Original Article

Siddiqui MA, Koh J, Kua J, Cheung T, Chang P
Correspondence: Dr Mohd Mashfiqul Arafin Siddiqui, mmashfiqul@yahoo.co.uk

ABSTRACT
Introduction Open surgical release remains the gold standard for treatment of recalcitrant lateral epicondylitis (tennis elbow). We aimed to evaluate the potential impact of perioperative factors on outcome after open surgical release for tennis elbow.
Methods All patients without elbow dislocation who underwent open surgical release for tennis elbow from January 2000 to June 2006 were included in the study. Comorbidities and associated pathologies of the upper limb as well as postoperative pain score, range of motion, evidence of instability, recurrence and other complications were noted.
Results There were 37 female and 24 male patients aged 22–60 (44.95 +/- 7.34) years. Five (8.1 percent) patients had diabetes mellitus. The mean duration of symptoms before surgery was 16.8 +/- 15.3 (range 2–84) months. The average duration of follow-up was 23.0 +/- 34.5(range 0.4–206) months. Overall, 59 (96.7 percent) patients reported improvement of symptoms post surgery. Median grip strength on the operated and unoperated sides were 25.5 +/- 9.0 (range 10.5–44.0) KgN and 23.7 +/- 9.1 (range 9.3–41.5) KgN, respectively. Patients with diabetes mellitus had significantly higher pain scores (2.80 versus 0.36, p-value less than 0.01, 95 percent confidence interval [CI] 1.2-3.7), reduced grip strength (0.91 KgN versus 1.06 KgN, p-value is 0.038, 95 percent CI 0.29–0.01) and higher recurrence rates (40 percent versus 7.7 percent, p-value is 0.018).
Conclusion Diabetes mellitus has a negative effect on surgical outcome in terms of pain scores, grip strength ratio and recurrence rate. This should be reiterated during preoperative counselling.

Keywords: diabetes mellitus, lateral epicondylitis, level III evidence, open surgical release, tennis elbow
Singapore Med J 2011; 52(2): 73-76

Wazir NN, Kareem BA
Correspondence: Dr Nayyer Naveed Wazir, nayyernaveed_wazir@imu.edu.my

ABSTRACT
Introduction Cervical spondylotic myelopathy (CSM) represents a spectrum of pathologies with progressive compression of the spinal cord. The clinical signs and symptoms play a key role in diagnosis. The characteristic hand myelopathy signs are of significant clinical importance. The aim of this descriptive study was to report a relatively easy to elicit new hand myelopathy sign. The basis for this is finger and wrist flexor disinhibition, which is used for the spinal specificity of cord compression at or above the C5/6 level.
Methods The new clinical test was conducted in 68 patients with a mean age of 62 (range 54–68) years. The patients were divided into two groups according to their level of stenosis. Group 1 (n is 58) patients had stenosis at or above the C5/6 level, while Group 2 (n is 10) patients had stenosis at or below the C6/7 level. All these patients were clinically evaluated and their level of stenosis was confirmed using magnetic resonance imaging.
Results The Wazir sign was observed and well reproducible in 54 (93%) patients (Group 1); the myelopathy signs of three patients were positive (Hoffman’s sign, finger escape and ten-second test). In Group 2, the Wazir sign was not reproducible, but the myelopathy signs were also positive in three patients.
Conclusion The Wazir hand myelopathy sign was found to be consistently present in our patients, in addition to the other hand myelopathy signs.

Keywords: cervical myelopathy, hand myelopathy signs
Singapore Med J 2011; 52(1): 47-49

Hussein NS, Gohar MR
Correspondence: Dr Naser Sabah Hussein, dr_nasser73@yahoo.com

ABSTRACT
Introduction Two to three percent of stone disease cases occur in the paediatric age group. It is common in some parts of the world, such as in Turkey, India and Thailand. More than 50 percent of stones in children are still managed through open surgery. Ureteroscopic intervention for children remains a challenging treatment option. However, in contemporary urology practice, this mode of intervention is becoming more common. In this retrospective study, we reviewed our experiences with ureteroscopy and pneumatic lithotripsy in the paediatric and adolescent age group.
Methods A total of 13 patients at or below the age of 18 years underwent 17 retrograde semirigid ureteroscopy between 1998 and 2008. Their median age was 14 (range 3–18) years. The technique of ureterolithotripsy used for this age group was similar to that used among adults. The ureteric orifice and intramural part of the ureter were not dilated in all the patients. A double J stent was inserted into all the patients.
Results The mean stone size was 7.9 (range 5–13) mm. The stone was in the distal ureter in eight patients, in the mid ureter in seven patients and at the ureterovesical junction in another two patients. The overall stone-free rate after one ureterolithotripsy procedure was 84.6%. We failed to clear the stones in two patients at the first sitting.
Conclusion Semi-rigid ureteroscopy and pneumatic ureterolithotripsy are safe and effective procedures that and can be performed without ureteric dilation in experienced hands.

Keywords: paediatric lithotripsy, pneumatic lithotripsy, ureteroscopy, urolithiasis
Singapore Med J 2011; 52(1): 42-46

Andrade R, Araújo RC, Tucci HT, Martins J, Oliveira AS
Correspondence: Prof Rodrigo Cappato de Araújo, rodrigocappato@yahoo.com.br

ABSTRACT
Introduction The purpose of this study was to compare the electromyography index of muscle coactivation of the following muscle pairs: posterior deltoid and pectoralis major (PD/PM); triceps brachii and biceps brachii (TB/BB); and serratus anterior and upper trapezius (SA/UT) during three different closed kinetic chain exercises (wall-press, bench-press and push-up) on an unstable surface at the maximal load.
Methods A total of 20 healthy sedentary men participated in the study. Integral linear values were obtained from three sustained contractions of six seconds each for the three proposed exercises. Mean coactivation index values were compared using the mixed-effects linear model, with a five percent significance level.
Results Electromyography indexes of muscle coactivation showed significant differences for the PD/PM and TB/BB muscle pairs. No differences were found between exercises for the SA/UT muscle pair.
Conclusion Our results seem to differ from those of previous studies, which reported that the similarity in exercises performed is responsible for the comparable muscle activation levels.

Keywords: coactivation, closed kinetic chain, electromyography, shoulder
Singapore Med J 2011; 52(1): 35-41

Ariff F, Suthahar A, Ramli M
Correspondence: Dr Mohd Ariff Fadzil, marif022@salam.uitm.edu.my

ABSTRACT
Introduction The objective of this study was to investigate the relationship between hypertensive patients and their coping style and associated lifestyle factors.
Methods A total of 502 participants attending nine outpatient clinics completed the validated Bahasa Malaysia version of the Coping Inventory for Stressful Situations and sociodemographic questionnaires. The height, weight, pulse rate and blood pressure of all the participants were measured using standardised methods.
Results A total of 264 (52.6 percent) participants were hypertensive, while 238 (47.4 percent) were not. Participants with a high task-oriented score showed a significantly lower risk of hypertension compared to those with a low score (odds ratio [OR] 0.546; 95 percent confidence interval [CI] 0.371–0.804). Those with a high emotion-oriented coping score were associated with an increased risk of hypertension (OR 1.691; 95 percent CI 1.107–2.582). Hypertension was also significantly associated with a higher mean body mass index, positive family history of hypertension, history of diabetes mellitus and hypercholesterolaemia. In multiple logistic regression analysis with hypertension status as the dependent variable, a high emotion-oriented coping score, a low task-oriented coping score, age, body mass index, positive family history of hypertension and history of diabetes mellitus remain significant factors in the final model.
Conclusion These results indicated a significant relationship between hypertension and coping styles and lifestyle factors. They underscored the importance of further study as well as the development and implementation of intervention measures to improve coping skills among hypertensive patients, which may be incorporated into the management of hypertension.

Keywords: coping skills, hypertension, lifestyle factors
Singapore Med J 2011; 52(1): 29-34

Mannan A, Anwar S, Qayyum A, Tasneem RA
Correspondence: A/Prof Abdul Mannan, mannanq@hotmail.com

ABSTRACT
Introduction This was a retrospective study conducted to assess the nature, presentation, mode of insertion, diagnosis and management of foreign bodies in the urinary bladder.
Methods Between January 1998 and December 2007, 20 patients with foreign bodies in their urinary bladder were treated at our centre. The records of these patients were reviewed and analysed for their symptoms, mode of insertion, diagnosis, management and complications.
Results A total of 20 foreign bodies were recovered from the urinary bladders during the study period. These included JJ stents with calculi, intrauterine contraceptive devices with stones, a rubber stick, ribbon gauze, encrusted pieces of Foley catheter, proline thread with calculus, a suture needle, broken cold knives, the ceramic beak of a paediatric resectoscope, a knotted suprapubic tube, a hair clip, a nail, an electrical wire and a hairpin. The common presenting features were dysuria and haematuria. The diagnosis was established radiologically in most of the cases. The circumstances of insertion were variable; iatrogenic in 16 (80.0 percent) cases, sexual stimulation in two (10.0 percent), accidental insertion by a child in one (5.0 percent) and physical torture in one (5.0 percent). 17 (85.0 percent) foreign bodies were recovered endoscopically, and cystolithotomy was required in three (15.0 percent) patients.
Conclusion The instances of foreign bodies in the urinary bladder are uncommon. A diagnosis is usually made radiologically. Iatrogenic foreign bodies were found to be the most frequent type of insertion encountered. Endoscopic retrieval is usually successful, with minimal morbidity.

Keywords: endoscopic management, foreign bodies, iatrogenic, urinary bladder
Singapore Med J 2011; 52(1): 24-28

Seah VWT, Chin PL, Chia SL, Yang KY, Lo NN, Yeo SJ
Correspondence: Dr Chin Pak Lin, chin.pak.lin@sgh.com.sg

ABSTRACT
Introduction Post total knee replacement pain control using parenteral opioids results in significant side effects like nausea and vomiting. Periarticular injections are used to control pain without these side effects. This study aimed to evaluate the safety and efficacy of periarticular steroid injection in patients undergoing total knee arthroplasty, as well as assess the patient’s functional outcomes over a period of two years.
Methods A total of 100 patients who underwent total knee arthroplasty were randomised into two groups. The treatment group received periarticular infiltration with triamcinolone acetonide, bupivacaine and epinephrine. The control group received only bupivacaine and epinephrine. The postoperative analgesic regime was standardised for all patients. The immediate postoperative outcomes evaluated included pain score, morphine consumption, time to ambulation, straight leg raise, range of motion and duration of hospital stay. Longer-term outcomes were assessed at 1, 3, 6 and 24 months using the SF-36 questionnaire and Oxford Knee Score.
Results Patients in the treatment group had significantly lower pain scores, reduced morphine consumption and earlier discharge. They also had better range of knee motion and were able to regain muscular strength earlier. There was no increase in major complications such as infection or tendon rupture in the treatment group. There was no difference between the groups with regard to the medium-term outcomes of up to two years.
Conclusion This modality of pain control is safe and efficacious for post total knee replacement pain control.

Keywords: knee arthroplasty, rehabilitation, steroid
Singapore Med J 2011; 52(1): 19-23

Rajasekaran S, Avadhani A, Shetty AP
Correspondence: Dr Rajasekaran S, sr@gangahospital.com

ABSTRACT
Introduction To circumvent the risk to the vertebral artery with C2 pars or pedicle screws, C2 laminar screws were considered as a method for rigid fixation of the axis. Although considered to be a relatively safe method, ventral spinal canal violations have been reported. Three-dimensional (3D) fluoroscopy-based image guidance may enhance the accuracy and safety of the technique. There is only one previous report in the literature on its use in the placement of C2 laminar screws. The purpose of this study was to assess the accuracy of C2 translaminar screws inserted using 3D fluoroscopy-based navigation.
Methods Data from a single centre was gathered retrospectively and then analysed. 3D fluoroscopy-based navigation was used to insert five translaminar screws in four patients (two male, two female). Their mean age was 45.3 years and the average follow-up period was 13.8 months. The accuracy of screw placement and fusion was ascertained using postoperative computed tomography imaging.
Results There were no complications in this series. No breach in the dorsal or ventral laminar wall was noted for any of the translaminar screws inserted. The average time required to set up the navigation platform and screen was 18 minutes. Successful fusion was observed in all four patients at six months follow-up.
Conclusion Although considered a relatively safe technique, laminar cortical violations have been reported with C2 translaminar screws. 3D fluoroscopy-based image guidance can greatly enhance the accuracy of C2 translaminar screw insertion, as this technology provides real-time images during screw insertion and permits accurate screw sizing.

Keywords: computer-assisted, intralaminar screw, isocentric C-arm, navigation, translaminar screw
Singapore Med J 2011; 52(1): 15-18

Wong MTC, Lim JF, Eu KW
Correspondence: Prof Eu Kong Weng, eu.kong.weng@sgh.com.sg

ABSTRACT
Introduction Anal canal malignancies are rare tumours of the gastrointestinal tract that represent less than five percent of anorectal malignancies.
Methods We retrospectively reviewed patients with anal canal malignancies who were treated from April 1989 to December 2008. Patients were identified from a prospective database and records were analysed for age, gender, presenting symptoms, duration of symptoms, mode of diagnosis, histological subtypes, stage of disease, treatment received, duration of follow-up, recurrence rates and survival.
Results A total of 61 patients were treated for anal canal malignancies, comprising 2.1 percent of all anorectal malignancies treated during the same period. There were 31 male and 30 female patients, with a median age at diagnosis of 61 (range 38–83) years. The commonest presenting symptoms were per rectal bleeding (69.4 percent) and pain (33.9 percent). The commonest histology was adenocarcinoma (50.8 percent) and squamous cell carcinoma (SCC) (40.3 percent). Patients underwent either surgery, radiotherapy, chemoradiation or a combination of modalities. The median duration of follow-up was 28 (range 1–120) months. Five patients developed recurrences after a median of 23 (range 2–36) months. The five-year overall survival and disease-free survival was 65.5 percent and 63.7 percent, respectively, with SCC showing a trend toward a better prognosis.
Conclusion Anal canal tumours are a rare clinical entity. They are usually present in the elderly with per rectal bleeding. They are usually treated using a multimodality approach, after the accurate establishment of histological diagnosis, which can yield reasonable survival rates.

Keywords: adenocarcinoma, anus, Asian, carcinoma, recurrence, squamous cell, survival
Singapore Med J 2011; 52(1): 9-14

Ru XF, Feng Q, Wang Y, Zhang X, Li X, Meng JW, Guo ZC
Correspondence: Dr Feng Qi, fengqizf@yahoo.com

ABSTRACT
Introduction This study aimed to determine the early growth patterns of preterm infants who required prolonged hospitalisation in terms of body weight Z-score, and to explore the influencing factors and predictors of their growth.
Methods The criteria of enrolment included preterm birth, singleton pregnancy, hospitalisation within the first 24 hours of life, hospital stay ≥ 28 days and clinical follow-up beyond 91 days of corrected age. Body weight Z-scores and the incidence of underweight infants were reviewed periodically, and the influencing factors and possible predictors of growth analysed.
Results Body weight Z-scores of all infants of gestational age (GA) groups kept decreasing, with a trough seen at 36 weeks corrected gestational age (CGA). At corrected full-term, body weight Z-scores for all birth weight groups achieved birth level and were higher than that at 36 weeks CGA. Body weight Z-scores at 61 days corrected age was (−0.300 × GA [weeks] + 0.210 × birth weight [g] + 0.682 × body weight Z-score) at 40 weeks CGA. The cut-off values for body weight Z-score at birth (cut-off, −1.79; sensitivity, 100%; specificity, 91.3%) and 61 days corrected age (cut-off, −1.95; sensitivity, 100%; specificity, 97.1%) were selected to predict the risk of being underweight at 183 days corrected age.
Conclusion Early growth restriction is a practical problem in preterm infants with prolonged hospitalisation. Body weight Z-scores at 40 weeks CGA and 61 days corrected age can be used to predict body weight gain prior to 183 days corrected age in these infants.

Keywords: body weight Z-score, follow-up, growth, infant, preterm, underweight
Singapore Med J 2012; 53(12): 832–839