulation, LIA should be considered as an effective adjunct therapy in achieving such goals.

 

Keywords: bikini incision, direct anterior approach, total hip arthroplasty, neglected femoral neck fracture, local

infiltration analgesia

 

From Ambulance to Ambulation: Prognostic Factors Associated with Ambulation Status in the Filipino Elderly Following Hip Fracture Surger

Samuel Nicolai Medina Baltazar, MD

Philippine Orthopedic Center

 

Introduction: Hip fractures among the elderly are associated with deleterious effects such as limitation of activities of daily living (ADL), gait impairment, and even death. Ambulatory status was identified aspredictive of 1-year mortality after hip surgery. In the study institution, operative treatment from admission to surgery averaged 26.9 days. This study aimed to associate prognostic factors such as delay in surgery and type of rehabilitation received with postoperative ambulatory status.

 

Methods: This ambispective analytical study included 140 patients aged 60 years and above admitted for hip fracture surgery. Pre-injury ambulation status was categorized as independent ambulatory (IA), assisted ambulatory (AA), and non-ambulatory (NA). Postoperative ambulatory status was assessed at 3-, 6-, and 12-month follow-ups. Type of rehabilitation was classified as either outpatient-based or home-based rehabilitation.

 

Results: Mean age was 74.8 years, with delay from injury to surgery at 33.1 days. 113/140 of patients were female, with 93 trochanteric and 47 femoral neck fractures. 76/140 patients underwent closed reduction internal fixation (CRIF). 75 patients had home rehabilitation while 65 underwent an outpatient program.

 

The average time to postoperative IA status was 4.4 months. IA status was achieved by 84.3% (118/140) of patients at 12 months.

 

Age increase by one year significantly lowers the probability of IA outcomes at 3-month and 6-month (RRR=0.89, p=0.015) follow-ups. Delay greater than 1 month from injury to surgery decreases IA outcomes significantly by 6 times at 3 months (RRR=0.17, p=0.006). Patients undergoing outpatient rehabilitation were 14 times more likely to achieve IA status at 3 months (RRR=14.19, p=0.003).

 

Conclusion: Increasing age, a delay greater than one month from injury to surgery, and home-based postoperative rehabilitation significantly hampered early independent ambulation in postoperative elderly patients. A multi-disciplinary approach in the management, from preoperative assessment and identification of delays to surgery to postoperative therapy and follow-up, is paramount to improved outcomes.

 

The degree of C-reactive protein elevation after total knee arthroplasty is related to bone and medullary injury rather than soft tissue

Won Kee Choi, MD

South Korea

 

First, we want to find out whether computer-assisted surgery (CAS) for total knee arthroplasty (TKA), which does not require opening the femoral medullary canal, results in a lesser CRP level increase postoperatively compared to manual TKA. Second, they seek to examine whether the CRP reduction in CAS TKA and manual TKA follows a similar pattern within the first two weeks after surgery. Third, the study aims to compare and analyze the CRP levels in three different groups: CRP levels in CAS TKA with surgeons who started TKA surgery by CAS, CRP levels in manual TKA by surgeons with little experience, and CRP levels in skillful manual TKA performed after conducting over 200 cases.

 

Methods: The three patient groups were as follows. Group 1: Patients who underwent non expertised surgeon’s CAS TKA (N=63). Group 2: Patients who underwent manual TKA after surgeon’s CAS TKA experience (N=108). Group 3: Patients who underwent manual TKA after surgeon’s 200 cases or more of either CAS TKA or manual TKA experience (more skillful manual TKA) (N=66). CRP levels were analyzed using electronic medical records for three time points: within 3 months before surgery, 5 days after surgery, and 11 days after surgery.

 

Results: There were no statistically significant differences in preoperative CRP values among the three groups. At 5 days after surgery, the CRP level were 48.59 ± 32.75 for CAS TKA, 69.82 ± 42.76 for early manual TKA, and 67.73 ± 44.00 for skillful manual TKA, indicating a statistically significant lower CRP level in the CAS TKA group compared to the manual TKA groups (P=0.01). At 11 days after surgery, there were no statistically significant differences in CRP level among the three groups, with was 12.12 ± 9.74 for CAS TKA, 14.07 ± 13.18 for early manual TKA, and 11.43 ± 11.45 for skillful

manual TKA.

 

Conclusions: The degree of C-reactive protein elevation after total knee arthroplasty is related to bone and medullary injury rather than soft tissue.

 

First Documented Case of Malignant Transformation in a Granular Cell Tumor of the Thoracic Spine in a 55-Year-Old Filipina

Gilbert John A. Mascardo, MD

University of Santo Tomas Hospital

 

BACKGROUND: Granular cell tumors are soft tissue tumors that originate from Schwann cells, which support and insulate nerve cells. Initially thought to be of muscular origin, they are now recognized as neural in nature due to advances in immunochemical staining and electron microscopy. These tumors are more common in females, particularly in their 4th to 6th decades of life, and usually present as solitary, painless masses. While most granular cell tumors are benign and slow growing, 1% to 2% can be malignant, characterized by local aggression or metastasis. Complete surgical excision with clear margins and close clinical follow-up is recommended for both benign and malignant cases. Malignant granular cell tumors have a poor prognosis and limited treatment options aside from surgery. This case report highlights a rare instance of a 55-year-old Filipina whose benign granular cell tumor of the T10 vertebrae underwent malignant degeneration.

 

CASE: This case report presents a 55-year-old retired teacher from Quezon City, Philippines, with a history of controlled hypertension, who experienced a gradually worsening upper back pain over several months. Initial symptoms included upper back pain that intensified over time, leading to difficulty in movement and ambulation. MRI revealed a compression deformity at the T9 and T10 vertebrae with signs suggesting tuberculous spondylitis. The patient underwent surgery for open biopsy and stabilization of the T10 vertebra. Post-operatively, the patient was diagnosed with a benign granular cell tumor based on histopathology. Despite initial recovery, the patient experienced a recurrence of symptoms, including an enlarging back mass, difficulty ambulating, and dyspnea. Further imaging showed a large, lobulated paravertebral mass with infiltration into adjacent structures. Eight months after the initial surgery, the patient underwent tumor debulking and posterior stabilization. Histopathology confirmed a malignant granular cell tumor involving the skeletal muscle and bone. The patient was eventually diagnosed with Stage IV malignant granular cell tumor and was placed on palliative care, receiving Pazopanib and pain management.

 

CONCLUSION: This case is significant as it represents the first reported instance of malignant transformation from a previously benign granular cell tumor in the spine, a rare occurrence with only 15 reported cases of spinal granular cell tumors. The prognosis for benign tumors is generally favorable, but malignant granular cell tumors are aggressive with a high risk of recurrence and metastasis. The case underscores the importance of complete tumor resection, close monitoring, and a multidisciplinary approach to manage symptoms and prevent complications in patients with granular cell tumors.

 

Comparison of Long Versus Short Cephalomedullary Nail Fixation for Unstable Intertrochanteric Femur Fractures: A Meta-analysis

Frederick Ferdinand S. Gomez, MD

University of Santo Tomas Hospital

 

BACKGROUND: This study aimed to primarily determine and compare clinical and treatment outcomes such as Harris hip score, mortality rate, complication rate, operative time, length of hospital stay and tip-to-apex distance of short and long CMN on fixation of unstable intertrochanteric fractures.

 

METHODOLOGY: This meta-analysis consisted of randomized control trials (RCTs) from electronic databases, PubMed and Google Scholar, published from 2013-2022 regarding CMN fixation for unstable intertrochanteric fractures. The RCTs included compared the results between short and long CMN using Review Manager 5.4 (RevMan 5.4) software. The random effects model was used to pool the data and the statistical heterogeneity.

 

RESULTS: A total of four RCTs and 330 patients were included in this study. The results showed that short CMN fixation has similar outcomes with long CMN, such as length of hospital stay, functional capacity after six months and complication rates. Lower length of operating time and mortality rate favored short CMN.

 

CONCLUSION: Short CMD provides better clinical and treatment outcomes than long cephalomedullary nail in fixation of unstable intertrochanteric fractures. This meta-analysis supports the use of short CMN.

 

Keywords: Intertrochanteric Fracture, Cephalomedullary Nail

 

Outcomes of Patients Undergoing Open Versus Percutaneous Release of Trigger Finger: A Meta - Analysis

Rafael Iñigo Mendoza Yutangco, MD

University of Santo Tomas Hospital

 

Background: Stenosing flexor tenosynovitis (trigger finger) is a condition involving inflammation of the flexor tendon sheaths and narrowing of the flexor pulleys, causing painful catching of the involved tendons. This condition can lead to significant functional impairment if it remains unaddressed. It can be treated conservatively with a variety of modalities, or operatively, with surgical release of the A1 pulley. Percutaneous release of the A1 pulley is another, less invasive alternative. Despite the published literature on the safety and viability of percutaneous release, surgeons prefer to perform open release due to reported complications of percutaneous release. This study aims to compare the outcomes of patients undergoing open versus percutaneous release in terms of success rate, recurrence rate, pain, and iatrogenic injury.

 

Method: The investigators conducted a comprehensive literature search using PubMed, Cochrane Library, Embase, Google Scholar and ScienceDirect from inception to 2021 for randomized controlled trials (RCT) comparing open release and percutaneous release of the A1 pulley in the management of trigger finger. Studies eligible for inclusion are randomized controlled trials comparing the outcomes of open and percutaneous release in adult patients diagnosed with trigger finger. Included studies were subjected for review and data extraction. Risk ratio, mean difference and 95% confidence intervals from each study were pooled using random-effects models.

 

Result: Five (5) RCTs involving a total 358 digits were included in this study. A total of 177 digits underwent percutaneous release and 181 underwent open release. There was no significant difference in the success rate of open and percutaneous release (RR=1, 95% CI=0.98-1.03, P=0.81). There were also no significant differences found in the recurrence rate (RR=1.4, 95% CI=0.25-7.99, P=0.70) of open release (2/43) and percutaneous release (3/46). In the studies that reported on iatrogenic injury, there were no reported incidences of iatrogenic injury in all 161 patients in each group. A standardized mean difference of 0.12 (P=0.51) for pain severity between both groups was found to be insignificant. In summary, there were no statistically significant differences found in the success rate, recurrence rate, iatrogenic injury, pain severity, and pain duration.

 

Conclusion: This meta-analysis shows that percutaneous release of the A1 pulley is comparable to open surgical release in the management of trigger finger in terms of success rate, recurrence rate, risk of iatrogenic injury, and pain severity. More studies may be warranted with standardized methods of percutaneous release technique, outcome measurement, and follow-up for even more reliable results.

 

Keywords: stenosing flexor tenosynovitis; trigger finger; hand surgery; percutaneous release;

open release; meta-analysis

 

 

 

Lateral Tibial Plateau Reconstruction using a Pedicled Patellar Transplant in a 35-year old male with Giant Cell Tumor: A case report

Francine Germaine S. Sy, MD

Jose R. Reyes Memorial Medical Center

 

Giant cell tumor, an aggressive benign tumor, primarily affects the epiphyseal-metaphyseal area of the long bones of young active adults. In such cases, preserving joint function is one of the therapeutic goals, thus articular restoration is ideally performed. We report a surgical approach in the treatment of a recurrent giant cell tumor in a 35-year-old male construction worker. The patient presented with an expansile lytic lesion on the epiphysis extending to the metaphyseal area of the lateral condyle of the tibia. Utilizing patella transplant with a vascular pedicle procedure, we performed a lateral tibial plateau reconstruction using a pedicled patellar transplant following a wide resection of the affected area. This intricate surgery also included augmentation with suture anchors to the application of a non-vascularized fibular strut graft, synthetic bone grafts, and extensive soft tissue reconstruction with a gastrocnemius flap and split thickness skin graft. Post-operative outcomes were promising, exhibiting significant healing, an improved knee motion range of 15 to 95 degrees, pain-free weight bearing, and no sensory or motor deficits. Follow-up radiographs confirmed the stability of the patellar and fibular grafts without any signs of tumor recurrence. This case presents the viability and benefits of using a pedicled patellar transplant in articular reconstructions, particularly for young, active patients. The technique offers several advantages including potential cost-effectiveness, lower risk of fibrosis and immunologic reaction due to its nature as an autograft and enhanced post-operative extensor mechanism functionality due to the vascular pedicle and augmentation with suture anchors.

 

Keywords: D’ Aubigne; pedicled patellar transplant; lateral tibial plateau reconstruction; giant

cell tumor

 

An Unusual Case of Septic Arthritis secondary to Pseudomonas Mendocina

Jason Christopher E. Salcedo, MD

University of Santo Tomas Hospital

 

Belonging to the family of Pseudomonadaceae, Pseudomonas mendocina is a rod shaped, aerobic, gram-negative bacteria that is found on soil and water (2). These are found rarely in humans and there are only a few cases reported around the world that, in contrast to the patient presented in this case, are commonly seen in immuno- incompetent and multi-comorbid individuals (2). When infected, this can lead to life- threatening conditions that can present diverse signs and symptoms. Due to its rare epidemiology, Pseudomonas mendocina is an organism not known to many, hence,signs and symptoms are initially under-treated and often present as severe upon diagnosis from physicians. The case presented was initially diagnosed as Hypertrophic Synovitis of the right knee due to his unremarkable history. But after a series of follow up, further evaluation and management, through specimens collected intraoperatively, the researchers were able to isolate the diagnosis as Septic Arthritis secondary to Pseudomonas mendocina.

 

Extraarticular total scapulectomy, with modified humeral suspension technique via polyethylene suture anchor; in patient with chondrosarcoma of scapula - a case report

Ryan Jasper Y. Ngo, MD

Jose R. Reyes Memorial Medical Center

 

INTRODUCTION: Scapula tumors, often presenting as pain or palpable lumps, pose a diagnostic challenge due to their potential for substantial growth before clinical intervention. Chondrosarcoma ranks as the second most prevalent bone sarcoma, constituting 20-25% of cases, with the scapula representing an uncommon site for its occurrence. Soft tissue sarcomas affecting the scapula, particularly in adults, necessitate careful assessment of surrounding anatomical structures. Surgical treatment, including the Tikhoff-Linberg procedure, has evolved to preserve functionality, replacing traditional forequarter amputation. Reconstruction options post-scapular resection involve diverse methods, with humeral suspension techniques, including suture anchors, gaining attention.

 

CASE SUMMARY: A 20-year-old male presented with right shoulder pain and a rapidly enlarging mass, ultimately diagnosed as malignant chondrosarcoma secondary to osteochondroma. Extensive palpable masses on limbs since childhood indicated a

delayed consultation. Radiographic and MRI findings revealed a sizable cystic mass infiltrating the scapula, surrounding muscles, and exhibiting bony erosion. Core needle biopsy confirmed the diagnosis.

 

DISCUSSION: Chondrosarcoma of the scapula’s rarity poses challenges in treatment standardization. Surgery remains pivotal, with ongoing debates on adjuvant therapies. Reconstructive challenges post-scapulectomy emphasize the importance of preserving deltoid function. The declining use of humeral suspension due to prosthetic advancements prompts strategic considerations. Alternatives, such as scapular allografts and innovative hip spacer techniques, provide diverse options.

 

CONCLUSION: The study introduces suture anchors as a viable humeral suspension alternative post-Tikhoff-Linberg resection, demonstrating satisfactory mid- to long-term outcomes. In resource-constrained settings, this technique offers a cost-effective option, preserving upper extremity function while acknowledging inherent shoulder motion limitations. The study contributes to the evolving landscape of scapula tumor management and reconstruction techniques.

 

A Case Report on Legg-Calve-Perthes Disease treated with Greater Trochanter Guided Growth using an Eight-Plate

Zakhira Maye R. Zipagan, MD

Jose R. Reyes Memorial Medical Center

 

Background: Legg-Calvé-Perthes disease is a pediatric orthopedic condition brought about by the disruption of blood supply to the femoral capital epiphysis which results to epiphyseal osteonecrosis and chondronecrosis with the cessation of growth of the epiphysis. If left untreated, this disease condition may pose life-long consequences on a child’s hip dynamics.

 

Case Summary: A 10-year-old boy presented in the Emergency Department with right hip pain and limping. After thorough history, physical examination, and diagnostics, patient was diagnosed with Legg-Calvé-Perthes disease, Waldenström Fragmentation Stage, Herring Lateral Pillar Classification B. He underwent right hip arthrogram, adductor tenotomy, and guided- growth of the greater trochanter with subsequent application of Petrie cast.

 

Conclusion: The concept of the current treatment approaches for Legg-Calvé-Perthes Disease is based on the principle of containment wherein the femoral head must be “contained” in the acetabular cup to prevent further deformation.

 

Historically, most surgical procedures indicated for management of LCPD are invasive and may still lead to complications requiring multiple surgeries. A relatively new and less invasive technique, guided growth of the greater trochanter was done for this patient. Although still in early stages of follow-up, there is already noted improvement

 

Machine Learning and Neural Networks in Spinal Imaging: A Systematic Review of Diagnostic Accuracy for Thoraco-Lumbar Degenerative Pathologies

Leo Francis S. Diaz, MD

The Medical City

 

Background: The diagnosis of thoracolumbar degenerative pathologies, such as Lumbar Disc Herniation (LDH) and Spinal Stenosis (LSS), traditionally relies on manual interpretation of MRI and CT scans, a process that is often subjective and prone to error. The integration of artificial intelligence (AI), particularly machine learning (ML) and neural networks (NN), offers a promising alternative by enhancing diagnostic accuracy and consistency.

 

Methodology: This systematic review followed PRISMA guidelines to evaluate the diagnostic accuracy, specificity, and sensitivity of AI technologies compared to traditional manual imaging analysis. A comprehensive search was conducted across databases including PubMed, Medline, Scopus, and Cochrane, focusing on studies published from 2018 to 2023. Twelve peer-reviewed studies met the inclusion criteria and were analyzed.

 

Results: The review found that AI technologies, specifically those utilizing machine learning (ML) and convolutional neural networks (CNNs), showed acceptable to high accuracy rates ranging between 80.5% to as high as 98%. The studies also showed enhancements in specificity and sensitivity, with sensitivity rates ranging between 65.2% to 98% and specificity ranging between 78.6% to 99%. Precision or reliability among observers was also acceptable, varying between 73.2% and 96.4%. However, heterogeneity in AI model development and technological application across different datasets was observed, highlighting the need for further validation.

 

Conclusion: AI integration in spinal imaging for thoracolumbar degenerative pathologies demonstrates substantial potential to improve diagnostic precision and reduce human error. Despite the promising results, the variability in AI performance indicates the necessity for ongoing research and validation before these technologies can be reliably implemented in clinical practice.

 

Keywords: Artificial Intelligence in Spinal Imaging, Machine Learning for Spinal Pathologies

 

Anterior Cervical Approach in Spine Surgery: A 10-Year Retrospective Analysis of Complications

Joseph Dan C. Bullecer, MD

Chong Hua Hospital

 

Background: The anterior cervical approach is a widely employed surgical technique for addressing cervical spine pathologies, including trauma, degenerative conditions, tumors, and infections. However, the complexity of the anterior cervical region’s anatomy, involving vital vascular, neural, and aerodigestive structures, makes the procedure prone to complications. Commonly observed complications include dysphagia, recurrent laryngeal nerve palsy, esophageal perforation, and new or worsening neurological deficits. Understanding the frequency and nature of these complications is essential for improving surgical outcomes and refining patient management.

 

Objective: This study aims to evaluate the incidence and types of complications encountered during anterior cervical spine surgery over a 10-year period. It seeks to identify the relationship between patient demographics and complication rates, assess the initial management strategies for these complications, and evaluate the associated clinical outcomes. The study also investigates the impact of surgical variables, particularly the number of operative levels, on the risk of complications.

 

Methods: A retrospective review of 131 anterior cervical surgeries conducted between January 2010 and June 2024 was performed. The study assessed key variables such as patient age, sex, operative time, blood loss, underlying pathology, number of operative levels, and type of procedure. Complications were categorized as intraoperative or postoperative, and statistical analyses, including chi-square and regression analyses, were used to identify significant factors influencing complication rates.

 

Results: The overall complication rate was 12%, with the most common complications being dural tears (3.1%), dysphagia (2.3%), new neurological deficits (2.3%), and airway-related complications (2.3%). Less frequent complications included vertebral artery injury (0.8%) and C5 palsy (0.8%). No statistically significant associations were found between complication rates and patient demographics, operative time, blood loss, or the underlying etiology of the surgery. However, a significant correlation (p = 0.034) was observed between the number of operative levels and complication risk. For each additional operative level, the odds of experiencing a complication increased by 1.43, with three-level surgeries carrying four times the risk of complications compared to single-level surgeries.

 

Conclusion: This study underscores the critical role of the number of operative levels in determining complication risk during anterior cervical spine surgery. While patient demographics and other surgical variables did not significantly affect complication rates, multi-level surgeries presented a higher risk, necessitating careful preoperative planning and patient counseling. The findings suggest that further research with larger sample sizes and exploration of additional factors, such as patient comorbidities and advanced surgical techniques, is needed to enhance the understanding and management of complications in anterior cervical surgeries.

 

Keywords: Anterior cervical spine surgery, complications, dural tears, dysphagia, vertebral artery injury, multi-level surgery, retrospective case series.

 

Outcome of Operative management in Lisfranc Injury: A 2 year prospective Study

Joan Francine Uy Perez, MD

Chong Hua Hospital

 

The Lisfranc joint is a critical structure in the foot, encompassing the tarsometatarsal joints and associated rticulations. Injuries to this area, termed Lisfranc injuries, in terms of management, nonoperative treatment is typically limited to cases without signs of instability. Conversely, operative intervention is usually warranted for most Lisfranc injuries. The lack of definitive evidence for treatment protocols contributes to uncertainty about long-term functional outcomes.

 

Study Design: This is a 2-year prospective study wherein the patient population was taken from a tertiary hospital from December 2022 to 2024. Patients of any age or sex regardless of comorbidities and smoking status, diagnosed with Lisfranc injury, injury classification, whether they sustained an open or closed injury, and those who underwent operative anagement. Operative management via open or closed reduction and type of fixation.

 

Results: Between December 2022 to 2024, 34 patients were diagnosed with Lisfranc injuries, only 23 underwent operative management and follow up at 6 weeks, 2 months, 6 months, 1 year and 2 years which shows a clear progression from non-weightbearing immediately after surgery to full weightbearing within 6 months. Both AOFAS and MFS showed good functional with recovery correlating with injury severity. Screw breakage observed at 1-year mark in 1 patient and another patient at 2 years. Infection was noted in one patient at 6 weeks. Overall, there is a favorable long- term outcome, with implant failure being minimal and primarily related to screw breakage and early-stage infections.

 

Conclusion: At 2-year follow-up, all patients were able to go back to their desired daily activities. Infection was correlated to the open injury which was resolved after antibiotic intake. Those with screw breakage were noted to be asymptomatic at 2 years follow up. Risks and benefits of removal of implant prior to failure should be comprehensively discussed and decision should be made by both surgeon and patient.

 

Conversion From Knee Arthrodesis to Megaprosthesis in Patients with Osteosarcoma Around The Knee: A Case Series From Chong Hua Hospital Cebu

Cail Aleksei Vizcarra Lingatong, MD

Chong Hua Hospital

 

Background: Osteosarcoma (OS) is the most common bone tumor in adolescents, often affecting the knee. While megaprostheses offer optimal functional reconstruction, their high cost in resource-limited settings necessitates alternative strategies such as arthrodesis. This study explores the use of arthrodesis utilizing a spacer (intramedullary nail and bone cement) as a temporary reconstruction method, followed by conversion to total knee megaprosthesis with an interval of more than 4 years, a scenario with limited documentation in literature.

 

Objective: To present cases of patients with osteosarcoma who underwent knee arthrodesis and were later converted to total knee megaprosthesis with an interval of more than four years.

 

Methods: We report three cases of patients initially treated with arthrodesis using intramedullary nails and bone cement spacers. Each patient received neoadjuvant and adjuvant chemotherapy, followed by conversion to megaprosthesis after four years. Patients were regularly followed up to monitor outcomes.

 

Results: All patients expressed high satisfaction post-conversion, reporting significant improvements in ambulation, emotional acceptance, and overall functional status. Despite complications and challenges inherent to the conversion procedure compounded by the prolonged knee fusion, the overall outcomes were positive, with a mean MSTS score of 23 and maximum knee flexion gain of 80 degrees in 1-year post-conversion.

 

Conclusion: Conversion of knee arthrodesis following tumor resection to total knee megaprosthesis can yield favorable functional outcomes, even after a prolonged time interval—a scenario rarely reported in literature. This option is particularly appealing for patients seeking to restore some degree of knee mobility for improved functionality. Despite not being able to fully regain normal knee range of motion, patients especially the younger ones, still opt for total knee megaprosthesis fully aware of the associated complications and challenges.

 

Scoliosis Surgery and Spinal Fusion in A Patient with Turner S Syndrome and its Outcome: A Case Report

Rosell, Jeremy Patrick, MD

Chong Hua Hospital

 

Turner’s syndrome is a major problem in health that is commonly a congenital disorder and is caused by missing chromosome X and presents itself with scoliosis and other abnormalities like webbed neck, short stature, amenorrhea osteoporosis, and other cardiovascular abnormalities. This is connected to the rise in prenatal ultrasound screening and the decision made by some mothers carrying babies with Turner syndrome to end the pregnancy. Again, when compared to people without Turner syndrome, the age at risk is extended and the likelihood of developing scoliosis is greater. Even though there is no absolute treatment for the condition still, these treatments have been successful in treating some of the conditions related to Turner’s and Scoliosis syndrome. Apparently, in Turner’s and Scoliosis syndrome condition, cardiovascular disease is the main cause of death for patients suffering from the disease. To manage this, cardiovascular surgery is the only operative management that can be taken in Turner’s and Scoliosis syndrome. This is a case of a fourteen-year-old female with Turner’s syndrome who underwent Scoliosis surgery with spinal fusion.

 

Closing Wedge Tibiotalar Osteotomy In a 21 Year Old with Recurrent Osteochondroma of the Talus: A Case Report

Isabella Victoria Sison Rosello, MD

Chong Hua Hospital

 

An osteochondroma is a common benign tumor of the bone usually developing in the metaphases of the long bones and involving both cortical and medullary bone and capped with cartilage. It is the most common bone tumor and usually develops in the metaphyses in the long bones of the proximal humerus, tibia, and distal femur. The location of an osteochondroma in the foot is exceedingly rare, with fewer than 30 cases previously described in literature. This case report describes the rare presentation of recurrent talar osteochondroma in a 21-year-old male who was managed with surgical resection and a closing wedge talar osteotomy.

 

Neuropathic Pain Following Open Femoral Nailing Using The Pain Detect Questionnaire-Cebuano

Leoncio S. Tajon, MD

Northern Mindanao Medical Center

 

Introduction: Neuropathic pain following surgery is a widespread complication observed across various surgical disciplines. In orthopedic surgery, open reduction of a femur fracture followed by intramedullary nailing is indicated for fractures that cannot be reduced by closed means or when treatment is delayed. In regions where open reduction is commonly performed for femoral fractures, neuropathic pain may be inadequately diagnosed and untreated. Although several screening questionnaires have been developed for neuropathic pain, only the painDETECT questionnaire (PDQ) has been translated and cross-culturally adapted from English to Cebuano (PDQ-Ceb).

 

Methods: A retrospective review of 50 open reduction femoral intramedullary nailing cases from May 2023 to June 2024 was conducted in a public referral hospital. Follow up was in the orthopedic outpatient clinic at 30, 60, and 90 days postoperatively. The validated Cebuano translation of the PDQ (PDQ-Ceb) questionnaire was used on each visit. Patients with neuropathic pain were given appropriate medication upon diagnosis. The PDQ-Ceb scores and VAS scores of the 50 patients were analyzed using a two-tailed paired t-test. Results: Thirty days after surgery, 8% of patients experienced neuropathic pain following open intramedullary nailing of the femur. The mean PDQ-Ceb score at the 30 th day postoperative was 11.8 (SD= 5.337, SEM= 0.759). Prevalence of neuropathic pain drops to 0% at the 60 th and 90 th postoperative day with mean scores of 5.8 (SD = 4.439, SEM= 0.628) and 3.5 (SD= 3.221, SEM= 0.456), respectively. A two-tailed paired t-test on the 30 th and 60 th day PDQ-Ceb scores showed a significant decrease in score (p-value= 0.0001) as well as on the 60 th and 90 th day (p-value= 0.0035). A significant decrease in VAS score was observed at intervals of 30 and 60 days (p-value= 0.0001) and 60 and 90 days postoperatively (p-value= 0.0001).

 

Conclusion: An 8% prevalence of neuropathic pain was observed at 30-days postoperative with a dramatic drop thereafter. Likewise, a significant decrease in PDQ-Ceb scores was seen at each interval. There was also a significant decrease in VAS scores as recorded using the PDQ-Ceb at each interval. Use of the PDQ- Ceb screening questionnaire after open femoral surgery may allow for the diagnosis and earlier initiation of treatment for neuropathic pain.

 

Keywords: neuropathic pain, femur nailing and PDQ-Ceb

 

Clinical Practice Guidelines in Action: Differences in Femoral Neck Fracture Management by General Orthopedics and Arthroplasty specialists in the Philippine Setting – A Cross-Sectional Study

Meryll S. Gilbuena, MD

Victoriano Luna Medical center/ Armed Forces of the Philippines Medical Center

 

Femoral neck fractures are common in older adults, with 125,000 cases annually, a number likely to grow with aging populations. Treatment options vary based on age, activity level, and bone quality. This study explores management differences between general orthopedic and arthroplasty-trained surgeons in the Philippines.

 

Methods: A cross-sectional survey of 120 orthopedic surgeons was conducted, with questions on demographics and clinical vignettes assessing surgical decision-making for femoral neck fractures.

 

Results: In Case 1, the arthroplasty group (n=47) had 2.12% of surgeons considering age, with 21.27% opting for hip hemiarthroplasty, 53.19% for total hip arthroplasty, and 19.14% for ORIF. In the non-arthroplasty group (n=73), 63.01% preferred hemiarthroplasty, 30.13% total hip arthroplasty, and 8.21% ORIF. For femoral fixation, 73.91% in the arthroplasty group chose cemented fixation, compared to 27.39% in the non-arthroplasty group. In prosthesis types, 67.39% of the arthroplasty group used bipolar heads, while 71.62% in the non-arthroplasty group did. The posterior approach was used by 58.7% in the arthroplasty group and 51.35% in the non-arthroplasty group.

 

In Case 2 (n=46), 76.08% in the arthroplasty group preferred hemiarthroplasty, and 19.56% chose total hip arthroplasty. For fixation, 73.91% in the arthroplasty group and 75.34% in the non-arthroplasty group selected cemented fixation. A bipolar prosthesis was preferred by 76.08% in the arthroplasty group, with the posterior approach used by 63.04%. Spinal or regional anesthesia was chosen by 71.73% in the arthroplasty group and 81.08% in the non-arthroplasty group.

 

Conclusion: This study highlights notable differences in surgical preferences between arthroplasty and non-arthroplasty groups. The arthroplasty group favored total hip arthroplasty, while the non-arthroplasty group preferred hip hemiarthroplasty. Both groups showed a strong preference for bipolar femoral heads and commonly used the posterior surgical approach. These findings reflect the varied strategies in hip fracture management based on the type of procedure.

 

Keywords: Femoral Neck Fractures, Orthopedic Surgery, Arthroplasty, Clinical Practice Guidelines (CPG), Geriatric Hip Fractures, Total Hip Arthroplasty (THA), Hemiarthroplasty (HHA), Surgical Decision-Making, Orthopedic Training, Philippine Healthcare, Evidence-Based Practice, Fracture Management, Resource-Limited Settings, Surgeon Experience, Surgical Techniques.

 

  

The Price of Motorcycle Accidents:A One-year Study on the Economic Cost of Motorcycle-related Orthopedic Treatment for Patients Admitted for Tibia Fractures in a Tertiary Specialty Orthopedic Hospital in the Philippines

AC Pimentel, MD

Northern Mindanao Medical Center

 

Background: Motor vehicular accidents are a frequent cause of musculoskeletal trauma and may lead to debilitating conditions that require admission and orthopedic surgical care, causing patients to lose days of work, signifying a socioeconomic impact. Motorcycle use in the Philippines has a growing trend. This growing trend can be appreciated in the Philippine Orthopaedic Association Trauma Registry Reports.

 

Methodology: A single-center, prospective, study was performed in Philippine Orthopedic Center, a tertiary, national orthopedic specialty government hospital. The study population included patients aged 18-65 years old with tibia fractures secondary to motorcycle-related trauma seen and treated at the Philippine Orthopedic Center Emergency Room. Patients admitted at the emergency room for motorcycle-related tibia fractures were asked to answer a demographic information form that acquired data such as occupation and salary of the patient and the companion.

 

Results and Discussion: There is a significant productivity loss of patients with motorcycle-related fractures, which also affects the productivity of their caretakers or relatives. For tibia fractures, it takes an average of 8 months of lost productivity, and a cost of more than 200,000 pesos projected income loss.

 

Keywords: “Motorcycle accident”; “Tibia fracture”; “Cost”

 

Disclosure: The authors of this study declare that they have not received benefits for personal or professional use from any commercial party related to the topics discussed in this paper.

              

Isolated Tillaux-Chaput fracture in an adult – Rare and neglectable fracture of the anterolateral tubercle of the distal tibia in adult: A Case Report

John Stephen De Mesa, MD

Makati Medical Center

 

Tillaux-Chaput fractures are a rare avulsion fractures of the tubercle, located at the anterolateral aspect of the distal tibia usually caused by failure of the anteroinferior tibiofibular ligament to rupture during extreme supination external rotation of the ankle. This fracture was initially described by Cooper in 1822 and further proven by Tillaux in 1848; the same injury at the posterior portion was coined by Chaput, hence the term Tillaux-Chaput fracture.

 

The tubercle is located inferior to the shallow triangular indentation that receives the distal portion of the fibula. The anteroinferior and posteroinferior tibiofibular ligaments are attached. We describe a case report of a Tillaux-Chaput

 

Fracture in an adult, when not diagnosed may lead to premature degenerative arthritis and restricted ankle movement. This is a case of a 52-year-old, ambulatory female, presented with accidental twisting of the left ankle while going down the stairs, sustained two weeks prior. Preoperatively, on physical exam, there were no gross deformities nor open wounds, but presented with severe tenderness on the anterolateral aspect of the left distal tibia. Radiographic findings showed a displaced fracture fragment at the anterolateral aspect of the distal tibia. Patient was temporarily placed on a coaptation splint, given pain mediation, and advised to apply ice compress and elevate the leg for 1 week to decrease swelling prior scheduling procedure. There was noted 14.8x 14.1x9.5mm fragment that has a 1.92mm displacement and a stepoff of 3.1mm. Patient underwent open reduction internal fixation using a 4mm lag screw with washer through an anterolateral approach, with K-wires to provide provisionary fixation. Adequate reduction of the fragment was directly visualized and with intraoperative imaging. Postoperatively, patient was then placed on a short leg posterior splint for immobilization and weight bearing was not allowed for 4 weeks. After which, progressive mobilization of the ankle will be allowed with partial weight bearing, then progress to full weight bearing with bootcast by 6 weeks. Boot cast will be fully removed by 8 weeks.

 

DISCUSSION: In adult Tillaux fracture, the shape is usually triangular, compared to Juvenile which is quadrangular. The mechanism of injury is an external rotation of the foot, and deforming force is anteroinferior tibiofibular ligament. It may be difficult to see on standard radiographic views, hence an oblique view is recommended. If the fracture displacement is less than 2mm, then it can be treated conservatively, while if more than 2mm surgical reduction may be of importance to stabilize. Single screw fixation is the most common surgical procedure. Early mobilization is important, weight bearing allowed once radiographic union seen.

 

CONCLUSION: Isolated Tillaux-Chaput fractures in adults are rare for distal tibial fractures and needs a comprehensive approach to avoid misdiagnosing and provide proper management. Open reduction with internal fixation with early mobilization will maximize a successful outcome. A meticulous follow-up is warranted to manage any complications that may arise. The case report demonstrates that the anterolateral approach with a simple lag screw can give a stable fixation and would allow early mobilization that leads to a successful outcome for the patient.

 

Anterior Lumbar Interbody Fusion Combined with Percutaneous Endoscopic Lumbar Discectomy in a Severely Obese Patient: A Case Report

Alfred Jerald I. Salvador, MD

Makati Medical Center

 

Background: Lumbar radiculopathy, primarily due to disc herniation and degenerative spondylolisthesis, often necessitates surgical intervention. Anterior lumbar interbody fusion (ALIF) and percutaneous endoscopic lumbar discectomy (PELD) are emerging as effective strategies, particularly in the context of increasing patient obesity.

 

Objective: This case report examines the surgical management of a severely obese patient with concomitant lumbar disc herniation and spondylolisthesis using a combination of ALIF and PELD. Case: A 35-year-old female with a BMI of 35.9 presented with severe right leg pain and radiculopathy. Preoperative imaging confirmed anterolisthesis at L5-S1, along with herniated discs at L4-L5 and L5-S1, with the one at L4-L5 being calcified. The patient underwent ALIF followed by PELD, with pedicle screw fixation performed percutaneously.

 

Results: The surgical approach utilized a paramedian incision with a retroperitoneal corridor for paramedian incision and a retroperitoneal corridor the ALIF, allowing for optimal visualization, preparation, and insertion of the interbody cage. PELD was subsequently performed to decompress the affected nerve roots. The patient experienced complete relief of radiculopathy and mechanical back pain within 24 hours postoperatively, with a visual analog scale (VAS) score of 2-3/10 for incisional pain. She was ambulating by postoperative day one and discharged uneventfully by day two.

 

Conclusion: This case illustrates the successful application of combined ALIF and PELD in a severely obese patient, highlighting the feasibility and advantages of a minimally invasive approach. The combination effectively addressed both instability and nerve root compression while minimizing incision size and postoperative recovery time. Preoperative imaging and careful surgical planning were essential to navigate the complexities presented by obesity, ultimately ensuring optimal surgical outcomes.

 

Review of Outcomes of Percutaneous Administration of Platelet-Rich Plasma as an Independent Treatment of Long Bone Aseptic Nonunion in the Upper Extremities among Military Personnel and their Dependents: A Case Series

Marlon P Mejia, MD

Victoriano Luna Medical center/ Armed Forces of the Philippines Medical Center

 

Background: Nonunion occurs when a fracture fails to heal within the anticipated time which varies depending on the bone involved. Limitations on bone healing management still leaves patients with pain, decreased quality of life, and related psychological, social, and economical consequences. Standard management for nonunion includes bone grafting with replacement or revision of the metallic implant; however, these would necessitate re-operation which is more costly, and which would place the patient at risk to develop surgically related complications. Recent Studies have proposed percutaneous Platelet rich plasma (PrP) injection as non-invasive management for the treatment of nonunion.

 

Methods: A case series design was employed with 7 patients diagnosed with nonunion on the upper extremity. PrP administration to the nonunion site using a standardized protocol was done. Improvements in pain scale and function

were assessed using the VAS and DASH scores. Radiographic union was assessed through Modified Lane Radiographic Scoring System. Results were analyzed using the weighted mean and standard deviation of the outcomes from various measurement tools.

 

Results: The initial mean VAS score was 4.29 (SD=2.56) and was decreased to 2.71 (SD=1.38) and 0.71 (SD=0.76) on consecutive follow up which showed a decreasing trend. Improved activities in daily living were observed in all subjects with improvement in functional scoring through the DASH scoring system with the mean DASH score of 28.74 (SD=4.06) on last follow up. Mean MLSRS score was 1.98 and demonstrated an increasing trend by the third evaluation with mean score of 7.10 (SD=1.59).

 

Conclusion: Platelet rich plasma (PrP) is a beneficial and a cost-effective mean of providing initial management of nonunion. The study provided evidence of enhanced bone healing process to achieve clinical and radiographic union

by administering percutaneous PrP resulting to better functionality.

 

Keywords: Nonunion, Platelet Rich Plasma, Modified Lane and Sandhu

 

Effectiveness of Augmentation Plating with Application of Iliac Bone Graft Over a Retained Intramedullary Nail for Managing Femoral Aseptic Nonunion: A Case Series

Marc Romy Sheehan M. de Guzman, MD

Victoriano Luna Medical center/ Armed Forces of the Philippines Medical Center              

 

Background: Aseptic femoral nonunion after treatment with intramedullary nailing poses a significant challenge, despite advancements in orthopedic surgery techniques. Nonunion is a complication in which the fractured bone fails to heal properly, leading to prolonged pain, functional impairment, and disability. Various treatment modalities are available for managing femoral nonunion, including dynamization, bone grafting, exchange nailing, compression plating, and Illizarov fixation. Among these, augmentation plating with iliac bone grafting over a retained intramedullary nail offers a promising alternative that may be more effective for specific patient populations. This method aims to enhance biomechanical stability and biological healing potential, reducing healing time and improving clinical outcomes.

 

Objective: This study aims to evaluate the functional outcomes of aseptic nonunion of femoral shaft fractures treated with augmentation plating and iliac bone grafting over a retained intramedullary nail.

 

Method: Five patients diagnosed with aseptic nonunion of femoral shaft fractures, previously treated with intramedullary nails, underwent treatment with augmentation plating and iliac bone grafting. The retained intramedullary nails were not removed during the procedure. These patients were treated between 2020-2023 and were regularly followed up post-operatively. Clinical and radiological signs of healing were assessed using X-rays and the Wu scoring system preoperatively and postoperatively, which evaluates the functional and radiographic aspects of bone healing.

 

Results: All five patients achieved successful bony union with a mean healing time of 5.4 months, ranging from 4 to 8 months. According to the Wu scoring system, three (3) patients demonstrated excellent outcomes, while two (2) showed good results. Importantly, no complications were recorded during the follow-up period.

 

Conclusion: Augmentation plating with iliac bone graft is an excellent option for treating aseptic nonunion of the femur as evidence by reduced pain levels, improved range of motion, enhanced ability to ambulate independently, reduced residual deformity and radiologic union with no complications.

 

Keywords Femoral nonunion · Augmentation plating · Bone Grafting · Intramedullary nailing

 

Chronic Distal Biceps Tendon Rupture: A Novel Technique in Tendon Reconstruction with Tensor Fascia Lata and Cortical Button: A Case Report

Ericson F. Hernandez, MD

De La Salle Medical and Health Sciences Institute

 

Introduction: Chronic distal biceps tendon ruptures are challenging due to tendon retraction, scarring, and tissue compromise. Surgical treatments often require autografts or allografts for augmentation, such as fascia lata, semitendinosus, or Achilles tendon. Although Fascia Lata was described for grafting there’s no published detailed operative technique. This paper highlights a novel technique using Autologous Tensor Fascia Lata (TFL) with a cortical button as a local graft source for chronic distal biceps tendon ruptures.

 

Case Discussion: A 57-year-old man presented with pain and limited motion in his left elbow after lifting heavy object, resulting in a distal biceps tendon rupture. Preoperative assessment showed a severe disability with a Fil DASH score of 50.6. Surgery involved reconstructing the ruptured tendon using a 16 cm x 2 cm TFL graft to bridge the gap. The TFL was chosen due to its strength, durability, and ability to reconstruct the significantly retracted tendon without significantly affecting the donor site. The patient showed marked improvement over 9 months, with an improved Fil DASH score and full range of motion in the elbow, including flexion, extension, pronation, and supination, without associated pain.

 

Conclusion: This novel approach using TFL for Distal Biceps Tendon Rupture Reconstruction is promising, offering benefits like strength, size, minimal donor site morbidity, and better healing potential. The technique may provide superior outcomes compared to conventional methods, and documenting its results is crucial for future surgical advancements.

 

Diagnostic Value of Neutrophil-Lymphocyte Ratio (NLR) in Early-onset Degenerative Osteoarthritis Among Military Personnel: A Retrospective Study

Rafael Angelo Z Cauilan, MD

Victoriano Luna Medical center/ Armed Forces of the Philippines Medical Center

 

Osteoarthritis (OA) is a degenerative joint disease and a leading cause of disability, particularly affecting the knees, hips, and hands. With an estimated 300 million people globally impacted, OA primarily manifests in older adults, leading to joint pain, stiffness, and reduced functionality. Knee osteoarthritis (KOA), in particular, poses a significant health challenge for individuals engaged in physically demanding activities, such as military personnel, where early detection is crucial for effective management. While radiographic imaging is the most common diagnostic tool, it has limitations in identifying early-stage OA. This study investigates the potential of using the neutrophil-to-lymphocyte ratio (NLR) as a diagnostic marker for KOA severity and progression. A retrospective cross-sectional analysis was conducted at Victoriano Luna Medical Center, Philippines, involving 35 patients with knee OA. Results showed significant correlations between NLR levels and OA severity, as classified by the Kellgren-Lawrence grading system. Higher NLR values were associated with more advanced stages of OA, highlighting the role of systemic inflammation in disease progression. Furthermore, a strong correlation between age, years of service, and OA severity was observed, suggesting that older individuals and those with longer service years are at higher risk for severe OA. The study concludes that NLR is a promising marker for early detection and monitoring of KOA. These findings advocate for incorporating NLR assessments into routine OA evaluations to enhance early intervention strategies, particularly among military personnel. Recommendations include increasing public awareness, promoting regular physical activity, improving healthcare access, and utilizing multidisciplinary treatment approaches. Further research on NLR and its role in OA progression is encouraged to optimize diagnostic and therapeutic protocols.

 

Sacral rib, An Aberrant bony outgrowth, A case report

Sharra Mae L. Martin, MD

Dr. Jose N. Rodriguez Memorial Hospital and Sanitarium

 

Background: Vertebral Anomalies are well defined and studied in many literatures. However, accessory ribs involving the sacrococcygeal region are rare, but if present, are more common in the cervical and lumbar area. Sacral rib is a benign congenital anomaly commonly seen in females. Patients are often asymptomatic and diagnosed incidentally radiographically. Sacral Rib, is often treated conservatively with observation and reassurance. Surgical management is

reserved for symptomatic and patients with functional impairment.

 

Case: This is a case of a 24-year-old female who presented with a mass on the superolateral border of the right gluteal area, associated with pressure pain. Radiographs revealed a rib-like osseous structure with smooth cortical lining attached to the sacrum with soft tissue extension. Marginal resection with lipectomy and skin plasty over the right gluteal area was done. Post operatively, patient was pain free and better cosmesis was provided. 

 

Conclusion: sacral rib should be recognized as one of the differentials for sacral mass. Our report provides a detailed description of a case of sacral rib, anatomic relationships, morphogenesis, and clinical implications.

 

Keywords: Sacral rib, congenital anomaly, accessory rib

 

Correlation of Femoral Tunnel Placement in Medial Patellofemoral Ligament Reconstruction with Functional Outcomes

Gian Dominique D. Galman, MD

Makati Medical Center

 

The isometric point in medial patellofemoral ligament reconstruction has been well defined. In 2007, Schöttle described radiographic landmarks of the isometric insertion of the MPFL. There have been literature stating that non-anatomical reconstruction of the MPFL may change patellofemoral contact pressures. This study aims to determine if the accuracy of femoral tunnel placement to the isometric point has a correlation with patient functional outcomes after medial patellofemoral ligament reconstruction. Secondarily, the study also aims to identify whether the direction of the femoral tunnel placement in reference to Schöttle’s point has a correlation with patient outcomes. This study is a retrospective cohort analysis. It included patients in a single tertiary hospital from 2018 to present who underwent isolated medial patellofemoral ligament reconstruction. Using postoperative lateral knee x-rays, the absolute distance of the femoral tunnel to the isometric point (as described by Schöttle) was measured. The absolute distance was then classified classified as the femoral tunnel position is acceptable if it is <10mm or unacceptable if >10mm. The femoral tunnel position in relation to the isometric point was determined by creating 4 quadrants on Schöttle’s point and verifying if the femoral tunnel falls antero-superior, antero-inferior, postero-superior, and postero-inferior. Patient functional outcome scores were determined using Kujala patello-femoral score and International Knee Documentation Committee score. The study included 26 patients who underwent isolated MPFL reconstruction. Out of the 26 patients, 9 (34.6%) femoral tunnel distances were classified as unacceptable and 19 out of the 26 femoral tunnels were antero- inferior, 3 were antero-superior, 2 postero-inferior, 1 posterior, and 1 postero-superior. The average Kujala score was 88 and IKDC scores were 80. There was no significant correlation noted between femoral tunnel distance and femoral tunnel position to patient functional outcomes.

 

Vietnamese Artificial Intelligence Models For Detecting Knee Injuries: Bench-to-bedside

A/Prof. Cao Thi, MD

 

Introduction: Efficient and accurate detection is vital for the diagnosis and treatment of knee injuries. In recent years, there is an increase in interest in deep learning approaches to detecting knee injuries in MR images. Studies have shown that deep learning models are capable of reaching the same level as human radiologists when it comes to sensitivity and specificity, while at the same time requiring significantly less training time. Current AI-based systems are, however, still limited by many different factors, such as unbalanced classes in training data, or the nature of these systems which makes false positives and false negatives almost an inevitability. There are multiple routes for improving upon the existing deep learning knee injury detection models. As they continue to become more and more advanced, it is expected that the use of these systems will become more popular in the future.

 

Method: In this study, we create multi models based on machine learning and deep learning algorithms to perform classification, recognition, and segmentation tasks on knee MRI images. In which the two most important components in the knee joint in this study are the anterior cruciate ligament (ACL) and meniscus. The first model, based on the DenseNet 121 neural network structure, was used to classify images with or without anterior cruciate ligament (ACL) injury. The dataset includes 799 knee MRI reports from Cho Ray Hospital (Vietnam). These MRI data were obtained from previous work in the hospital, containing knee-MRI reports from a 5-year period (January 1st, 2015 – December 31st, 2019) According to the characteristic imaging characteristics, the second group of models uses the modified Faster-RCNN with several CNN backbone tests, such as VGG-16, Res-Net50, DenseNet-121, EfficientNet-B0, and EfficientNetV2-B0 algorithms, to recognize the anterior cruciate ligament on MRI images. For this study, the dataset was collected retrospectively from exam records made with a Siemens Avanto 1.5T MR scanner and obtained through a proton density-weighted fat suppression technique at the Clinical Hospital Center Rijeka, Croatia, between 2006 and 2014. The third model focuses on automatic identification and classification of meniscus based on the Yolo-v4 object detection model. At the same time, the lesion location is also shown on images by the GRAD-CAM technique. The total number of subjects used in this study was 704 patients, including meniscus lesion and the control group. All MR images in this study were collected before the surgery, and all had no prior surgical history. The MRI scanner at Cho Ray Hospital is MAGNETOM Skyra 3T (Siemen), and at Hoan My Hospital is 3.0T MRI Scanners SIGNA (GE Healthcare).

 

Results: The AUC for the ACL injury classification system was 80.63% with the axial plane and around 78% with sagittal, and coronal planes, respectively. All sensitivity and specificity point estimates of the proposed ACL injury detection system were all over 96%, indicating no significant differences in diagnostic performance between different planes. Our deep learning model detected meniscus tears with 91.4% accuracy on the internal testing dataset, 89.2% accuracy on the external validation dataset, and 79.9% accuracy on the MRNet dataset, respectively. The meniscus tears were visualized by auto-enlarging the detection area and Grad-CAM images.

 

Conclusion: This report describes the various approaches in Knee MRI images experiment to provide different AI models for the prediction of knee injuries. The CNN model applied to classify injured ACL images had high sensitivity and specificity, showing that using a simple structured 2D-CNN is more effective for small datasets and can assist non-experts in assessing the assessment of ACL injuries. The proposed model applied to detect meniscus lesions had high accuracy and specificity, showing that our model can assist non-experts in assessing the assessment of meniscus injuries.

 

Keywords: Artificial intelligence, deep learning, machine learning, Knee MRI image, ACL, meniscus

 

Life and Limb: The Surgical Management of Foot Complications in People with Diabetes

Marinus Stowers, Leah Slykerman, David Xu, Luke McClean, Surendra Senthi (AOA AusOA/NZOA Travelling Fellow – New Zealand)

 

AIM: Diabetic patients commonly present to orthopaedic services with an ulcerated or infected foot.

Management can involve surgical debridement or amputation. International literature indicates that amputation may lead to further complications and an increased mortality rate. The aim of this study was to investigate the mortality rate associated with different surgical interventions. This will inform management of diabetic patients with acute foot complications.

 

METHODS: We conducted a retrospective review of medical records of diabetic patients with foot complications. Eligible patients were those aged over 16 years presenting for care at Middlemore Hospital between 2012-2021. Patients were divided into three groups based on the type of treatment received: no surgery, surgery without amputation, and amputation. Baseline characteristics and comorbidities were recorded, and regression models were used to determine the relationship between type of intervention and mortality.

RESULTS: Over the study period, a total of 1,260 patients were analysed and divided into three groups: those with no surgical intervention (n=554), those receiving surgery but not amputation (n=269), and those that underwent amputation (n=437). After adjustment for confounders, mortality rates 5-years postoperatively were significantly higher among patients who underwent amputation compared to those who received surgical intervention without amputation (p=0.034). Furthermore, increased mortality in the amputation group at the 1-year postoperative mark showed a notable trend towards significance.

 

CONCLUSION: The results of this study suggest that surgical intervention without amputation is associated with lower mortality rates in patients with acute foot complications from diabetes. Treatment that aims to salvage the limb rather than amputate should be considered in management of patients with diabetic foot complications to optimise their care.

 

 

Translation, Cross-cultural Adaptation, Validity and Reliability Study of the Indonesian Version of the Constant Murley Score (CMS-INA)

Juniarto Jaya Pangestu1, Andri Maruli Tua Lubis1, Iman Widya Aminata2, Romy Deviandri1, Erica Kholinne4

1Department of Orthopaedic and Traumatology, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia; (AOA Junior Travelling Fellow 2024 - Indonesia)

2Department of Orthopaedic and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia

3Department of Physiology, Faculty of Medicine, Universitas Riau, Pekanbaru, Indonesia

4Department of Orthopedic Surgery, St. Carolus Hospital, Jakarta, Indonesia

 

Introduction: Shoulder pain is one of the main complaints of patients coming to the orthopaedic clinic. To the extent of our knowledge, there has been no outcome measure relating to shoulder complaints in Indonesian language. Constant Murley Score (CMS) is widely used in publications and literature to explain shoulder functional outcome.

 

Method: Cross-cultural adaptation of the Constant Murley score to Indonesian language and culture was performed according to recommendation by Beaton et al. Data from patient with shoulder pain were collected consecutively in the orthopaedic clinic in Cipto Mangunkusumo National General Hospital and Fatmawati General Hospital. Validity and reliability study of the final version of CMS-INA was conducted by one researcher in 2 meetings, within 1-2 weeks. The Indonesian version of SF-36 was also given to the respondents.

 

Results: A total of 102 shoulders (101 patients) were included in the study. CMS-INA showed excellent construct validity between items of questionnaire (correlation coefficient 0,429-0.846; p < 0,05) and criterion validity with SF-36 (Pearson correlation 0.90; p < 0,05). Reliability study showed good internal consistency (Cronbach’s α = 0,85) and intraclass correlation (ICC = 0,90). There is no floor and ceiling effects observed in this study.

 

Conclusion: Cross-cultural adaptation of CMS-INA exhibits good validity and reliability for Indonesian population complaining of shoulder pain.

 

Keywords: Constant Murley score, cross-cultural adaptation, validity, reliability

 

 

Operative vs. non-operative management: 1-year mortality of geriatric hip fracture patients in a developing country

1Toyat SS; 2Reena N; 2TM Shah; 1Rashdeen F

1Orthopaedics Department, Hospital Selayang, Lebuhraya Selayang - Kepong, 68100 Batu Caves, Selangor;  (AOA Junior Travelling Fellow 2024 - Malaysia)

2Geriatric Unit, Medical Department, Hospital Selayang, Lebuhraya Selayang - Kepong, 68100 Batu Caves, Selangor

 

INTRODUCTION: Incidence of geriatric hip fractures in Asia is estimated to increase from 1.12 million in 2018 to 2.56 million in 2050.  While systematic reviews have shown surgery is associated with lower mortality rate, studies in the reviews are extracted from developed countries.  Also, there is little mortality data comparing patients managed operatively vs. non-operatively.  We aimed to explore mortality rates between these 2 at 1 year, in a developing country.

 

MATERIALS & METHODS: We conducted a retrospective study of patients aged 60 years and above with proximal femur fracture admitted to a single institution in Malaysia from January-December 2022. Pelvic and pathological fractures were excluded. Data collected included age, American Society of Anaesthesiologists (ASA) score, and co-morbidities. Telephone follow-up was performed at one year to assess patient’s survival. Statistical analysis was performed using χ2 test, with p<0.05 considered significant.

 

Results: Out of 130 patients, 1 was excluded due to active malignancy, 29 were lost to follow-up. Of the remaining 100 patients, 66% had surgery, while 34% were managed non-operatively, based on patient preference or medical grounds.

 

Table 1: Patient demographics

Characteristics                Operated (n=66)             Not operated (n=34)                     p-value

Mean age (years)            77.68                   79.06                                  0.41

 

ASA grade I-II    22.73%               23.53%                              0.93

ASA grade III-IV 15.00%               32.00%                              0.04

 

Co-morbidities                              

- Dementia         6.06%                  5.88%                                 0.97

- Ischaemic heart

disease or failure            9.09%                  8.82%                                 0.96

- CKD III-IV         13.64%               20.59%                              0.37

                                            

The 1-year mortality rate in the operated group was 16.7%, and 52.9% in the non-operated group, with a statistically significant difference of p<0.001.

 

DISCUSSION: Due to comparable numbers of patients who underwent surgery or been managed conservatively, we were able to analyse the difference in mortality rates between the groups, revealing slightly higher 1-year mortality rate of 52.9% in non-operated group, compared to average of 48.5% in developed countries.2 While non-operated group had higher ASA grade, there were no significant differences in co-morbidities between the 2 groups to account for difference in choice of management or mortality rate.

 

Conclusion: Geriatric hip fracture patients managed non-operatively have a significantly higher 1-year mortality rate, compared to patients managed operatively, consistent with global 1-year mortality rates.

 

Endoscopic DORR Procedure for Recalcitrant Plantar Fasciitis: Early Clinical and Radiological Outcomes

Eric Cher WL (AOA Junior Travelling Fellow 2024 - Singapore), Walter Soon YW, Dhivakaran G, I Singh, Png WX, Chong KW

 

Plantar fasciitis is a common cause of heel pain affecting close to 1 in 10 patients. The complex pathophysiology influenced by various biomechanics factors has led to numerous theories with no consensus on the optimal surgical treatment for recalcitrant cases.

 

The DORR procedure is a fully endoscopic technique that combines supra-fascial plantar Debridement, calcaneal spur Ostectomy, Radiofrequency microtenotomy, and partial medial plantar fascia Release via a biportal suprafascial approach, with an optional gastrocnemius release. This procedure aims to incorporate commonly performed and proven techniques under endoscopic guidance whilst leveraging on its minimally invasive surgery to improve short term outcomes. This study evaluated the early clinical and radiological outcomes of this procedure in patients with recalcitrant pain.

 

Fifteen patients with plantar fasciitis refractory to conservative treatment for over 6 months, and with MRI confirmation of fasciitis and calcaneal bony edema, underwent the DORR procedure. Functional outcomes were assessed using VAS, AOFAS, and EFAS scores pre-operatively and at 6 months post-operatively. Post-operative MRI evaluated the radiological improvement. All patients had a minimum follow up period of 6 months.

 

At 6 months, significant improvements were observed across all functional outcome scores when compared to pre-surgery measurements. VAS scores improved from 7.5 to 1.75, AOFAS scores increased from 32 to 89, and EFAS scores increased from 6 to 14.3. Post-operative MRIs performed at 6 months showed near-complete resolution of bony edema at the calcaneal-fascia interface in all patients. No patients reported persistent plantar fasciitis pain and no significant complications were noted.

 

The DORR procedure is a safe and effective treatment for recalcitrant plantar fasciitis, demonstrating significant early improvements in functional outcomes and radiographic healing. The amalgamation of multiple proven techniques into one single procedure provides a comprehension solution for patients with persistent pain.

 

 

Combined Fascia Lata Autograft/allograft (Sushi graft) usage in Arthroscopic Superior Capsular Reconstruction for Massive Irreparable Rotator Cuff Tear: Optimization by Combination

Prakasit Chanasit

(AOA Junior Travelling Fellow 2024 - Thailand)

 

Superior capsular reconstruction is considered as one of the options for treatment of massive irreparable rotator cuff tendon tear in young patients without arthropathy of glenohumeral joint. Not only the pain symptoms that can be eradicated by this procedure but also the pseudoparalysis that can be restored. The surgical technique, using fascia lata (FS) autograft, is presented by Mihata. One of the most common complications is donor site morbidity at the thigh. The allograft usage in superior capsular reconstruction was introduced and popularized by Burkhart et al. Even though the donor site morbidity was eradicated, the integrity of the graft is still weaker than autograft. This technique is introduced to overcome this limitation.

 

From the literature reviews, the failures of SCR graft usually occur on the bursal side due to subacromial abrasion. So, the thickness of the graft is one of the most important points for getting a good result of surgery. The allograft was a good option for making the graft thicker. This also reduced the donor site morbidity from graft harvesting. But the critical drawback for allograft is the biological healing. The preparation of the combined graft is important. The biologic healing from the graft to the bone bed is better with autograft. The strength of the graft that secures the graft from subacromial abrasion depends on the thickness of the graft. So, the allograft is advantageous for making the thicker graft without donor site morbidity.

 

We harvested the smaller FL autograft than the conventional full patch FL autograft described by Mihata. Then, topping up the folded allograft onto the autograft to make the graft thicker than 8-millimeter in total. After preparing the graft, we inserted the graft acting as the superior capsule by mini open technique.

 

The short-term clinical results at 6 months were evaluated. The ROM was recorded. The motor power and postoperative MRI was evaluated in the follow up treatment. The good results showed in the short term follow up in terms of both clinical and radiological. This technique is considered to be the option for making a good SCR graft.