Study of Learning Curve in a Surgeon for Near-Infrared Fluorescence Cholangiography During Laparoscopic Cholecystectomy-A Retrospective Evaluation

BACKGROUND

Near-infrared indocyanine green fluorescence cholangiography (NIRF) has shown promising results on delineating extra-hepatic biliary anatomy during laparoscopic cholecystectomy to avoid bile duct injury. However its routine usage remains in question. In this study, the technique was evaluated further with learning curve estimation and learning factors were observed.

METHODS

One hundred ninety-nine cases which underwent laparoscopic cholecystectomy for acute or chronic cholecystitis within a 2-year period including 51 cases with initial use of NIRF by 2 surgeons were studied retrospectively. The learning curve was evaluated for a surgeon as primary objective. A case-matched comparison of the operative time between NIRF and conventional group, in terms of acute and chronic cholecystitis was also conducted as a secondary calculation.

RESULTS

Learning curve was evaluated with 61% learning rate for NIRF experience. Cysto-biliary junction non-illuminated cases under fluorescent view, had mean operative time of 80.83 ± 22.82 min, which was shorter than the cysto-biliary junction illuminated cases. The NIRF group exhibited longer operative time compared with the conventional group with mean difference of 34.39 min (significant at P < .05).

CONCLUSIONS

While the initial learning phase might be affected by surgeons' behavior and attitude, our results may provide a reference to learn at one's own pace and to employ NIRF teaching strategies during surgical training programs to overcome the initial phase during training period itself and facilitate universal achievement.

Anatomical Versus Non-anatomical Resection for Hepatocellular Carcinoma, a Propensity-matched Analysis Between Taiwanese and Japanese Patients

BACKGROUND/AIM

The aim of the study was to compare the outcomes of anatomical resection (AR) versus non-anatomical resection (NAR) for Japanese and Taiwanese patients with single, resectable hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

A propensity score matched (PSM) analysis was performed to compare the outcomes of the AR group to those of the NAR group. Tumor size <5 cm, T1 or T2 grade, without evidence of extrahepatic metastasis, invasion of portal or hepatic veins, or direct invasion of adjacent organs, were included in the study.

RESULTS

A total of 385 cases (Taiwanese 105, Japanese 280) were analyzed. After PSM, a total of 152 cases remain (Taiwan and Japan both 76 cases). Disease-free survival (DFS) and overall survival (OS) data were not significantly different between the two groups at 5 years follow-up.

CONCLUSION

AR of HCC in Japanese patients has a similar 5-year DFS and OS as NAR of HCC in Taiwanese patients.

Intracholecystic administration of indocyanine green for fluorescent cholangiography during laparoscopic cholecystectomy-A two-case report

•

It is difficult to visualize extra-hepatic biliary anatomy clearly because of long-presence of ICG in liver when administered intravenously.

•

Intracholecystic ICG injection illuminates extra-hepatic biliary tree preferentially thus reducing background hepatic noise.

•

Surgeons can experience more satisfaction with the use of fluorescent cholangiography during laparoscopic cholecystectomy when the intracystic route of ICG administration is utilized.

Introduction

The utility of intracystic administration of indocyanine green for near-infrared fluorescent cholangiography in acute calculous cholecystitis initially treated with percutaneous transhepatic gallbladder drainage (PTGBD) was described in this report.

Presentation of case

Two cases who underwent near-infrared fluorescent cholangiography guided interval laparoscopic cholecystectomy two weeks post-PTGBD were studied retrospectively. Both patients were diagnosed with moderate acute calculous cholecystitis based on diagnostic criteria of the Tokyo guidelines. Two routes of indocyanine green administration were utilized during surgery, first through direct intracystic administration through PTGBD tube (5 ml of 12.5 mg ICG) to achieve critical view of safety and then intravenous administration (1 ml of 2.5 mg ICG) to visualize cystic artery.

Discussion

Both patients had critical view of safety visualized clearly with ICG with the operation time of 84 and 125 min in cases 1 and 2, respectively without any intra or postoperative complications.

Conclusion

In comparison with intravenous ICG administration, trans-PTGBD ICG route can provide better signal-to-noise ratio by avoiding hepatic fluorescence and thus increasing the bile duct to liver contrast. However, ICG may enter the lymphatic system through necrotic and inflammatory gallbladder mucosa, of which lymph spillage during gallbladder dissection can obscure the fluorescent view.

The use of indocyanine green imaging technique in patient with hepatocellular carcinoma

Near-infrared indocyanine green (ICG) fluorescence application in liver cancer surgery have been reported in the literature since 2008. To date, most reports emphasized not only to the safety, feasibility and reproducibility, but also the potential benefits of its clinical applications in term of demarcating segmentation for an anatomical resection, tumor identification to achieve tumor free resection margin, detection of small unidentifiable subcapsular nodules as well as extrahepatic metastatic lesions, and fluorescence cholangiography. The purpose of this review is to present the fundamental concept of the interpretation of fluorescence enhancement by different timing through intravascular ICG distribution to liver and biliary washout; to describe step-by-step technical aspects of its use in different purposes, and to expose the diagnostic and therapeutic perspectives of this innovative imaging technique in liver cancer surgery.

Study on the Discrepancies between the Admitting Diagnoses from the Emergency Department and the Discharge Diagnoses

Objective

To study the extent of diagnostic discrepancies at admission (diagnoses made by doctors in the Emergency Department) and discharge (final diagnoses at the ward) in our Emergency Department (ED) where the doctors have direct admitting rights; and how such discrepant diagnoses affected inter-departmental transfer of patients after their admission.

Method

A non-concurrent cohort study was performed on admissions through our ED between 24th to 30th April 1997. The admitting and discharge diagnoses and units were recorded. The reasons for the unmatched diagnoses and inter-departmental transfers were studied. The significance of transfers amongst patients who had matched and unmatched diagnoses was compared using the Chi-test at 95% confidence interval.

Results

Three hundred and sixty-one admissions were recorded during the study period. There were 314 (86.7%) and 47 (13.3%) admissions with matched and unmatched diagnoses respectively. Nine of the 47 admissions with unmatched diagnoses and 16 of the 314 admissions with matched diagnoses were transferred (p=0.001).

Conclusion

The ED doctors achieved a high level of diagnostic accuracy. The most common reason for unmatched diagnosis was because of the difficulty of diagnosing the patient's complex medical problem in the short contact time in the ED. The level of accuracy should increase with the advent of more diagnostic modalities and increased contact time with the patients in the ED.

Management of knee osteoarthritis presenting with tibial stress fractures

Stress fractures of the tibia secondary to tibial deformities from osteoarthritis are rare, and may be difficult to manage. We treated two patients with stress fractures of the proximal tibial diaphyses over a period of two years. Both patients had osteoarthritis of the knee; one with genu valgus deformity and the other, genu varus deformity. The former patient also had a distal tibial fracture and had previously undergone open reduction and internal fixation. The stress fractures of both the patients had been treated conservatively by nonoperative means, but their fractures failed to unite. They then underwent a modular total knee prosthesis with a long tibial stem extension, and subsequently, their fractures united. Both patients recovered uneventfully.

Telomere lengths in human oocytes, cleavage stage embryos and blastocysts

Telomeres are repeated sequences that protect the ends of chromosomes and harbour DNA repair proteins. Telomeres shorten during each cell division in the absence of telomerase. When telomere length becomes critically short, cell senescence occurs. Telomere length therefore reflects both cellular ageing and capacity for division. We have measured telomere length in human germinal vesicle (GV) oocytes and preimplantation embryos, by quantitative fluorescence in situ hybridization (Q-FISH), providing baseline data towards our hypothesis that telomere length is a marker of embryo quality. The numbers of fluorescent foci suggest that extensive clustering of telomeres occurs in mature GV stage oocytes, and in preimplantation embryos. When calculating average telomere length by assuming that each signal presents one telomere, the calculated telomere length decreased from the oocyte to the cleavage stages, and increased between the cleavage stages and the blastocyst (11.12 versus 8.43 versus 12.22 kb, respectively, P < 0.001). Other methods of calculation, based upon expected maximum and minimum numbers of telomeres, confirm that telomere length in blastocysts is significantly longer than cleavage stages. Individual blastomeres within an embryo showed substantial variation in calculated average telomere length. This study implies that telomere length changes according to the stage of preimplantation embryo development.

Persistent knee instability following revision total knee arthroplasty

Instability is an important cause of failure following total knee arthroplasty (TKA). Knee stability needs to be optimal in both the coronal and sagittal planes. We describe failed revision TKA with persistent deformity and instability secondary to a deficient medial collateral ligament in a 71-year-old Chinese woman. Revision knee arthroplasty using constrained implants was performed on her with good result. During both primary and revision TKA, assessment of knee stability is critical. Constrained prosthesis would need to be considered when there is significant ligamentous deficiency.

The relationship between postoperative complications and outcomes after hip fracture surgery

INTRODUCTION

We studied the prevalence of postoperative complications in a series of consecutive patients who received surgery for hip fractures in a major public hospital in Singapore. We also studied the predictors for the occurrence of complications and the impact of these complications on patient outcomes.

MATERIALS AND METHODS

A retrospective chart review of patients admitted with hip fracture, from March to November 2001, was carried out. Patients were classified as having postoperative complications if they developed any of the following conditions after surgery: dislocation of prosthesis, deep vein thrombosis, postoperative confusion, foot drop, stroke, cardiac arrhythmias or acute myocardial infarctions, urinary retention, urinary tract infection, pneumonia, wound infection and incident pressure sores.

RESULTS

Of the 180 patients studied, 60 developed postoperative complications. Significant predictors of complications after logistic regression included being of female gender [odds ratio (OR), 2.79; 95% confidence interval (CI), 1.13 to 6.89] and pre-fracture mobility status (OR for independent ambulators 0.45; 95% CI, 0.23 to 0.87), but not the age of the patients. Postoperative complications significantly affected the length of stay within the acute hospital (beta coefficient, 6.42; 95% CI, 2.55 to 10.29), but were not associated with a decline in mobility status at 3 months post-fracture, eventual discharge destination or readmission within 1 year.

CONCLUSION

Postoperative complications are common after surgery for hip fractures and result in significantly longer hospitalisation periods. Significant predictors for such complications include being of female gender and pre-fracture mobility. Age, in itself, does not result in a higher risk of complications and should not preclude older hip fracture patients from surgical management.

Hip fractures in nonagenarians--a study on operative and non-operative management

Hip fractures in nonagenarians represent a special group because of their advanced age and co-morbidities. Surgery is advocated for their younger counterparts but may not appear desirable in nonagenarians. Eighty-four patients were studied over a 2-year period. There were 73 female and 11 male patients. Forty-seven patients sustained an intertrochanteric fracture of the femur. 37 suffered a neck of femur fracture. ASA score of II was the largest group with 51. At least 62 had one co-morbidity or more; 46 were considered demented with a mental test score of less than 7. The mean length of stay was 31 days. Treatment consisted of either traction or surgery. Forty-six patients were managed surgically and 38 non-surgically. Patient review was done 2 years after the fracture. The overall rate of complications was 52% for the operative and non-operative groups. Death outcome at 24 months was not significantly affected by ASA status, number of co-morbidities at admission, or between surgical and non-surgical treatment. However, there was statistical significance between death and the mini-mental test score of less than 7 (P < 0.05). Forty-three patients were still alive after 2 years; of which 27 had been treated surgically and 16 non-surgically. The overall mortality in both operative and non-operative groups is 49%. Surgery significantly increases the ability for independent ambulation (P < 0.01). Therefore the outcome of non-operative and non-operative treatment in nonagenarians with hip fractures is poor due to the high rates of mortality and morbidity.

A case of anterior interosseous nerve syndrome after peripherally inserted central catheter (PICC) line insertion

Palsies involving the anterior interosseous nerve comprise less than 1% of all upper extremity nerve palsies. Patients often present initially with acute pain in the proximal forearm, lasting several hours to days. The pain subsides, to be followed by paresis or total paralysis of the pronator quadratus, flexor pollicis longus and the radial half of the flexor profundus, either individually or together. Patients with a complete lesion will have a characteristic pinch deformity. We report a case of anterior interosseous syndrome in a 42-year-old male. The patient was admitted initially for chronic osteomyelitis of the left calcaneum. He had a peripherally inserted central catheter (PICC) line inserted into a brachial vein for the administration of intravenous antibiotics, and developed anterior interosseous nerve palsy as a complication of this procedure. The catheter was subsequently removed and a new line was placed on the other side, and his neurological deficit has been improving since. This case highlights the potential hazards of venupuncture or arterial puncture of the brachial vein or artery respectively, even under controlled conditions with the benefit of ultrasound guidance. It also serves as a reminder to look out for the complications of these common procedures, and to be able to react appropriately when they arise.

History of the Singapore Orthopaedic Association

Since emerging from the shadows of General Surgery, the specialty of Orthopaedic Surgery in Singapore has grown from strength to strength. The year 2002 commemorates 50 years of orthopaedic specialty practice in Singapore. It also celebrates the 34th birthday of the Singapore Orthopaedic Association and coincides with the 25th Annual Scientific Meeting. The Singapore Orthopaedic Association, from its humble beginnings, has grown into a credible organisation that aims to fulfill the academic aspirations of its members as well as serve as a bridge to other related organisations abroad. Apart from its academic activities, it also aims to broaden the bond of friendship with other orthopaedic organisations.

Long but dysfunctional telomeres correlate with chromosomal radiosensitivity in a mouse AML cell line

PURPOSE

To compare the chromosomal radiosensitivity of C3H mouse acute myeloid leukaemia (AML) cell lines 7926 and 8709 and to investigate the mechanistic basis of the radiosensitivity observed in 7926.

MATERIALS AND METHODS

Yields of chromosome aberrations following X-irradiation were determined in Giemsa-stained metaphases. Cell cycle phase distributions were determined by BrdU incorporation and microscopy, apoptosis was assessed by caspase assays. Telomerase activity (TRAP assay), telomere length (Q-FISH and Southern blotting) and telomere function (Robertsonian-like fusion formation) were also examined. The expression levels of telomerase components, telomerase regulators and DNA PKcs were determined on Northern blots.

RESULTS

A total of 4.5-7.6-fold elevated chromosome aberration yields were found in 7926 by comparison with 8709 3-24h after 0.5 and 1 Gy X-ray exposure. This difference could not be accounted for by differences in chromatid break-rejoining rates, cell cycle phase distribution or the induction of apoptosis. Telomeres and telomerase were dysfunctional in 7926. However, average telomere length was approximately two-fold greater than in 8709.

CONCLUSION

Defective telomere function in 7926 correlates with chromosomal radiosensitivity. This implicates telomere function in addition to telomere length as a determinant of chromosomal radiosensitivity.

Predictors of outcome of floating knee injuries in adults: 89 patients followed for 2-12 years

Of the 98 floating knee injuries that were consecutively treated from 1987 to 1997, 89 patients were available for analysis. There were 80 males and 9 females, ranging from 15 to 70 years old. Average follow-up was 5 (2-12) years. Injury severity scores ranged from 18 to 45. 21 fractures were intra-articular. 55 fractures were open. Substantial comminuted and segmental fractures occurred in 57 cases and 35 cases, respectively. Multivariate analysis showed that increasing age was associated with delays in bony union and full weight bearing ability. An increase in the number of pack years smoked at the time of injury predicted the likelihood of knee stiffness, delays in bony union and full weight bearing ability. Higher injury severity scores were associated with delayed full weight bearing ability. The presence of open fractures predicted the likelihood of knee stiffness and delayed full weight bearing ability. Comminuted fractures were associated with malunion, and segmental fractures with delayed bony union. Using the outcome of floating knee injuries as fair or poor, according to Karlström and Olerud's criteria, we constructed a preoperative prognostic scoring scale which showed a sensitivity of 0.72 and a specificity of 0.90.

The pattern of ambulance arrivals in the emergency department of an acute care hospital in Singapore

OBJECTIVES

(1) To determine the pattern of ambulance arrivals in the emergency department (ED) and (2) to review resource allocation based on these data.

METHODS

All (13 697) ambulance arrivals in 1996 to the ED of Tan Tock Seng Hospital were studied and where relevant compared with the walk in and total arrivals of the same year. The following data were obtained from computer records: (a) patients' demographic data; (b) number of ambulance arrivals by hour; (c) the classification of the ambulance arrivals by emergency or non-emergency, trauma or non-trauma; (d) cause of injury for trauma cases; (e) discharge status.

RESULTS

The ambulance arrivals in 1996 constituted 12.4% of the patient load for this department. There was no difference in modes of patient arrival to the ED by sex and ethnic group. However, there was significant evidence to show that more patients age > 60 came by ambulance than those age < 12 (p << 0.01). Some 98.5% of the ambulance arrivals were emergencies; 40.7% of the ambulance arrivals were attributable to trauma versus 27.3% of the walk in arrivals. The majority of the trauma cases brought in by ambulance were because of road traffic accidents (15.3%) or home accidents (7.4%). The peak in ambulance arrivals was between 2100-2300 hours compared with 1000-1200 for the walk in arrivals. More than half of the ambulance arrivals were admitted.

CONCLUSION

In planning resource allocation and in the development of contingency plans, the resource use of ambulance patients and the pattern of their arrivals should be taken into account.

Timing of microcirculatory injury from ischemia reperfusion

The low flow state that results from ischemia and reperfusion injury is a potentially reversible process that is important in numerous clinical situations. However, the point in time during the course of reperfusion where tissue injury becomes irreversible is unknown. This experiment evaluated the continuum of tissue damage in skeletal muscle after ischemic insult by quantifying the number of flowing capillaries and percentage muscle necrosis in a male Wistar rat skeletal muscle model. A gracilis muscle flap was raised on the vascular pedicle of 39 male Wistar rats and examined at 832x using intravital videomicroscopy. The numbers of flowing capillaries in five consecutive high-power fields were counted for baseline values. The flap was then subjected to 4 hours of global ischemia (except in sham animals, n = 7) by placing a microvascular clamp on the pedicle artery and vein. Upon reperfusion, flowing capillaries were counted in the same five high-power fields at intervals of 5, 15, 30, and 60 minutes, then at 2 to 8 (1-hour intervals), 24, and 48 hours. The gracilis muscle was then harvested at these intervals during reperfusion and assessed for viability. Compared with baseline, flowing capillaries from the ischemia and reperfusion group (mean +/- SEM) decreased significantly in the first 8 hours of reperfusion (7.7 +/- 0.2 to 3.2 +/- 0.3, p < 0.001) with minimal change noted from 8 to 48 hours. Percentage muscle necrosis increased progressively in ischemia and reperfusion preparations from 1 to 7 hours of reperfusion (16.5 +/- 2.6 percent to 38.9 +/- 1.2 percent, p < 0.001). No significant change in muscle necrosis in the ischemia and reperfusion group was noted between 7 and 48 hours. Sham preparations showed no change in the number of flowing capillaries through 3 hours of reperfusion, with a slight decrease at 24 hours. This rat gracilis microcirculation skeletal muscle model demonstrates a heterogeneous reperfusion injury. The decrease in flowing capillaries correlated with the increase in percentage necrosis and appeared to stabilize at the 7- to 8-hour interval. This finding may have important implications for the timing of interventions aimed at minimizing tissue damage from ischemia-reperfusion.

Surgical results of intercondylar fractures of the adult femur

INTRODUCTION

Although surgical treatment of intercondylar fractures of the adult femur gives satisfactory results in the majority of cases, there are complications reported with operative management. We aim to analyse the surgical results of these cases performed in our institution and compare them to other reported series.

MATERIALS AND METHODS

A total of 16 patients with intercondylar fractures of the femur were operatively treated from 1989 to 1997. The ages of these patients ranged from 24 to 77 years, with a mean age of 42 years. Average length of follow-up was 28 months. The fractures were classified according to AO classification. Twenty-five per cent of the fractures were significantly comminuted. They were internally fixed with various implants such as cancellous screw fixation, dynamic condylar screw plate, condylar blade plate and condylar buttress plate.

RESULTS

Average time to full weight bearing was 12 weeks. Results of treatment were assessed according to the criteria described by Shelbourne. Eighty-three per cent of minimally comminuted fractures had a good result, but only 50% of significantly comminuted fractures did well.

CONCLUSIONS

We recommend the use of anterior midline approach and condylar buttress plate for very comminuted fractures. Infection, if detected early and treated aggressively could avoid a poor outcome. Elderly patients should benefit from internal fixation and earlier mobilisation.

Emergency department organisation for disasters: a review of emergency department disaster plans in public hospitals of Singapore

Disaster management plans of emergency departments (EDs) in four major public hospitals were reviewed. A comparison was made between these plans, and they were analyzed to gain an understanding of the differing objectives and doctrines behind the practices. These were summarized into five major management concepts, which are considered to be critical to the success of a disaster plan: 1) staff mobilization systems (cascading vs batch mobilization); 2) staff deployment systems; 3) team organization (surgeons vs residents); 4) area management (the role of the area manager); 5) casualty volume management (accommodation vs expansion vs extension concepts). The concepts derived should serve as a useful guide to the development of an ED disaster plan and potentially influence how new ED facilities could be planned.

Transscaphoid perilunate fracture/dislocations--results of surgical treatment

Sixteen cases of dorsal transscaphoid perilunate fracture/dislocations in 15 patients were treated by open reduction and internal fixation of the scaphoid with a Herbert screw and/or Kirschner wires. All patients were male, with a mean age of 31 years. The average follow-up period was 3 years. These perilunate dislocations were transscaphoid in 13 cases, and transstyloid and transscaphoid in 3 cases. There was one case of median nerve deficit preoperatively. Open reduction was performed through a volar approach in all cases. Herbert screw fixation of the scaphoid was performed on 13 cases, of which supplemental Kirschner wires were used in 2 cases. Three cases had fixation with Kirschner wires only. There were 2 cases of non-union which required bone grafting on follow-up. A clinical evaluation scoring system assessing pain, occupational ability, range of motion and grip strength was used. Based on this, there were 10 excellent to good (62.5%) and 6 fair results. For the majority of our patients, surgical outcome is characterised by acceptable relief of pain, functional motion and grip strength.

The Ottawa Ankle Rules in Asia: validating a clinical decision rule for requesting X-rays in twisting ankle and foot injuries

This was a study to determine if the Ottawa Ankle Rules (OAR) for requesting x-ray studies in twisting ankle and foot injuries are applicable in our Asian population. Four hundred ninety-four consecutive eligible patients presenting to the emergency department with twisting injuries about the ankle were examined by emergency physicians for clinical criteria requiring ankle and foot x-ray studies according to the OAR. Four hundred eighty-eight of these patients underwent x-ray studies that were interpreted by a radiologist. The sensitivity and specificity of the OAR for predicting the presence of fracture were calculated to be 0.9 and 0.34, respectively. When the rules were modified to cast a wider screening net, sensitivity improved to 0.99. We conclude that the OAR are not applicable to our population because of inadequate sensitivity, but when modified become acceptable and can reduce the number of x-ray studies requested by 28%.

L-selectin and leukocyte function in skeletal muscle reperfusion injury

HYPOTHESIS

Treatment with anti-L-selectin monoclonal antibody will reduce venular neutrophil-endothelial rolling (flux and velocity) and adhesion associated with ischemia reperfusion injury in rat skeletal muscle.

DESIGN

Prospective, randomized experimental trials.

SETTING

Basic science research laboratory.

MATERIALS

Male Wistar rats weighing 109 +/- 5 g (mean +/- SEM).

INTERVENTIONS

Gracilis pedicle muscle flaps were elevated and microcirculation was observed by intravital microscopy. Two groups were evaluated: (1) the control group, which received 4 hours of global ischemia, and (2) the experimental group, which received 4 hours of global ischemia, plus treatment with anti-L-selectin monoclonal antibody 30 minutes before reperfusion.

MAIN OUTCOME MEASURES

The number of rolling and adherent leukocytes in postcapillary venules were counted in the 2 groups at baseline and at 1 through 5, 10, 15, 20, 30, 45, and 60 minutes of reperfusion.

RESULTS

Treatment with the monoclonal antibody to L-selectin significantly reduced the number of rolling leukocytes (flux) at 2 through 5, 20, 30, 45, and 60 minutes of reperfusion compared with controls (P<.05). Use of the monoclonal antibody significantly reduced the number of adherent neutrophils at 5, 10, 15, 20, 30, 45, and 60 minutes of reperfusion (P<.05). There was no significant difference in leukocyte velocity.

CONCLUSION

L-Selectin plays a significant role in leukocyte rolling and adherence to venular endothelium in rat skeletal muscle ischemia reperfusion injury.

Extent and appropriateness of emergency department services usage by foreign workers in Singapore

The objective of this study was to determine the extent and appropriateness of emergency department services usage by foreign workers. A prospective questionnaire survey of foreign workers who attended the Emergency Department (ED) of Tan Tock Seng Hospital was conducted from 30 December 1996 to 29 January 1997. A foreign worker was defined as a non-citizen, non-permanent resident working in Singapore, excluding students and tourists. Demographic and clinical data were collected. During the study period, 7409 patients above the age of 15 attended the ED of which 1174 (15.8%) were foreign workers. Forty-seven per cent of these foreign workers could not speak English, of whom 48.2% did not come with any English-speaking companion. Most of their ED visits were on weekdays and during office hours. Of the foreign workers, 43.1% were classified as non-emergency by ED doctors compared to 6.7% of other ED patients (P < 0.01). Trauma-related complaints accounted for 43.4% while febrile and minor infectious illnesses accounted for 26.7% of foreign workers' complaints. Admissions from ED into the hospital were 17.1% for foreign workers and 28.3% (P < 0.01) for other patients. Language barrier and lack of information on types of health care services available could have led to the high proportion of inappropriate use of ED services by foreign workers. Most of their complaints were minor injuries and illnesses which could be managed by non-ED health care providers. Care provided across a language barrier raises ethical and medico-legal questions. A multi-agency approach involving the Manpower and Health Ministries, employer and foreign worker representatives is needed to eliminate language barrier and help these workers to use health care services appropriately.

Operative treatment of displaced talar neck fractures

Twenty-two displaced talar neck fractures were treated by open reduction and internal fixation. Four open fractures were operated within 8 hours and 18 closed injuries were treated at an average interval of 13.8 hours after injury. Fractures were classified according to Hawkins' classification into 14 type II, 7 type III and 1 type IV. At an average follow up of 4.4 years, 18 cases obtained excellent or good results. Result was fair in 2 cases of delayed union and 1 case of avascular necrosis. Another case of avascular necrosis developed osteoarthritis of the ankle and had poor result. The overall incidence of avascular necrosis of the body of the talus was 9%.

A case report of Atasoy antenna procedure

A 25-year-old man presented with hook nail and painful atrophic pulp over the tip of the terminal phalanx of the right thumb 3 months following a crush injury. Lateral nail folds were poorly defined and the nail was curved. The patient was unable to pick up objects with a precision pinch. Reconstruction was performed with Atasoy antenna procedure. One year later, normal pulp contour of the injured thumb was restored and appearance of the nail was normal.

The effect of the extent of A1 pulley release on the force required to flex the digits. A cadaver study on the thumb, middle and ring fingers

The A1 pulley was released distally in consecutive stages by 25%, 50%, 75% and 100% of its length. The force required to fully flex the digit at each stage was recorded. The force decreased with more extensive A1 pulley release and this became significant when more than 50% of the pulley was released. These changes were probably due to loss of friction force rather than bowstringing of the tendon.

Spine surgery in geriatric patients

AIM

Many elderly patients are crippled by degenerative spine conditions. Operative treatment is often not offered due to fear of complications and consideration of life span. The objective of this study was to look at the diagnosis, surgical results and post-operative complications of elderly patients who underwent spinal surgery.

METHODS

A cohort of 44 patients, 65 years and older, who had surgery in Tan Tock Seng Hospital from January 1990-August 1995 were reviewed. Twenty-five of them had spinal stenosis, II had tumour and 9 had traumatic fracture/dislocation/subluxation. There were 3 patients each with disc herniation, infection and spondylolisthesis. Nine patients had more than one diagnosis. All patients were investigated post-operatively. The data was entered into a computer-coded protocol. The diagnosis was determined intraoperatively. Type of surgery, co-morbid conditions and results were looked into. Patient's opinion on relief symptoms was graded on a 5-point scale. Functional improvement was tabulated as the patient's ambulatory status.

RESULTS

The analysis of results was divided into two groups, patients with tumour and those without tumour. Twenty-seven of the 33 patients without tumour were alive at follow-up. Twenty-six of these patients had improvement of symptoms and 18 of 27 had improved functional status post-operatively. In the group with tumours, 2 had worsening symptoms and 3 had decreased function.

CONCLUSION

Surgical intervention should be a treatment option in elderly patients with spinal disease.

Comparison between single injection transthecal and subcutaneous digital blocks

A randomized double blinded study was performed on 142 patients to evaluate two different techniques of single injection digital anaesthesia. In group A, 86 digits in 71 patients were anaesthetized by a single injection transthecal technique using 3 cc of lignocaine and bupivacaine mixture. Anaesthesia of the whole digit was achieved in 83 (97%) digits. In group B, 80 digits in 71 patients were anaesthetized with a single injection subcutaneous technique using the same amount of anaesthetic mixture. Total anaesthesia of the digit was achieved in 75 (94%) digits. These two techniques were found to have no differences in effectiveness, distribution, onset and duration of anaesthesia.

Evaluation of hyperbaric oxygen for diabetic wounds: a prospective study

The purpose of this study was to prospectively evaluate the effect of hyperbaric oxygen (HBO2) on the healing of diabetic lower extremity wounds. Ten consecutive insulin-dependent diabetic patients with chronic lower extremity wounds were referred for HBO2 treatment. The control group consisted of five patients, two claustrophobic and three rural. The latter refused HBO2 treatments because of logistic reasons. Five patients underwent 30 HBO2 treatments in the problem wound protocol (100% oxygen, 2 atm abs, 2 h/day, 5 days/wk). All patients were evaluated with transcutaneous oxygen measurements and had an initial surgical debridement of the wound. Weekly tracings of the wound surface area were made by a nurse or resident who was blinded to the group assignment. At the end of 7 wk, the mean wound area expressed as a percentage of pretreatment baseline area was compared between groups (analysis of variance, Duncan's post hoc). No significant differences were noted between groups with respect to age, gender, baseline wound area, wound site O2 tension, or presence of osteomyelitis. At the completion of each of the 7-wk treatment periods, a significantly greater reduction in wound surface area was noted in the HBO2 vs. the control group (P < 0.05). HBO2 treatment significantly reduced wound size compared to controls in this small, non-randomized prospective study. These results should serve as a basis for larger multicenter prospective, randomized, double-blind controlled studies to definitively evaluate the effect of HBO2 on the healing of diabetic foot wounds.

A retrospective evaluation of operative treatment of ankle fractures

Between 1990 and 1992, 89 patients with ankle fracture were treated by open reduction and internal fixation in accordance with the Arbeitsgemeinschaft für Osteosynthesefragen (AO) principles and were available for evaluation with a mean follow-up period of 3.6 years (range 3 to 5 years). According to the AO classification, there were 21 type A, 37 type B and 31 type C fractures. The results were rated by the Olerud and Molander score. Excellent or good results were seen in 20 type A, 35 type B and 25 type C fractures. Fair or poor results in 1 type A, 2 type B and 6 type C fractures. Complications included screws in the joint in 2 cases and infection in 3 cases.

A retrospective study on elbow function after internal fixation of intercondylar fracture of adult humerus

Between 1989 and 1993, 20 intercondylar fractures of the distal humerus were treated by open reduction, internal fixation and early postoperative mobilisation. One patient died on the third postoperative day as a result of multiple injuries, leaving 19 patients for evaluation. The mean follow-up period was 4.1 years (range 2.0 to 6.7 years). According to the Muller system, there were 7 type C1 and 12 type C2 fractures. Using the Jupiter criteria, 6 elbows were rated as excellent, 9 good and 4 fair. Complications included late ulnar neuritis in one patient and wound infection in another patient.

Effect of hyperbaric oxygen on neutrophil concentration and pulmonary sequestration in reperfusion injury

OBJECTIVE

To evaluate the effect of hyperbaric oxygen (HBO) on muscle flap arterial neutrophil concentration and pulmonary neutrophil sequestration following ischemia-reperfusion injury in a rat gracilis muscle microcirculation model.

DESIGN

Prospective randomized experimental trials.

SETTING

Laboratory.

MATERIALS

Male Wistar rats weighing 150 to 300 g.

INTERVENTIONS

Gracilis muscle flaps were raised on isolated vascular pedicles. Three groups were evaluated: (1) sham (flap raised, 4-hour observation, no ischemia, no HBO), (2) ischemia control (4-hour flap is ischemia, no HBO); and (3) ischemia (4-hour flap is ischemia) plus HBO (last 90 minutes of ischemia, 100% oxygen, 2.5 atm absolute).

MAIN OUTCOME MEASURES

Flap pedicle arterial leukocyte and neutrophil concentrations were assessed at 5 and 90 minutes of reperfusion in the 3 groups. Pulmonary neutrophil sequestration was measured in a blinded fashion, using histologic examination and myeloperoxidase assay in the 3 groups at 5 and 90 minutes of reperfusion.

RESULTS

Ischemia produced an increase in pedicle arterial leukocyte and neutrophil concentrations in blood flowing to the gracilis muscle flap; administration of HBO significantly reduced concentration to sham levels (P < .05). There were no significant differences in pulmonary neutrophil sequestration among the experimental groups.

CONCLUSIONS

In this rat gracilis muscle microcirculation model, the increase in pedicle arterial leukocyte and neutrophil concentrations following ischemia-reperfusion injury was significantly reduced to sham levels by HBO treatment. This observed reduction was not attributable to HBO-induced pulmonary sequestration, which did not significantly change with HBO administration. Further investigation is required to elucidate the mechanisms of action of HBO in ameliorating ischemia-reperfusion injury in this model.

Venous thromboembolism in association with prolonged air travel

OBJECTIVE

To study risk factors for the development of air travel-related acute venous thromboembolism.

METHODS

A retrospective study of 254 patients admitted from 1988 to 1993 under the diagnosis of deep vein thrombosis (DVT) and/or pulmonary embolism (PE) identified 44 patients who developed symptoms during or after air flight.

RESULTS

There were 24 males and 20 females with a mean age of 63 years. Flight times were 5-17 hours. Twenty-eight patients (63.6%) had DVT only, five patients (11.4%) PE only, and 11 patients (25%) DVT and PE. Ninety-five percent had extension of the thrombus above the calf: popliteal vein, 10 patients; superficial femoral vein, 13 patients; common femoral vein, six patients; and iliac vein, eight patients. Five patient-related risk factors were identified: history of previous DVT (34%), presence of chronic disease or malignancy (25%), hormone therapy (16%), recent lower limb injury (11%), and recent surgery or femoral catheterization (9%).

CONCLUSIONS

We can speculate about the role of seven cabin-related risk factors: low humidity, hypoxia, diuretic effect of alcohol, insufficient fluid intake, smoking, "coach" position, and immobilization. In travelers with patient-related risk factors, the cabin-related risk factors are superimposed and may increase the risks for air travel-related acute venous thromboembolism. Active prophylaxis is recommended.

Complications following metal removal: a follow-up of surgically treated forearm fractures

We undertook a retrospective study of 82 patients with 128 diaphyseal fractures of the forearm who had been operated at our institution for their initial injury and subsequently had implant removal when the fractures had healed. The majority of the patients (97.5%) had no major complications after the removal of implants but 2 patients sustained a re-fracture of the same bone within 6 months after plate removal. Both patients had suffered from open fracture at the initial injury and sustained re-fracture in the original fracture site after implant removal. These fractures were both treated conservatively in a cast and united without further problems. Another 20 patients (24.4%) had minor complications ranging from mild superficial wound infection to nerve injury.

A cadaver study of the effects of dorsal angulation and shortening of the metacarpal shaft on the extension and flexion force ratios of the index and little fingers

Two experiments were performed on the second and fifth metacarpals of five normal cadaver hands. The forces obtained on full extension and flexion of the digits were measured. An oblique osteotomy was performed on the shaft of the metacarpal and fixed with dorsal angulation. The forces obtained on extension and flexion of the digits were measured. The relationships between the changes in force and the angle were analyzed. Flexion force decreased and extension force increased as the dorsal angulation increased, and these were significant beyond 30 degrees of dorsal angulation. The differences between index and little fingers were not significant. In the second experiment, the metacarpal bone was shortened at the osteotomy site, and the same measurements made. Flexion and extension forces both decreased, and were significant beyond 3 mm of shortening. The differences between index and little fingers were not significant.

Tibial tuberosity fractures in adolescents

Tibial tuberosity fracture is uncommon. We reviewed five patients with the injury, presenting over a two-year period. All of them were adolescent boys who sustained the injuries during sport. They were treated with open reduction and internal fixation using cancellous screws with additional tension band wiring for comminuted fragments. Results were excellent, with complete union of fracture site, full range of movement by three to five months and no evidence of complication on follow-up for thirty months.

Cadaveric study on the vascular anatomy of the ulnar nerve at the elbow--a basis for anterior transposition?

The clinical results of anterior transposition of the ulnar nerve in compressive ulnar neuropathy have been unsatisfactory. This study aims at qualifying and quantifying the vascular anatomy of the ulnar nerve at the elbow so as to enable us to appreciate the possible effects of anterior transposition of the ulnar nerve. In our study of 16 cadaveric limbs, we found that the average number of nutrient vessels supplying the ulnar nerve is 14.3. The main contributing vessel in the arm is the superior ulnar collateral artery, at the elbow, the inferior ulnar collateral artery proximally, and the posterior ulnar recurrent artery distally. In the forearm, the main supply is from the ulnar artery. The average length of the nutrient vessels ranges from 1 cm at the elbow to about 2.6 cm in the arm. The nutrient vessels at the elbow are short, small and numerous. Blood supply to the nerve is segmental in nature. In our histological study of the nerve at the elbow, we found that overall, there are more vascular channels in the intrinsic system than the extrinsic system (statistical significance p < 0.01). From this study, we were able to postulate that there is devascularisation of the ulnar nerve following an anterior transposition. The significance of the devascularisation will require further studies.