Original Article

Yusof NM, Halim AS
Correspondence: A/Prof Nazri Mohd Yusof, nazrimy2000@yahoo.com

ABSTRACT
Introduction Infection following grade IIIB open tibial fracture is common. The primary aim of managing this condition is to achieve control of infection before the bone reconstruction procedure is performed. The outcomes for such patients have not been evaluated in the literature. This study was conducted to examine the outcome of a multi-stage procedure for the treatment of infected grade IIIB open tibial fractures.
Methods Between 2004 and 2008, we treated 11 patients with infected grade IIIB open tibial fractures in our unit. The management of infected grade IIIB open tibial fracture comprised three stages, which included serial debridement, wound closure by local flap surgery and bone reconstruction. The margin of resection and the type of bone reconstruction depended on the anatomical location of the disease, the extent of osteomyelitis and patient preference regarding treatment options. Bone reconstruction procedures included bone grafting, plating, interlocking nail, hybrid and monolateral external fixator, and Ilizarov bone transport.
Results Gram-negative organisms were isolated from all patients. Pseudomonas aeruginosa (P. aeruginosa) (44%) was the most common organism cultured. Infection was resolved in all patients. Nine fractures achieved union, with a mean union time of 15 months. Two patients with P. aeruginosa infection developed non-union of the fracture and refused additional surgery after three years of treatment.
Conclusion The multi-stage management approach is well-accepted and effective in controlling infection in infected grade IIIB open tibial fractures.

Keywords: severe open fracture, wound infection
Singapore Med J 2012; 53(9): 591–594

Elbuken F, Baykara M, Ozturk C
Correspondence: Dr Filiz Elbuken, drflz@yahoo.com

ABSTRACT
Introduction The morphology of the proximal femur has often been investigated in the literature, but the normal population ranges and standard deviations have still not been determined for this area. This study aimed to determine the age-, gender- and body mass index (BMI)-related changes in the femoral neck, especially on the neck-shaft angle, by using dual-energy X-ray absorptiometry (DXA) measurements.
Methods Retrospective analyses of DXA images of the proximal femur from 18,943 individuals aged 20–108 years were performed. The age, gender, weight and height of each individual were obtained at the time of bone measurement. Data on theta angle were obtained from DXA measurements. Simple linear regression analysis and Pearson’s correlation coefficients were used to investigate the relationships between theta and age, gender and BMI.
Results There was a significant correlation between theta and age (p < 0.001). We also found a significant difference between the various age groups using analysis of variance (p < 0.001), but there was no meaningful correlation between theta and BMI (p = 0.377) and the BMI groups (p = 0.180). There were small but statistically significant differences in the neck-shaft angle between males and females (p < 0.05).
Conclusion In this study, DXA-based measurements were used and many parameters of proximal femur geometry were calculated with limited radiation exposure. We have demonstrated that the mean neck-shaft angle is greater in males than in females, and that theta increases with age. We also found a significant difference between different age groups, but no meaningful correlation between theta and BMI.

Keywords: DXA femur, hip, neck-shaft angle 
Singapore Med J 2012; 53(9): 587–590

Hegde AN, Mohan S, Tan KK, Lim CC
Correspondence: Dr Tchoyoson CC Lim, tchoyoson_lim@nni.com.sg

ABSTRACT
Introduction We reviewed the clinical features, brain and spinal cord magnetic resonance (MR) imaging findings and associated abnormalities in six patients with spinal cavernous malformations (CMs).
Methods Lesions were defined on gradient-recalled echo (GRE) images but measured on T2-weighted images performed on 1.5- and 3-tesla clinical scanners.
Results Four patients had associated multiple cranial CMs and one patient had multiple spinal CMs. All spinal CMs were predominantly hypointense on GRE images, and most were predominantly hyperintense and surrounded by hypointense edge on T2-weighted images. Other associations included asymptomatic vertebral body and splenic haemangiomas.
Conclusion We conclude that intramedullary spinal CMs typically have ‘mulberry’ or ‘popcorn’ appearances similar to those of cranial CM. The presence of associated haemangioma or familial cranial CM syndrome on MR imaging may suggest the correct diagnosis without requiring invasive investigations.

Keywords: cavernomas, cavernous malformations, familial cavernomatosis, spinal cord, venous angioma
Singapore Med J 2012; 53(9): 582–586

Yang WR, Ng ZX, Koh KM, Low SW, Lwin S, Choy KS, Seet E, Yeo TT
Correspondence: Dr Ng Zhi Xu, kokoach2002@yahoo.com.sg

ABSTRACT
Introduction This study aimed to evaluate the clinical and radiological outcomes, and safety and efficacy of percutaneous pedicle screw fixation (PPSF) in the treatment of thoracolumbar burst fractures.
Methods This was a retrospective review of patients with thoracolumbar burst fractures treated with PPSF in a single hospital from 2010 to 2011. Baseline data included patient demographics, mechanism of injuries, fracture level, neurologic status and the number of percutaneous screws inserted. Kyphotic angle correction, vertebral body height restoration and mid-sagittal canal diameter improvement were used to assess radiological outcome. Screw misplacement, operative complications, functional improvement (ASIA score) and pain score on visual analogue scale were used to assess safety and clinical outcomes.
Results 21 patients with 25 thoracolumbar burst fractures were treated with 134 percutaneous screws. There was significant improvement in kyphotic angle correction (mean difference 6.1 degrees, p = 0.006), restoration of anterior and posterior vertebral height (mean difference 19.7%, p < 0.01 and mean difference 6.6%, p = 0.007, respectively) and mid-sagittal canal diameter (mean difference 15.6%, p = 0.007) on discharge. These improvements remained statistically significant at six months post operation for restoration of anterior vertebral body height (mean difference 9.8%, p = 0.05) and mid-sagittal diameter (mean difference 30.0%, p < 0.01).
Conclusion In this first local review, we have shown that PPSF is a relatively safe and effective technique for treating selected thoracolumbar burst fractures, and that it yields satisfactory results. However, its long-term outcome and efficacy need to be further evaluated.

Keywords: minimally invasive, thoracolumbar fractures 
Singapore Med J 2012; 53(9): 577–581

Teo AT, Gan BK, Tung JS, Low Y, Seow WT
Correspondence: Dr Seow Wan Tew, seow.wan.tew@kkh.com.sg

ABSTRACT
Introduction Anorectal malformations (ARMs) and low-lying spinal cord (LLC) are commonly associated owing to their common embryonic origin. LLC may lead to tethered cord syndromes (TCS), requiring surgery. This study aimed to review the incidence of LLC in children with ARMs using ultrasonography (US) and magnetic resonance (MR) imaging, the incidence of TCS and the surgical outcomes of these patients after detethering.
Methods We conducted a retrospective study of children who underwent surgery for ARMs in 2002–2009 at KK Women’s and Children’s Hospital, Singapore.
Results Out of 101 (16.8%) ARM patients, 17 had LLC, of which 12 (70.6%) were high ARMs. 12 of the 17 (70.6%) patients had abnormal US and MR imaging findings. Five (29.4%) had normal US but abnormal MR imaging results; in these five patients, MR imaging was performed due to new symptoms and equivocal US findings. These 17 patients subsequently underwent surgical detethering. Three out of seven patients with TCS improved after surgery. None of the 17 patients had any complications.
Conclusion LLC appeared to be associated with high ARMs, although this was not statistically significant. LLC should be investigated for whenever ARM is diagnosed, regardless of its type. Lumbar US is useful for first-line screening for LLC. Abnormal US or onset of new symptoms should subsequently be investigated with MR imaging. Equivocal US findings are also likely to benefit from further MR imaging. Surgery to detether LLC can improve outcome in TCS, while prophylactic detethering for asymptomatic patients with lipoma of the filum terminale has very low surgical risk.

Keywords: anorectal malformation, low-lying spinal cord, surgical outcome, tethered cord, tethered cord syndrome 
Singapore Med J 2012; 53(9): 570–576

Aye M, Sazali M
Correspondence:Dr Mra Aye, mraaye@hotmail.com

ABSTRACT
Introduction Metabolic syndrome (MS) is a cluster of risk factors that increases the risk of cardiovascular disease and type 2 diabetes mellitus (DM). Waist circumference (WC), a surrogate indicator of abdominal fat mass, is used to measure central obesity associated with increased risk of hypertension, insulin resistance and type 2 DM, whereas body mass index (BMI) is traditionally used to measure somatic obesity. This study aimed to identify the WC and BMI cut-off points to predict the metabolic risk factors for MS and to determine which is a better predictor.
Methods This was a cross-sectional study conducted over a period of six months. The study involved 355 subjects aged 13–91 years. Youden’s index was used to identify the optimal cut-off points.
Results The optimal cut-off point of WC to predict individual metabolic risk in females was 84.5–91.0 cm. The BMI cut-off point to predict hypertension and raised fasting blood sugar was 23.7 kg/m², and that for low level high-density lipoprotein cholesterol was 22.9 kg/m². For males, the corresponding cut-off points were 86.5–91.0 cm for WC and 20.75–25.5 kg/m² for BMI, with corresponding sensitivities and specificities. Area under the curve and the odds of developing individual and ≥ 2 metabolic risk factors for MS were higher for WC than for BMI.
Conclusion WC is a better predictor of metabolic risk factors for developing MS than BMI. Therefore, we propose that metabolic risk factors be screened when WC ≥ 80 cm is found in both genders regardless of BMI.

Abu Bakar NF, Chen AH, MD Noor AR, Goh PP
Correspondence: A/Prof Dr Chen Ai Hong, aihong0707@yahoo.com

ABSTRACT
Introduction The visual status of children with learning disabilities has not been extensively studied. This study aimed to compare vision disorders between children in mainstream classes and those with learning disabilities attending special education classes in government primary schools in Malaysia.
Methods In this cross-sectional comparative study, 60 school children (30 from mainstream classes and 30 from special education classes) who were matched in age (6–12 years old) and ethnicity (Malay, Chinese and Indian) were examined. The subjects were recruited using non-probability convenience sampling. A complete eye examination was performed to detect three major vision disorders, namely refractive error, lag of accommodation and convergence insufficiency.
Results The overall prevalence of refractive error, lag of accommodation and convergence insufficiency was found to be 65.0%, 43.3% and 35.2%, respectively. Convergence insufficiency (χ² = 24.073, p < 0.001) was found to be associated with children in special education classes. No association was found between refractive error and lag of accommodation (p > 0.05) with the type of classes.
Conclusion Children in special education classes are more likely to have convergence insufficiency compared to children in mainstream classes. Thus, vision screening programmes for children in special education classes may need to be modified.

Ersoz F, Sari S, Arikan S, Altiok M, Bektas H, Adas G, Poyraz B, Ozcan O
Correspondence: Dr Feyzullah Ersoz, feyzullahersoz@gmail.com

ABSTRACT
Introduction Fournier’s gangrene (FG) is a life-threatening infection of the perineal and genital areas. We examined the comorbid diseases, treatments and factors affecting mortality in FG.
Methods This retrospective clinical study involved 52 patients who were treated for FG. The demographics, aetiologies, comorbid diseases, laboratory and bacteriology findings, treatment methods and length of hospital stay were compared between patients who died and those who survived the infection.
Results Out of the 52 patients, 12 died and 40 survived. Patients who died and those who survived were similar in terms of their mean age at first presentation (62 vs. 55 years), the mean number of debridements (3.6 vs. 2.9), the mean length of hospital stay (25 vs. 34 days) and gender (p > 0.05 for each). However, the mean leukocyte count was higher in patients who died than in surviving patients (33.6 ± 7.2 vs. 14.3 ± 4.9 cells/mml; p < 0.05). The most common aetiology in both groups was perianal abscess. Deviating colostomy was performed in 13 patients. Of the patients who died, nine had haemodialysis-dependent chronic renal failure and type II diabetes mellitus (DM), while one had type II DM and hypertension.
Conclusion Haemodialysis-dependent chronic renal failure and a high leukocyte count at first presentation were found to be the factors affecting mortality in FG patients.

Mittal N, Miyttal R, Sharma A, Jose V, Wanchu A, Singh S
Correspondence: Dr Aman Sharma, amansharma74@yahoo.com

ABSTRACT
Introduction Rheumatoid arthritis (RA) patients taking disease-modifying antirheumatic drugs (DMARDs) may experience treatment failure due to adverse effects or a lack of efficacy/resistance. The purpose of this study was to evaluate the prescription patterns, the incidence and reasons for failure, and the time to treatment failure of DMARDs in RA patients.
Methods The medical records of patients visiting the Rheumatology Clinic were scrutinised retrospectively in order to extract the relevant data, including demographics, clinical and laboratory investigations and drug usage, for analysis.
Results More than 60% of the 474 eligible patients were started on a combination of DMARDs. Hydroxychloroquine (HCQ) (79.7%) and methotrexate (MTX) (55.6%) were the most common DMARDs prescribed initially. There was a significant difference in survival times among the various treatment groups (p ≤ 0.001). Adverse effect was the main reason for treatment failure of sulfasalazine (SSZ) (88.9%) and MTX (75%), while addition or substitution DMARDs was more common for those taking HCQ (72.2%). Adverse event was reported as the most significant predictor of treatment failure. The most commonly reported adverse effects were bone marrow suppression and hepatotoxicity.
Conclusion A combination of DMARDs was used to initiate therapy in more than 60% of RA patients, with HCQ and MTX being prescribed most frequently. Adverse effects accounted mainly for treatment failures with MTX and SSZ, while lack of efficacy was responsible for major treatment failures with HCQ.

Hasan SS, Lim KN, Anwar M,Sathvik BS, Ahmadi K, Yuan WL, Kamarunnesa MA
Correspondence: Mr Syed Shahzad Hasan, shahzad_pharmacy@yahoo.com

ABSTRACT
Introduction The primary and secondary objectives of this study were to identify and assess the risks associated with the occurrence of drug-drug interactions (DDIs) and to determine the value of pharmacists’ interventions in the management of clinically significant DDIs, respectively.
Methods A prospective, case-control study was carried out on patients admitted to the intensive care unit (ICU), and involved a review of patients’ medication chart daily by the pharmacist and the clinical parameters. All identified DDIs were carefully analysed in order to provide recommendations on the management of clinically significant DDIs.
Results The majority of DDIs were categorised as Type-C severity level (n = 305, 75.9%). ‘Substitution’ was recommended in 34 cases of clinically significant DDIs, ‘dosage adjustment’ in 17 (4.2%) and ‘stop or avoid’ in 13 (3.2%). The number of drugs prescribed (p = 0.001, rS = 0.539) and length of ICU stay (p = 0.001, rS = 0.364) were significantly associated and positively correlated with the occurrence of DDIs. Patients with DDIs had a longer length of ICU stay than those without DDIs (9.5 days vs. 2.4 days, p = 0.001). No significant difference was found between patients aged below 50 years and those above 50 years (odds ratio 0.488, 95% confidence interval 0.166–1.434) in terms of the risk of DDIs.
Conclusion A large number of DDIs were identified in this study, but only a small number were clinically significant. Pharmacists’ participation in daily ward rounds could play an important role in the detection and management of clinically significant DDIs.