Hamid Rahmatullah Bin Abd Razak

Surgically treated cervical myelopathy: a functional outcome comparison study between multilevel anterior cervical decompression fusion with instrumentation and posterior laminoplasty

BACKGROUND CONTEXT Multilevel cervical myelopathy can be treated with anterior cervical discectomy and fusion (ACDF) or corpectomy via the anterior approach and laminoplasty via the posterior approach. Till date, there is no proven superior approach. PURPOSE To elucidate any potential advantage of one approach over the other with regard to clinical midterm outcomes in this study. STUDY DESIGN A prospective, 2-year follow-up of patients with cervical myelopathy treated with multilevel anterior cervical decompression fusion and plating and posterior laminoplasty. PATIENT SAMPLE In total, 116 patients were studied. Sixty-four patients underwent ACDF two levels and above or anterior cervical corpectomy and fusion one level and above. Fifty-two patients underwent posterior cervical surgery (laminoplasty C3-C6 and C3-C7). OUTCOME MEASURES Self-report measures: Japan Orthopedic Association (JOA) score, JOA recovery rate, visual analog scale for neck pain (VASNP), neck disability index (NDI), and American Academy of Orthopaedic Surgeons (AAOS) neurogenic symptom score (AAOS-NSS). Physiologic measures: range of motion (ROM) flexion and extension of neck. Functional measures: short-form 36 (SF-36) score comprising physical functioning, physical role function, bodily pain, general health, vitality, social role function, emotional role function, and mental health scales. METHODS Comparison of the JOA scores, JOA recovery rates, NDI scores, SF-36 scores, VASNP, and ROM preoperatively to 2 years. Chi-square and two-sided Student t tests were used to analyze the variables. RESULTS Posterior surgery took an hour shorter (p<.05) and had better improvement in JOA scores at early follow-up of 6 months (p=.025). Anterior surgery group had better improvement of NDI scores at early follow-up of 6 months (p=.024) and was associated with less blood loss intraoperatively compared with posterior surgery. There was no statistical difference between the two groups for JOA scores, JOA recovery rates, SF-36 quality-of-life scores, NDI, AAOS-NSS, VAS neck pain, and ROM at 2 years. Complications were higher for anterior surgery group: two hematoma postoperation, one vocal cord paresis, and one new onset C6/C7 dermatome numbness versus one dura leak in posterior surgery group. CONCLUSIONS Our study showed that patients with multilevel disease treated with laminoplasty do well and compare favorably with patients treated with an anterior approach. Notably, posterior surgery was associated with shorter operating time, better improvement in JOA scores at 6 months, and a tendency toward lesser complications. Posterior surgery was not associated with increased neck disability and neck pain at 2 years. Anterior surgery had better NDI improvement at early follow-up. There is a need for a larger study that is prospectively randomized with long-term follow-up before we can confidently advocate one approach over the other in the management of cervical myelopathy.

Postoperative Delirium in Patients Undergoing Total Joint Arthroplasty: A Systematic Review

We systematically reviewed the English-language literature to assess the incidence, risk factors and prevention strategies for postoperative delirium following total joint arthroplasty (TJA). A total of 10 studies were included in the final review, of which 3 (30%) were Level I studies, 6 were Level II (60%) studies and 1 (10%) was a Level III study. Incidence of postoperative delirium ranged from 5% to 14.3%. Pre-screening of patients was shown to reduce its incidence. Independent predictors include age, history of psychiatric illness, decreased functional status and decreased verbal memory.

Incidence of Clinically Significant Venous Thromboembolic Events in Asian Patients Undergoing Total Knee Arthroplasty Without Anticoagulation

This study aimed to evaluate the incidence of clinically significant venous thromboembolic events (VTE) in Asian patients undergoing total knee arthroplasty (TKA) without anticoagulation. All patients who underwent TKA by a single surgeon from 2006 to 2010 in Singapore General Hospital were reviewed. Only symptomatic patients were referred for ultrasonography. Of the 531 patients reviewed, 3 patients developed symptoms of deep vein thrombosis with subsequent ultrasonographic confirmation, whereas 1 patient developed fatal pulmonary embolism without any clinical or radiologic evidence of deep vein thrombosis. Hence, the incidence of clinically significant VTE was 0.75%. Given the low incidence of clinically significant VTE, there is a need to review the current practice of routine chemoprophylaxis in Asian patients undergoing TKA.

Generalized ligamentous laxity may be a predisposing factor for musculoskeletal injuries.

OBJECTIVES The aim of this study is to determine if generalized ligamentous laxity may be a predisposing factor for musculoskeletal injuries in young males. We hypothesized that generalized ligamentous laxity would be more common in individuals with musculoskeletal injuries compared with controls. DESIGN Prospective Age- and Gender-matched Case-Control Study examined generalized ligamentous laxity in 100 consecutive individuals aged 18-25 who reported with musculoskeletal injuries to a primary healthcare center in the military. The Beighton score was used to measure joint laxity, which was determined to be present by overall scores equal to or exceeding 4. The control group comprised 100 age- and gender-matched individuals without any musculoskeletal injuries or complaints. The prevalence of generalized ligamentous laxity was then compared between cases and controls. Subgroup analyses were also performed to evaluate the epidemiology of injury within the cases. METHODS This prospective case-control study examined generalized ligamentous laxity in 100 consecutive individuals aged 18-25 who reported with musculoskeletal injuries to a primary healthcare center in the military. The Beighton score was used to measure joint laxity, which was determined to be present by overall scores equal to or exceeding 4. The control group comprised 100 age- and gender-matched individuals without any musculoskeletal injuries or complaints. The prevalence of generalized ligamentous laxity was then compared between cases and controls. RESULTS Generalized ligamentous laxity was present in 12% of the cases compared with 4% of controls Clearer to be presented as (P-value: 0.043). Individuals who presented with musculoskeletal injuries were 3.35 times more likely to have generalized ligamentous laxity as compared to controls. Lower limb injuries were more common than upper limb injuries amongst the cases. CONCLUSIONS Generalized ligamentous laxity was more common in individuals who presented with a musculoskeletal injury. Hence, it may be a predisposing factor for musculoskeletal injuries.

The use of pneumatic tourniquets is safe in Asians undergoing total knee arthroplasty without anticoagulation.

BACKGROUND There has always been controversy surrounding the use of pneumatic tourniquets in total knee arthroplasty (TKA) as they have been implicated in venous thromboembolic events (VTE). We aimed to evaluate the incidence of clinically significant VTE in Asians who underwent conventional TKA under tourniquet throughout the duration of surgery, without post-operative chemical VTE prophylaxis, but using post-operative pneumatic compression devices. METHODS Five hundred and thirty-one patients of a single surgeon who underwent elective total knee arthroplasty were retrospectively reviewed. All patients had a tourniquet applied to the operated limb. None of the patients received chemoprophylaxis against VTE. Post-operatively, only symptomatic patients were referred for ultrasonography. The patients were then stratified according to the tourniquet time: <60, 61 to 90, 91 to 120, and >120 min. The overall incidence as well as the incidence of venous thromboembolic events for each group was then calculated. RESULTS Of the 531 patients reviewed, 3 patients suffered from deep venous thrombosis (DVT) while 1 patient developed a fatal pulmonary embolism (PE). Hence, the overall incidence of clinically significant VTE was 0.75%. The 3 patients with DVT had tourniquet time of 61 to 90 min while the patient with PE had a tourniquet time of more than 120 min. CONCLUSION With a low overall incidence of VTE, the use of tourniquet in Asians during conventional total knee arthroplasty appears safe when post-operative pneumatic compression devices are used instead of chemical VTE prophylaxis. However, the risk of VTE seems to increase with a tourniquet time of more than 60 min. LEVEL OF EVIDENCE Therapeutic studies, level III.

Epidemiology of surgically managed anterior cruciate ligament ruptures in a sports surgery practice

Introduction: Anterior cruciate ligament (ACL) tears are common knee injuries, especially among sportsmen and sportswomen. The aim of this study is to better understand the epidemiology of surgically managed ACL tears sustained in our institution. Methods: All patients who underwent arthroscopic ACL reconstruction by the senior author of this article in Singapore from 2008 to 2013 were studied. Patients who were diagnosed clinically and/or radiologically to have a complete tear of the ACL and subsequently underwent arthroscopic ACL reconstruction were included. Patients who suffered from traumatic knee dislocation were excluded. Two hundred and ninety-two patients were available for analysis. All patients were operated on by the senior author. Results: 83.9% of patients were male. 60.5, 23.0, 8.46, and 8.11% were of Chinese, Malay, Indian and other origins, respectively. 69.6 and 28.7% were in white-collared and blue-collared jobs, respectively, while 1.69% were unemployed. Mean age at operation was 29.4 years. Mean body mass index was 25.3 kg/m2. 82.4 and 17.6% of ACL tears were sports (contact—27.5%; non-contact—72.5%) and non-sports injuries (activities of daily living—94.2%, road traffic accidents—5.77%), respectively. The top four sporting activities causing ACL tears were soccer, basketball, racquet games and volleyball. 56.2% of ACL tears presented with concomitant knee injuries (medial meniscus—63.4%; lateral meniscus—31.1%; posterior cruciate ligament—5.49%). 84.5% were primary tears. Conclusions: In this epidemiological review of ACL injuries, we found that ACL injuries tend to cluster within certain population subgroups. Patterns of mechanisms of injuries have been observed. These findings may lead to better preventive and treatment strategies in the management of ACL tears.

Diagnosis of ligamentous and meniscal pathologies in patients with anterior cruciate ligament injury: comparison of magnetic resonance imaging and arthroscopic findings.

BACKGROUND Magnetic resonance imaging (MRI) is routinely used to diagnose or support clinical diagnoses for meniscal or ligamentous injuries prior to offering patients arthroscopic treatment. However, the sensitivity of MRI for the detection of meniscal injury is not yet 100%. Sportsmen have occasionally returned to play with undiagnosed meniscal lesions on the basis of a normal MRI examination. This study was designed to assess the diagnostic parameters of MRI in patients with acute anterior cruciate ligament (ACL) injury. METHODS MRI and arthroscopic findings of 320 patients with acute ACL injury were included in this retrospective review. Patients belonged to a single surgeon from a high volume tertiary healthcare institution. All patients had either a MRI or an arthroscopic diagnosis of an acute ACL injury of one knee or both. All patients underwent therapeutic arthroscopy by the senior author routinely as part of arthroscopy-aided ACL reconstruction. Arthroscopic findings were the diagnostic reference based on which the positive predictive value (PPV), negative predictive value (NPV), sensitivity, specificity and concordance strength of association of MRI were calculated for ACL, posterior cruciate ligament (PCL), medial meniscus (MM) and lateral meniscus (LM) injuries. RESULTS MRI was most accurate in diagnosing cruciate ligament injuries with a PPV approaching 100%. The PPV of MRI in diagnosing meniscal injuries was approximately 60%. MRI was almost 100% sensitive and specific in diagnosing ACL injuries and 82% sensitive and 100% specific in diagnosing PCL injuries. Conversely, MRI was 77% sensitive and 90% specific in diagnosing MM injuries; and 57% sensitive and 95% specific in diagnosing LM injuries. CONCLUSIONS MRI remains the gold standard for diagnosing soft tissue injuries of the knee. However, there is a false positive rate ranging from 6% to 11% for meniscal tears.

Correlation between radiographic and arthroscopic findings in Asian osteoarthritic knees

Purpose. To evaluate the correlation between radiographic and arthroscopic findings for severity of knee osteoarthritis (OA) in 119 Asians. Methods. Medical records of 52 men and 67 women aged 33 to 70 (mean, 51) years who had complaints of chronic mechanical knee pain for >3 months and were arthroscopically diagnosed with articular cartilage degeneration of the knee were reviewed. The severity of knee OA was classified using the Kellgren-Lawrence (K&L) scale and the modified Outerbridge classification. The highest grade in any compartment of the knee was used to represent the severity of OA. The correlation between the radiographic and arthroscopic findings for severity of knee OA was evaluated. Results. 17 of the 119 patients with no radiographic evidence of OA (K&L grade 0) had articular cartilage degeneration arthroscopically (mean grade, 1.14). In general, higher K&L grades correlated with more severe articular cartilage degeneration. The Pearson correlation coefficient was 0.32, indicating that the association between the radiographic and arthroscopic findings for severity of knee OA was weak. Conclusion. The K&L scale correlated poorly with arthroscopic findings of articular cartilage degeneration in an Asian population with knee OA.

Single-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion Provides Sustained Improvements in Clinical and Radiological Outcomes up to 5 Years Postoperatively in Patients with Neurogenic Symptoms Secondary to Spondylolisthesis

Study Design Retrospective review of prospective registry data. Purpose To determine 5-year clinical and radiological outcomes of single-level instrumented minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in patients with neurogenic symptoms secondary to spondylolisthesis. Overview of Literature MIS-TLIF and open approaches have been shown to yield comparable outcomes. This is the first study to assess MIS-TLIF outcomes using the minimal clinically important difference (MCID) criterion. Methods The outcomes of 56 patients treated by a single surgeon, including the Oswestry disability index (ODI), neurogenic symptom score, short-form 36 questionnaire (SF-36), and visual analog scale (VAS) scores for back pain (BP), and leg pain (LP), were collected prospectively for up to 5 years postoperatively. Radiological outcomes included adjacent segment degeneration, fusion, cage subsidence, and screw loosening rates. Results Our patients were predominantly female (71.4%) and had a mean age of 53.7±11.3 years and mean body mass index of 25.7±3.7 kg/m2. The mean operative time, blood loss, time to ambulation, and hospitalization were 167±49 minutes, 126±107 mL, 1.2±0.4 days, and 2.8±1.1 days, respectively. The mean fluoroscopic time was 58.4±33 seconds, and the mean postoperative intravenous morphine dose was 8±2 mg. Regarding outcomes, postoperative scores improved relative to preoperative scores, and this was sustained across various time points for up to 5 years (p<0.001). Improvements in ODI, SF-36, VAS-BP, and VAS-LP all met the MCID criterion. Notably, 5.4% of our patients developed clinically significant adjacent segment disease during follow-up, and 7 minor complications were reported. Conclusions Single-level instrumented MIS-TLIF is suitable for patients with neurogenic symptoms secondary to lumbar spondylolisthesis and is associated with an acceptable complication rate. Both clinical and radiological outcomes were sustained up to 5 years postoperatively, with many patients achieving an MCID.

Improvement in health-related quality of life after unilateral total knee arthroplasty in patients with bilateral knee osteoarthritis

Purpose To review the outcome of unilateral total knee arthroplasty (TKA) in patients with bilateral knee osteoarthritis (OA) to determine whether unilateral TKA can achieve good health-related quality of life (HRQoL). Methods Records of 68 women and 25 men with severe bilateral knee OA who underwent unilateral TKA on the more symptomatic knee by a single surgeon and did not return for the second TKA within 2 years were reviewed. Outcome at 6 months and 2 years was assessed using the mental and physical component summary (MCS and PCS) of the Short-Form 36 (SF-36) for HRQoL as well as the Oxford Knee Score (OKS) and Knee Society Score (KSS) for knee-specific outcome. Results The SF-36, OKS, and KSS improved significantly after unilateral TKA. Respectively for MCS and PCS of SF-36, OKS, and KSS knee and function scores, 65%, 89%, 98%, 98%, and 98% of patients reported absolute improvement at 2 years. Respectively for PCS, OKS, and KSS function score that a minimal clinically important difference (MCID) was established, 77%, 96%, and 80% of patients achieved MCID at 2 years. Conclusion Unilateral TKA achieves good outcome in HRQoL at 2 years in patients with bilateral knee OA.