The incidence of common orthopaedic problems in newborn at Siriraj Hospital

BACKGROUND

The congenital orthopaedic anomalies in Thai population had a limited data and the previously studies are based on only hospital chart records.

OBJECTIVE

To determine the incidence of common congenital orthopedic problems by physical examination in newborn at Siriraj Hospital.

MATERIAL AND METHOD

A prospective study was conducted by physical examination of 3,396 newborns from June 2009 to September 2009. All orthopaedic abnormalities of newborns were recorded along with maternal age, obstetric history of mother, complications during pregnancy, complications in labour stage, mode of delivery and presentation. Sex of newborn, birth weight, body length and APGAR score were recorded.

RESULTS

Incidence of calcaneovalgus was found in 60:1,000 live births following by metatarsus adductus in 7.6:1,000, polydactyly or syndactyly in 2.6:1,000, talipes equninovarus in 2.4:1,000, brachial plexus injury in 1.5:1,000, developmental dysplasia of hip in 0.6:1,000, osteogenesis imperfecta in 0.6:1,000, skeketal dysplasia in 0.6:1,000, congenital vertical talus in 0.3: 1,000 and fracture clavicle at birth in 0.3: 1,000.

CONCLUSION

In the present study, the calcaneovalgus was the most common orthopaedic problem followed by metatasus adductus, polydactyly or syndactyly.

Chronic Monteggia lesions treatment with open reduction and Z-lengthening technique with annular ligament reconstruction

BACKGROUND

The purpose of the present study is to evaluate the clinical and radiographic outcomes after open reduction and Z-lengthening technique with annular ligament reconstruction for the treatment of a chronic Monteggia fracture-dislocation.

MATERIAL AND METHOD

The authors postoperatively investigated the clinical and radiographic outcomes for ten children with a chronic Monteggia fracture. The present study group included seven boys and three girls mean age of nine years and one month at the time of open reduction. Each patient had been treated with open reduction of the radial head combined with ulna osteotomy and elongation, bending with z-plasty technique and annular ligament reconstruction. Clinical and radiographic outcomes were reviewed over a mean duration of follow-up of thirty-eight months.

RESULTS

The postoperative Mayo Elbow Performance Index (MEPI) at the time of follow-up ranged from 95 to 100 and no poor results. The radial head remained in a completely reduced position in ten patients. In three patients, osteoarthritic changes were observed at the radiohumeral joint. Radiographically, there were seven good, three fair and no poor results. A fair radiographic result was obtained in the patients who had undergone open reduction more than three years after the injury and two patients was operation at the age of eleven and thirteen years old.

CONCLUSION

Good clinical and radiographic outcomes can be expected if open reduction for the treatment of a chronic Monteggia fracture is performed when the patient is less than twelve years of age or within three years after the injury. Open reduction and Z-lengthening technique with annular ligament reconstruction for the treatment of a chronic Monteggia fracture-dislocation is safe with good clinical and radiologic outcomes without the need for bone graft. No nonunion is report in our series.

The outcomes of treatment of giant cell tumor of bone around the knee

BACKGROUND

Giant cell tumor of bone has been characterized as an aggressive benign bone tumor and commonly occurs at the distal femur and the proximal tibia. The recommended treatment has ranged from intralesional curettage to wide excision and the decision depends on severity of the tumor extent, rate of local recurrence,functional and morbidity outcomes.

OBJECTIVE

To compare extended curettage and wide excision in Grade II-III giant cell tumor of bone around the knee with regard to their effectiveness in tumor control and complication.

MATERIAL AND METHOD

There were 54 patients with a giant cell tumor which involved the distal femur or proximal tibia who had been managed consecutively at Siriraj Hospital between 1994-2009. The lesion of all patients were staged according to the system of Campanacci et al. There were 21 males and 33 females with mean age of 34 years. Thirty-five tumors located at distal femur and 19 located at proximal tibia. Fourteen patients had a Grade II lesion and 40 had a Grade III lesion. Thirty patients received extended curettage whereas other 24 patients had a wide excision. Fisher's exact analysis was used for statistical analysis for the outcome of tumor recurrence in each surgery.

RESULTS

The mean follow-up time was 59 months. There were 7 (23.3 percent) local recurrences in the extended curettage group and 2 (8.3 percent) in the wide excision group. Most recurrences occurred within one year postoperatively. There was no statistical difference for the outcome of tumor recurrence in each group (p = 0.270). All patients with tumor recurrence were successfully treated with re-curettage, except for 3 patients who was treated by above-knee amputation. The functional analysis was excellence in the extended curettage group (94 percent) and good in the wide excision group (77.6 percent) according to the Musculoskeletal Tumor Society functional classification.

CONCLUSION

The authors believe that using extended curettage was not significantly different in percentage of local recurrence when compared with wide excision for Campanacci's Grade II-III of giant cell tumor of bone. Even better function was found in extended curettage group, the choice of surgical treatment should be considered in individual patient which depends on the extent of bone destruction and risk of tumor recurrence.

Limb salvage in tibial hemimelia

OBJECTIVE

To study the results of treatment of tibial hemimelia with limb salvage procedure in term of patient satisfaction, clinical results and complications.

MATERIAL AND METHOD

From 1993 to 2007 the authors treated six cases of tibial hemimelia with limb salvage procedures. Three legs of type Ia and four legs of type IV tibial hemimelia classified by Jones classification. The age at the operation ranged from 2 to 11 years. For type Ia cases, the Brown procedure,foot centralization and ilizarov lengthening of the fibula were used to correct limb length discrepancy. For type IV the foot centralization, soft tissue release and ilizarov lengthening were used to correct limb length discrepancy. The follow-up range from 4 to 10 years.

RESULTS

In two patients with type Ia, one patient could bear weight without gait aids, the other walked with orthosis and axillary crutch because this patient had bilateral Ia type and knee instability with progressive flexion contracture due to weakness of the quadriceps muscle. All patients with type IV can walk independently without gait aids. Three patients were performed limb lengthening. One case was fibular lengthening following Brown procedure in Ia type. Two cases were tibial lengthening in type IV The mean lengthening was 5.1 cm. Mean lengthening index was 2.4. Satisfactory functional and cosmetic results were achieved in all patients with partial deficiency, whereas in patients with completely deficiency of the limbs, none of the 3 knees treated by fibular transfer achieved a satisfactory functional result because of insufficient quadriceps strength, progressive knee flexion contracture and persistent ligamentous instability. Nevertheless, in these 3 legs, all patients were ultimately able to withstand weight bearing.

CONCLUSION

Patients and families were satisfied even though patients must have multiple surgery to correct deformities of the foot and the knee joint, as well as leg-length discrepancy and also a prolong treatment time. Limb salvage procedure in tibial hemimelia is appropriate in Thai culture because patients can weight with bare feet in the house and have sensation in the feet.

Combined Ilizarov Fixation and Intramedullary Nailing for Treatment of Congenital Pseudarthrosis of the Tibia

BACKGROUND

Congenital pseudarthrosis of the tibia (CPT) is one of the most challenging conditions in pediatric orthopedics. Multiple objectives must be achieved to correct this condition successfully, including obtaining union, prevention of refracture, management of limb-length discrepancy (LLD), and correction of deformities of the ankle and leg. This combined treatment conjoins the improved union rate and improved limb-length equalization of Ilizarov fixation and the controlled alignment and refracture prevention associated within tramedullary nailing.

OBJECTIVE

To evaluated the outcome of combined Ilizarov fixation with intramedullary pinning in term of union of pseudathrosis and residual deformities.

MATERIAL AND METHOD

Thirteen children who were treated by this technique were evaluated in this study. Clinical presentation and radiographs were evaluated and union time, secondary operations and time of follow-up were recorded. At final follow-up, condition of tibial and fibula pseudarthrosis, LLD, refracture and deformities of the tibia and ankle were documented.

RESULTS

Union was achieved in 11 children. For the other 2 children, a secondary procedure using iliac bone graft was required to achieveunion. Fibular pseudarthrosis persisted in 9 patients. A total of 30 secondary operations were performed for various indications. At final follow-up, mean anterior bowing was 8.5 degrees (range: 0-20°), mean medial bowing was 9.5 degrees (range: 0-25°), and ankle valgus was present in 5 patients. The mean LLD was 1.7 cm (range: 0-3). Two patients had limping gait. No donor site morbidity was observed in any patient. Refracture occurred in three cases after nail removal. In these three cases, secondary operations using the same technique were performed with favorable outcome.

CONCLUSION

The results of this study demonstrate that Ilizarov fixation combined with intramedullary nailing is a safe, effective and practical treatment for management of CPT. This combination technique achieves multiple objectives including rigid-stable fixation, management of LLD, correction of residual deformity and prevention of refracture. Moreover, this technique can be used in cases with previous operations that resulted in nonunion.

Meiotic chromosomes and sex determination mechanism in Thailand and Hawaii isolates of Angiostrongylus cantonensis (Nematoda: Angiostrongylidae)

Angiostrongylus cantonensis, the nematode lungworm of rats, has a XX/X0 sex-determination mechanism. The chromosome constitution consists of 10 autosomes, with 2n=12, XX in the female and 2n=11, X0 in the male. Meiosis-I shows five bivalents and one univalent for the male worm, and six bivalents for the female worm. The chromosome constitution of the Thailand and Hawaii isolates of A. cantonensis is similar to those reported for the taxa from Japan, Egypt and mainland China.

A dot-blot ELISA comparable to immunoblot for the specific diagnosis of human parastrongyliasis

A dot-blot enzyme-linked immunosorbent assay (dot-blot ELISA) using an electroeluted 31-kDa glycoprotein from adult worms ofParastrongylus cantonensisas the specific antigen was evaluated for the immunological diagnosis of patients infected withP. cantonensis. The sensitivity and specificity for the detection of serum antibody toP. cantonensisin dot-blot ELISA were both 100%, as determined with serum samples of tenP. cantonensis-infected patients, 60 patients with other related parasitic infections, and 20 uninfected controls. The test was as sensitive and specific as the immunoblot test which revealed a reactive band of 31 kDa. Both the dot-blot ELISA and immunoblot detected all sera from tenP. cantonensis-infected individuals, but not with those of other heterologous parasitoses (gnathostomiasis, toxocariasis, filariasis, paragonimiasis, cysticercosis and malaria) or sera from healthy controls. The dot-blot ELISA is much simpler to perform than the immunoblot technique, and the test can be applied under field conditions where sophisticated facilities are lacking.

Multi-immunodot for rapid differential diagnosis of eosinophilic meningitis due to parasitic infections

A multi-dot enzyme-linked immunosorbent assay (ELISA) was developed for the rapid and simple differential diagnosis of eosinophilic meningitis due to helminth infections. Ultrafiltered, purified antigens of Parastrongylus (=Angiostrongylus) cantonensis, Gnathostoma spinigerum and Taenia solium metacestodes, the most common parasites that invade the central nervous system and cause eosinophilic pleocytosis, were dotted onto a single nitrocellulose membrane strip. Antigen-coated strips, when blocked with 5% skimmed milk and dried, were stable for at least 6 months at 4 degrees C. With peroxidase conjugated anti-human immunoglobulins and 4-chloro-1-naphthol as a substrate, antibodies in the corresponding patients' sera were clearly detected on the membrane strip as well-defined blue dots. Although cross-reactions between P. cantonensis and G. spinigerum antigens were observed with the use of partially purified antigens, the darkest dot correlated well with the infecting parasites in all cases. This fast, easy and economical multiple dot-blot ELISA method is useful for the differential diagnosis of eosinophilic meningitis caused by parasitic helminths, as semi-purified antigens can be easily obtained by ultrafiltration and used. Further improvements using highly specific parasite antigens may make this multi-immunodot test more suitable for wide-scale use in field studies and diagnostic laboratories.

Purification of a specific immunodiagnostic Parastrongylus cantonensis antigen by electroelution from SDS-polyacrylamide gels

A 31-kDa glycoprotein antigen was purified by electrophoresing the crude extract of Parastrongylus cantonensis adult worms in a 12% SDS-polyacrylamide gel, identifying the 31-kDa component with prestained molecular weight standards, cutting the desired gel strip, and then isolating it by electroelution. Antigen fraction of 31 kDa was re-electrophoresed, transferred to a nitrocellulose membrane and found to be reactive with only the sera from patients with parastrongyliasis. No reactive band was observed with the sera from other related parasitic infections, eg, gnathostomiasis, toxocariasis, filariasis, paragonimiasis, cysticercosis and malaria, and the normal healthy control sera. This antigen fraction isolated showed 100% sensitivity and 100% specificity in the enzyme-linked immunosorbent assay (ELISA) for the detection of 31-kDa specific antibody in the sera from patients with parastrongyliasis. The P. cantonensis antigen of 31 kDa has been obtained by this means with a high degree of purity and applied successfully in conventional ELISA for the specific immunodiagnosis of human parastrongyliasis.

Detection of circulating antigens of Parastrongylus cantonensis in human sera by sandwich ELISA with specific monoclonal antibody

A specific monoclonal antibody (AW-3C2) as revealed by ELISA was produced against the adult worm antigens of Parastrongylus cantonensis and used in a sandwich ELISA for the detection of circulating antigens in the sera of parastrongyliasis patients and those with other parasitic diseases. A total of 60 sera was used in this study. Of these, 10 each were from patients with parastrongyliasis filariasis, gnathostomiasis, malaria and toxocariasis. The control group consisted of 53 serum samples from normal healthy Thais and Malaysians. The mean +/- optical density (OD) values for the normal Thai and Malaysian groups were 0.126 +/- 0.028 and 0.124 +/- 0.029, respectively. Mean OD values of parastrongyliasis patient group differed significantly from that of the normal groups as well as those of other parasitic infections. Using a cut-off point of mean OD +/- 3SD of the normal control groups as indicating a positive reading, the specificity of the assay with this monoclonal antibody was 100% while the sensitivity was 50%.

Detection of circulating antigens of Parastrongylus cantonensis in human sera by dot-blot ELISA and sandwich ELISA using monoclonal antibody

A dot-blot ELISA was compared with a previously performed sandwich ELISA for the detection of Parastrongylus cantonensis antigens in sera from patients. Using the same monoclonal antibody and the same sera, 6 of 10 sera (60%) from parastronglyiasis patients were positive in dot-blot ELISA, whereas with sandwich ELISA, 5 of the same patient sera (50%) were positive. The specificity in both assays was 100% using 50 sera from patients with other parasitic diseases; of these, 10 each were from patients with cysticercosis, filariasis, gnathostomiasis, malaria and toxocariasis. The control group consisted of 53 sera from normal health Thais and Malaysians. The sensitivity of the assays was, however, slightly better with dot-blot ELISA and because it is simple, quick and cost-effective, it may be a test of choice for specific diagnosis of human parastrongyliasis.

Detection of circulating antigens of Parastrongylus cantonensis in human sera by sandwich ELISA with specific monoclonal antibody

A specific monoclonal antibody (AW-3C2) as revealed by ELISA was produced against the adult worm antigens of Parastrongylus cantonensis and used in a sandwich ELISA for the detection of circulating antigens in the sera of parastrongyliasis patients and those with other parasitic diseases. A total of 60 sera was used in this study. Of these, 10 each were from patients with parastrongyliasis, cysticercosis, filariasis, gnathostomiasis, malaria and toxocariasis. The control group consisted of 53 serum samples from normal healthy Thais and Malaysians. The mean +/- optical density (OD) values for the normal Thai and Malaysian groups were 0.126 +/- 0.028 and 0.124 +/- 0.029, respectively. The mean OD values of the parastrongyliasis patient group differed significantly from that of the normal groups as well as those of other parasitic infections. Using a cut-off point of OD +/- 3SD of the control groups as indicating a positive reading, the specificity of the assay with this monoclonal antibody was 100% while the sensitivity was 50%.

Parasitology proficiency testing in the quality assessment programme in Thailand

Review of participant performance in the quality assessment programme from 1988 to 1991 shows that laboratories have been able to identify most common helminths and protozoa in multiple fecal samples. Ability has improved during the period reviewed. Proficiency in identifying the diagnostic stages of helminths is considerably higher than in protozoa. Analyses of results have shown that participant laboratories correctly identified approximately 64 per cent of intestinal helminths and 40 per cent of intestinal protozoa. Correct identification of blood parasites was achieved by an average of 50 per cent of the laboratories. Their rate of achievement was 10 per cent higher than in the last period reviewed. There is still room for improvement and well-trained personnel should lead to better performance.

Identification of fecal parasites in the quality assessment programme for the year 1984-1987, in Thailand

Review of data from the quality assessment programme of the DHLQC for the years 1984-1987 shows that some laboratories still have difficulty identifying fecal parasites; particularly the protozoa and the rare parasites although percentages of correct identification have improved in recent years. Helminth ova or larvae in fecal specimens were correctly identified by approximately 55 per cent of the laboratories. Correct identification of intestinal protozoan cysts, however, was achieved by an average of only 29 per cent of the participants.

In vivo and in vitro studies of tinidazole in Trichomonas vaginalis infection

A total 787 patients with complaints of vaginal discharges were examined, of which 106 patients were found to be positive for Trichomonas vaginalis by the normal saline method, and 114 patients were positive by the culture method. In the in vivo series, 55 patients were treated with a single dose of 1.8 gm of tinidazole, and with a follow-up examination 7 days there after. For the in vitro study 55 swab specimens were cultured to study the tinidazole sensitivity of Trichomonas vaginalis. The survival of Trichomonas vaginalis at each concentration of tinidazole was presented as a cumulative frequency. At the concentration of 1 microgram/ml, none of the organisms were killed; but at the concentration of 6 micrograms/ml, the mortality rate was 100%. In the in vivo series a 100% cure rate was obtained with tinidazole with no side effects, and in vitro series the mean minimum trichomonicidal concentration (MCC) at 24 hours was 3.76 +/- 1.25 micrograms/ml, with the range of 2--6 micrograms/ml. These studies revealed the sensitivity of Trichomonas vaginalis to tinidazole in Thailand and that tinidazole at a single oral dose of 1.8 gm perferably after a meal is effective, safe and cheap for the treatment of Trichomonas vaginalis.