Original Article

Rao JP, Tiruchelvarayan R, Lee L
Correspondence: Dr Rajendra Tiruchelvarayan, rajspineclinic@gmail.com

ABSTRACT
INTRODUCTION The present study aimed to assess the immediate/early clinical outcomes and surgical results of 11 consecutive patients who underwent palliative cervical spine surgery for symptomatic spinal metastases.
METHODS This single-surgeon retrospective case series analysed 12 surgical procedures that were performed for symptomatic cervical spinal metastasis in 11 consecutive patients. All surgeries were carried out at Singapore General Hospital, Singapore, from 2007 to 2013. Preoperative medical oncological assessment/staging was performed on each patient – all patients presented with either axial neck pain or neurological deficits, and had no bladder or bowel symptoms. The primary outcomes analysed were postoperative neurological power and improvement in neck pain.
RESULTS Anterior (n = 5), posterior (n = 4) and combined (n = 2) surgical approaches were used for decompression and stabilisation. Comparing between pre- and postoperative pain scores (scored according to the visual analog scale), and pre- and postoperative limb power scores (scored according to the Medical Research Council scale for muscle strength), we found that all patients showed improvement in their symptoms. Postoperatively, patients had either improvement or preservation of neurological power, and all patients had a decrease in axial neck pain after surgery. Although there was one case of minor pedicle screw instrumentation malplacement, this did not result in any neurological symptoms. Median survival for the patients was 108 (range 7?1,095) days.
CONCLUSION Palliative surgery for cervical spine metastasis is safe with good neurological results, low complication rates, and improvement in neck pain. A multidisciplinary approach involving surgeons, medical oncologists and radiotherapists is needed to optimise patient care and outcome.

Keywords: cervical spine, metastasis, palliative surgery
Singapore Med J 2014; 55(11): 569-573; http://dx.doi.org/10.11622/smedj.2014152

REFERENCES

Jain K, Singh R
Correspondence: Dr Kowshik Jain, kowshikjain@gmail.com

ABSTRACT
INTRODUCTION Arthroscopic excision of the hypertrophic dorsal synovium is performed on patients with dorsal wrist pain in hyperextension. Although dorsal wrist impingement has been described in cadaveric studies, to our knowledge, there is no published clinical data on its treatment with arthroscopic synovial excision. Herein, we present the results of arthroscopic management of this condition in our hospital.
METHOD A total of 13 patients underwent arthroscopic excision of the hypertrophic dorsal impinging synovium. All patients presented with the cardinal symptom of dorsal-radial wrist pain in extreme extension. The diagnoses were made after excluding other causes and confirmed on wrist arthroscopy. Arthroscopy was offered after nonoperative measures failed. The mean postoperative follow-up period was 14 (range 6–31) months.
RESULTS Mean pre- and postoperative quick Disabilities of the Arm, Shoulder and Hand scores were 49 (range 34–82) and 17 (range 0–48), respectively; paired t-test revealed a significant difference between the two (p < 0.001). Mean postoperative flexion-extension arc and radial-ulnar deviation arc were 120º and 46º, respectively. Postoperatively, one patient developed complex regional pain syndrome, with tethering of the dorsal branch of the ulnar nerve, which required surgical release, while another patient required revision arthroscopic excision of the impinging tissue. Both patients had good postoperative outcomes.
CONCLUSION When treating patients with dorsal wrist pain, dorsal wrist impingement caused by synovial hypertrophy should be included in the differential diagnosis. Arthroscopic excision of the impinging synovium can achieve reliable pain relief with significant functional improvement in the short term, although further research on its long-term benefits is required.

Keywords: arthroscopic, impingement, pain, synovium, wrist
Singapore Med J 2014; 55(10): 547-549; http://dx.doi.org/10.11622/smedj.2014139

REFERENCES

Singh VA, Haseeb A, Alkubaisi AA
Correspondence: Dr Vivek Ajit Singh, drvivek69@gmail.com

ABSTRACT
INTRODUCTION Morbidity and mortality from malignant diseases are usually the result of metastasis. The bone is the third most common site of metastasis.
METHODS This is a retrospective study of patients with metastatic bone disease who were referred to the Orthopaedic Department of University Malaya Medical Centre, Malaysia, between January 2004 and October 2009.
RESULTS A total of 151 patients (51.0% men, 49.0% women) had metastatic bone disease, with the highest incidence at the age range of 50–59 years. The commonest primary cancer was breast (23.3%), followed by lung (21.2%), prostate (9.3%), thyroid (7.3%) and renal cell carcinoma (5.3%); unknown primary cancer was 6.6%. There was long bone involvement in 52.7% of cases, axial bone in 44.5%, and both long and axial bones in 2.8%. The majority (90.1%) were symptomatic, with pain as the commonest symptom. 106 (70.2%) patients had pathological fractures. Neurological deficit was reported in 90.7% of patients, with 41.1% having extraskeletal metastases. 67.8% of the lesions were osteolytic, 24.3% were sclerotic, and 7.9%, mixed. Palliative and therapeutic interventions were undertaken for 62.0% of patients. The mean survival times were: breast 21.0; thyroid 20.7; prostate 20.3; lung 16.0; and unknown primary cancer 32.6 months.
CONCLUSION In our study, breast and lung cancers were the commonest primary cancers in metastatic bone disease. Most patients had more than one site of involvement, pain at presentation and pathological fractures. Surgery is beneficial to relieve pain and improve function and neurology. Duration of survival depends on the type of primary cancer and whether systemic metastasis is present.

Keywords: bone, metastasis, outcome, survival
Singapore Med J 2014; 55(10): 539-546; http://dx.doi.org/10.11622/smedj.2014138

REFERENCES

Lau A, Neo GH, Lee HC
Correspondence: Dr Adrian Lau Cheng Kiang, adrianlck@yahoo.com

ABSTRACT
INTRODUCTION This study aims to describe the factors associated with surgical site infection (SSI) in elderly patients who underwent hip hemiarthroplasty following a hip fracture, in a single institution over a nine-year period.
METHODS All patients who underwent hip hemiarthroplasty between 1 January 2004 and 31 December 2012 in our hospital were included in the present study. The detection of SSI was carried out by a trained, independent infection control nurse using the United States Centers for Disease Control and Prevention criteria. Demographic and clinical data were collected retrospectively. Demographics and clinical factors were analysed for potential associations with SSI.
RESULTS Among the 1,320 patients who met the study inclusion criteria, a total 57 SSIs were documented, giving an infection rate of 4.3%. Patients who waited for more than one week for surgery had a statistically significantly higher risk of SSI (odds ratio 3.030, 95% confidence interval 1.075–8.545, p = 0.036). The presence of SSI was also significantly associated with increased length of hospital stay (p < 0.001). The two main microorganisms detected were methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa, which accounted for 50.9% and 26.3% of the SSIs, respectively.
CONCLUSION We concluded that the number of days from admission to surgery is a main risk factor for the development of SSI. Steps should, therefore, be taken to prevent unnecessary delay of surgery in elderly patients requiring hip hemiarthroplasty.

Keywords: hemiarthroplasty, neck of femur, surgical site infections
Singapore Med J 2014; 55(10): 535-538; http://dx.doi.org/10.11622/smedj.2014137

REFERENCES

Liow MH, Chin PL, Tay KJ, Chia SL, Lo NN, Yeo SJ
Correspondence: Dr Liow Ming Han Lincoln, lincoln.liow.m.h@sgh.com.sg

ABSTRACT
INTRODUCTION The use of robotics in total knee arthroplasty (TKA) has been shown to minimise human error, as well as improve the accuracy and precision of component implantation and mechanical axis alignment. The present study aimed to demonstrate that robot-assisted TKA using ROBODOC® is safe and capable of producing a consistent and accurate postoperative mechanical axis.
METHODS We prospectively recruited 27 consecutive patients who underwent robot-assisted TKA between May and December 2012. Two patients were excluded from the study due to intraoperative technical problems with the robot. Long-leg radiography and computed tomography were performed prior to surgery, and used for mechanical axis measurements and component sizing. DigiMatch™ ROBODOC® Surgical System software version 4.3.6 (Curexo Technology Corp, Fremont, CA, USA) was used in all cases to perform bone cuts in accordance with the preoperative plan.
RESULTS The postoperative coronal mechanical alignment was within 3 degrees, with a mean alignment of –0.4 ± 1.7 degrees, confirming the accuracy of the preoperative surgical plan and bone cuts. The mean operating time was 96 ± 15 min, and preoperative planning yielded 100% implant sizing accuracy.
CONCLUSION Robotics has the potential to enable surgeons to consistently attain ideal postoperative alignment. The use of bone movement monitors and an integrated navigation system enhances the safety profi le of ROBODOC® by minimising errors. However, the role of the surgeon in TKA is still vital, as the surgeon is ultimately in charge of planning the surgery, its execution and ensuring soft tissue balance during TKA.

Keywords: coronal mechanical axis alignment, ROBODOC®, robot-assisted, robotic surgery, total knee arthroplasty
Singapore Med J 2014; 55(10): 529-534; http://dx.doi.org/10.11622/smedj.2014136

REFERENCES

Ang CY, Yew A, Tay D, Chia SL, Yeo SJ, Lo NN, Chin PL
Correspondence: Dr Ang Chay-You, angchayyou@msn.com

ABSTRACT
INTRODUCTION The Singapore General Hospital Bone Bank, which exclusively stores femoral head allografts, relies on flash sterilisation to prevent allograft-related disease transmission and wound infection. However, intraosseous temperatures during autoclaving may be lower than required to eliminate human immunodeficiency virus, and hepatitis B and C viruses. The aim of this study is to determine the intraosseous temperatures of femoral head allografts during autoclaving and to assess the adequacy of autoclaving in preventing disease transmission.
METHODS Six femoral heads were acquired from patients who underwent hip arthroplasty. The specimens were divided into two groups. The first group underwent flash sterilisation with a sterilisation time of 4 min, while a longer sterilisation time of 22 min was used for the second group.
RESULTS The highest core temperature in the first group was 130°C, while the core temperatures in the second group plateaued at 133°C for all allografts. In the first group, only smaller allografts maintained temperatures sufficient for the inactivation of the clinically relevant viral pathogens. In contrast, all allografts in the second group were terminally sterilised.
CONCLUSION There is an inverse correlation between the size of allografts and intraosseous temperatures achieved during autoclaving. Therefore, we recommend dividing large allografts into smaller pieces, in order to achieve intraosseous temperatures adequate for the elimination of transmissible pathogens during flash sterilisation. Allografts should not be terminally sterilised, as the resulting allografts will become unusable. Despite modern processing techniques, stringent donor selection remains vital in the effort to prevent allograft-related infections. Autoclaving is an economical and efficacious method of preventing allograft-related disease transmission.

Keywords: allografts, autoclaving, bone bank, disease transmission, femoral heads
Singapore Med J 2014; 55(10): 526-528; http://dx.doi.org/10.11622/smedj.2014135

REFERENCES

Htwe TT, Sabaridah I, Low GK
Correspondence: Dr Than Than Htwe, lavenderhtwe@yahoo.com

ABSTRACT
INTRODUCTION Assessment is an important factor that drives student learning, as students tend to mainly focus on the material to be assessed. The current practice in teaching pathology extensively applies objective-structured practical examination for the assessment of students. As students will have to deal with real patients during clinical years, it is preferred that students learn and practise via potted specimens and slides instead of picture plates. This study aimed to assess the preferred assesment method of pathology practical exercises.
METHODS This was a cross-sectional survey carried out in two consecutive batches of Phase 2 medical students. Student competency was assessed using both the traditional (TD) (i.e. use of potted specimens and slides) and picture plate (PP) methods. To compare the two assessment methods, we compared the mean scores obtained by the students and examined student perception of the two methods.
RESULTS The mean scores obtained via the PP method were significantly higher than those obtained via the TD method for almost all the components tested.
CONCLUSION We found that students performed significantly better (p < 0.05) when assessed using the PP method instead of the TD method. PP preparations might provide better visuals, thus aiding understanding, than the TD method. The findings of this study are valuable in identifying and improving our current teaching and assessment methods of medical students, in line with advancements in information technology.

Keywords: OSPE, pathology, undergraduate medical students
Singapore Med J 2014; 55(9): 502-505; http://dx.doi.org/10.11622/smedj.2014121

REFERENCES

Songpatanasilp T, Mumtaz M, Chhabra H, Yu M, Sorsaburu S
Correspondence: Dr Thawee Songpatanasilp, thaweesps@yahoo.com

ABSTRACT
INTRODUCTION We evaluated reduced back pain in a multiethnic population treated with teriparatide and/or antiresorptives in real-life clinical settings over 12 months.
METHODS This prospective observational study comprised 562 men and postmenopausal women (mean age 68.8 years) receiving either teriparatide (n = 230), antiresorptives (raloxifene or bisphosphonates; n = 322), or both (n = 10) for severe osteoporosis. The primary endpoint was the relative risk of new/worsening back pain at six months.
RESULTS At baseline, a higher proportion of teriparatide-treated than antiresorptive-treated patients had severe back pain (30.9% vs. 17.7%), extreme pain/discomfort (25.3% vs. 16.8%), extreme anxiety/depression (16.6% vs. 7.8%) and were confined to bed (10.0% vs. 5.3%). Teriparatide-treated patients had higher visual analog scale (VAS) scores for pain (5.8 ± 2.42 vs. 5.1 ± 2.58) and lower mean European Quality of Life-5 Dimensions (EQ-5D) scores (37.7 ± 29.15 vs. 45.5 ± 31.42) than antiresorptive-treated patients. The incidence of new/worsening back pain at six months for patients on teriparatide and antiresorptives was 9.8% and 10.3% (relative risk 0.99, 95% confidence interval 0.80–1.23), respectively. The incidence of severe back pain at 12 months was 1.3% and 1.6% in the teriparatide and antiresorptive treatment groups, respectively. Teriparatide-treated patients had lower mean VAS (2.71 ± 2.21 vs. 3.30 ± 2.37) and EQ?5D (46.1 ± 33.18 vs. 55.4 ± 32.65) scores at 12 months. More teriparatide-treated patients felt better (82.7% vs. 71.0%) and were very satisfied with treatment (49.4% vs. 36.8%) compared to antiresorptive-treated patients.
CONCLUSION Patients treated with either teriparatide or antiresorptives had similar risk of new/worsening back pain at six months.

Keywords: antiresorptives, back pain, EQ-5D, osteoporosis, teriparatide
Singapore Med J 2014; 55(9): 493-501; http://dx.doi.org/10.11622/smedj.2014120

REFERENCES

Venkateswaran S, Tee A
Correspondence: Dr Sridhar Venkateswaran, sridhar_venkateswaran@cgh.com.sg

ABSTRACT
INTRODUCTION Overlap syndrome between obstructive sleep apnoea (OSA) and chronic obstructive pulmonary disease (COPD) is important but under-recognised. We aimed to determine the prevalence of overlap syndrome and the predictors of OSA in patients with COPD.
METHODS Patients aged ≥ 40 years were recruited from a dedicated COPD clinic and underwent overnight polysomnography. A diagnosis of OSA was made when apnoea-hypopnoea index (AHI) was ≥ 5.
RESULTS In all, 22 patients (aged 71 ± 9 years), predominantly men, were recruited. Mean values recorded were: predicted forced expiratory volume in the first second percentage 55 ± 15; body mass index 23.7 ± 6.5 kg/m2; Epworth Sleepiness Scale score 5.6 ± 5.8; and AHI 15.8 ± 18.6. Among the 14 patients with OSA (prevalence of overlap syndrome at 63.6%), the mean number of hospital visits for COPD exacerbations in the preceding one year was 0.5 ± 0.7. Patients with overlap syndrome had worse modified Medical Research Council dyspnoea scale scores and a lower percentage of rapid eye movement (REM) sleep than patients without. There were no other statistical differences in lung function or sleep study indices between the two patient groups.
CONCLUSION The majority of our patients had overlap syndrome and minimal exacerbations, and were not obese or sleepy. Significant differences between patients with and without overlap syndrome were seen in two aspects – the former was more dyspnoeic and had less REM sleep. Our findings suggest that standard clinical predictors cannot be used for patients with overlap syndrome, and therefore, a high index of suspicion is needed.

Keywords: chronic obstructive pulmonary disease, obstructive sleep apnoea, overlap syndrome
Singapore Med J 2014; 55(9): 488-492; http://dx.doi.org/10.11622/smedj.2014117

REFERENCES

Maniam R, Subramanian P, Singh SK, Lim SK, Chinna K, Rosli R
Correspondence: Dr Pathmawathi Subramanian, pathmawathi@um.edu.my

ABSTRACT
INTRODUCTION Fatigue and quality of sleep are the main factors that contribute to a poor quality of life among patients on long-term haemodialysis. Studies have also emphasised the importance of exercise for improving the wellbeing of dialysis patients. This study aimed to determine the effectiveness of a predialysis low-to-moderate-intensity exercise programme for reducing fatigue and improving sleep disorders among long-term haemodialysis patients.
METHODS In this quasi-experimental study, an exercise programme was conducted three times a week for 12 weeks before long-term haemodialysis patients underwent dialysis at two centres. The patients were categorised into either the exercise group (n = 28) or control group (n = 27). The latter was asked to maintain their current lifestyles. Assessments of fatigue and sleep disorder levels were performed for both groups using self-reported questionnaires at baseline and after intervention. The patients’ perception of the exercise programme was also determined using self-reported questionnaires.
RESULTS Paired sample t-test indicated improvements in fatigue level in the exercise group (mean fatigue score: post-treatment 40.5 ± 7.9 vs. pre-treatment 30.0 ± 10.9). Improvements in sleep disorders were also observed in the exercise group (mean score: post-treatment 7.6 ± 3.3 vs. pre-treatment 10.1 ± 3.8). However, sleep quality deteriorated in the control group (mean score: post-treatment 10.7 ± 2.9 vs. pre-treatment 9.3 ± 2.9).
CONCLUSION Simple low-to-moderate-intensity exercise is effective for improving fatigue, sleep disorders and the overall quality of life among haemodialysis patients.

Keywords: exercise, fatigue, haemodialysis, sleep disorder
Singapore Med J 2014; 55(9): 476-482; http://dx.doi.org/10.11622/smedj.2014119

REFERENCES