The Thai Journal of Orthopaedic Surgery

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Optimal Entry Point for Retrograde Femoral Nailing with Tibial SIGN Nail in Asians: a Cadaveric Study
(The Thai Journal of Orthopaedic Surgery, 2010-02-08) Tanawat Vaseenon, MD
Purpose: To identify the optimal entry point for retrograde femoral nailing with tibial SIGN nail.Design: Descriptive analytic studyMethods: Twelve cadaveric thigh bones with attached knee joints underwent closed retrograde femoral nailing with tibial SIGN nail. After nail insertion, each femur was osteotomized at 10 cm proximal to the articular surface. Conventional radiographs were taken. Correlations between the entry point and fracture displacement were analyzed.Results: A mid intercondylar sulcus and 9 mm anterior to the femoral PCL attachment resulted in the least displacement of the femoral fracture. This entry point allowed for minimal disruption of the patellofemoral joint during knee flexion.Conclusion: When tibial SIGN nail is used in retrograde femoral nailing, a mid intercondylar sulcus and 9 mm anterior to the femoral PCL attachment provides the optimal balance of fracture reduction and sparing of the knee joint. Key words: entry point, retrograde femoral nailing, tibial SIGN nail
Using Digital Wound Photography to Improve Communication among Orthopaedic Health Care Professionals in Orthopeadic Patients
(The Thai Journal of Orthopaedic Surgery, 2010-02-08) Boonsin Tangtrakulwanich, MD., Ph.D
Objective: To evaluate the usefulness and reliability of digital photographs in communicating wound assessment.Methods: 50 open wounds from Orthopaedic inpatients.were studied. First, one senior nurse evaluated the wound and took a picture with a digital camera before verbally communicating the wound’s characteristics to other nurses, Orthopaedic residents, and staff. All assessors then evaluated the digital photograph of the same wound before assessing the wound of the patient. All assessors rated the usefulness of the digital photograph compared with verbal communication. The second part of this study involved the reliability test. Fifty previous digital photographs were tested twice, one month apart, for inter-rater and intra-rater agreement among nurses, residents, and staff. Results: Most assessors agreed that communication via digital photograph was significantly better than verbal communication. Mean acceptability scores of digital photographs were significantly higher than verbal communication for clarity, details, decision guidance, and satisfaction. However, the reliability of wound care assessment was still at a fair of level of agreement among all assessors.Conclusion: Digital photographs are useful for communication among members of a health care team. Key words: Digital photograph, usefulness, reliability
Rotational Alignment of Femoral Fractures : Does Fluoroscopic Assessment of the Lesser Trochanter be Helpful?
(The Thai Journal of Orthopaedic Surgery, 2010-02-09) Rangson Chiawsirikajorn, MD Banchong Mahaisavariya, MD
The simulation study was performed on 15 pairs of adult cadaveric femora to determine whether the size or width of the apparent lesser trochanter (ALT) from the image screen of different projection of the C-arm image intensifier will be useful or not for the prediction of rotational profile of the proximal femur. From the study, the width of ALT is smallest at the position of internal rotation and gradually increase with the decreasing degree of internal rotation to neutral AP projection. The width of ALT is gradually increase with increasing degree of external rotation projection. However from the pairs study, it wasfound that the apparent width of ALT from right femur is larger than that of the left side in almost all projection between 30 degree internal rotation to 30 degree external rotation of the C-arm. The difference of the width of ALT at internal rotation 30 degree averaged 1.9 mm and the difference at external rotation 30 degree averaged 6.2 mm. The range of difference of the width of ALT in the pairs study ranged from 0 to 24 mm. No any relationship of the difference of the width of ALT and the degree of internal or external rotation was found. There was no tendency that width of ALT can be used as a reference to each other to any degree of femoral rotation.
The H-Index
(The Thai Journal of Orthopaedic Surgery, 2010-02-09) Banchong Mahaisavariya, M.D.
The h-index was suggested by Jorge E. Hirsch as a tool for determining theoretical physicists’ relative quality and is sometimes called the Hirsch index.1The h-index is defined as follows :A scientist has index h if h of his/her Np papers have at least h citations each and the other (Np-h) papers have no more than h citations each.In other words, a scholar with an index of h has published h papers each of which has been cited by others at least h times. Thus, the h-index reflects both the number of publications and the number of citations per publication. The index is designed to improve upon simpler measures such as the total number of citations or publications. The index works properly only for comparing scientists working in the same field ; citation conventions differ widely among different fields.
Autologous Chondrocyte Implantation (ACI)
(The Thai Journal of Orthopaedic Surgery, 2010-02-09) Cholawish Chanlalit, MD Channarong Kasemkijwattana, MD
Limitation of cartilage tissue repair is a wellknown condition. The cartilage is lack of nerve and vascular supply and thus, likely to be the isolate tissue system. Reparative process initiated from vascular system and the recruitment of repairing cells cannot be expected when the cartilage injury does not penetrate the subchondral bone. The cartilage matrix property that can block the migration of chondrocyte to the defect is also precluded cartilage repair.In case that the injury involves the subchondral bone, bleeding from underneath bone will occur and the cell repair can be recruited from vascular supply system. However, the property of the repaired cartilage tissue is still different from healthy cartilage (hyaline cartilage). This is because the content of matrix will be the collagen type I dominant (fibrocartilage) which also have different mechanical property from the hyaline cartilage.The results after treatment of cartilage lesion can be categorized into either from repair or regeneration process. The results of repairing will be fibrocartilage while that of regeneration is renewed hyaline cartilage. From this aspect, the allograft or autologous osteochondral transplant (large or small), periosteal or perichondial transplant (soft tissue arthroplasty), autologous chondrocytes implantation (ACI) have been reported that the cartilage lesion can have regeneration. These treatments may be categorized as a regenerate treatment group.
The Simple Distraction Device for Bone Transport Combined with Minimally Invasive Plate Osteosynthesis (MIPO) in the Treatment of Segmental Bone Defect
(The Thai Journal of Orthopaedic Surgery, 2010-02-09) Theerachai Apivatthakakul, MD
The authors present two cases of segmental bone defect of the femur and tibia treated with bone transport using the simple distraction device which has been designed and adapted from Chiang Mai University (CMU) external fixator combine with MIPO technique. It can be applied for the femur and tibia with the distraction length of 7.5 cm. The device is simple, effective, cheap and reproducible.
The Effect of Sequencial Insertion of Tibial Polyethelene to the Stability of Total Knee Arthroplasty
(The Thai Journal of Orthopaedic Surgery, 2010-02-09) Wallop Adulkasem, MD
Stability of the knee after total knee arthroplasty(TKA) is very important. Good alignment may not be maintained in case with unstable knee. Furthermore, knee instability may result in abnormal motions of femoral condyle on tibial surface (slipping) in all direction such as ; anteroposterior, rotation, varus and valgus tilting. This will result to the rapid wear and tear on polyethelene surface and lead to implant failure in later stage. This paper present the investigation to show that the sequencial tibial polyethelene insertion can effect the knee stability after TKA. The experimental model of TKA was performed on saw bone with three difference tibial polyethelene inserting techniques; group I, tibial polyethelene is inserted before femoral part, group II tibia polyethelene is inserted after femoral part with push and pull and group III tibia polyethelene is inserted after femoral part with subluxated tibia.Varus and valgus stress test, drawer tests were done on saw bone after saw bone operation. The study was also performed in 70 knees from 65 patients. The stability test after TKA at ; immediate, 3, 6 months and 1 year after operation was performed. There were 50 knees in group I, 16 knees in group II and 4 knees in group III. Varus and valgus stress, drawer tests were positive grade1 or more in all knees in group II \& III but none in group I both in saw bone and in the studied patients. From the study both in experimental model and in the study patients it was found that the sequential of tibial inserting may have important effect in knee stability for TKA. This effect has not been reported and is not recognized by most surgeons.
Image-based Navigation in Orthopaedic Surgery
(The Thai Journal of Orthopaedic Surgery, 2010-02-09) Kongkhet Riansuwan, MD Banchong Mahaisavariya, MD
Image-based navigation is recently accepted as one of the most profitable devices utilized to improve the accuracy of many procedures in orthopaedic surgery. Actually, navigation-assisted surgery systems were initially used in neurosurgery in the late 1980s. The interactive computer system is able to match the co-ordinate pre-or intraoperative images, patient’s anatomy and the surgical instruments by using tracking and registration process. The initial image-based navigation system has based upon preoperative computer tomography (CT) images and clinical application has been successfully introduced in spinal instrumentation since 1994.1-2 However, time consuming, comsplicated techniques and error in the registration process known as a pair-point matching remain the major concern and may cause CT-based navigation less popularity with time.
Intermediate Screws in Short Segment Pedicular Fixation for Thoracolumbar and Lumbar Burst Fractures
(The Thai Journal of Orthopaedic Surgery, 2010-02-09) Suwit Ekapichon, MD
Purpose: To evaluate the clinical relevance of short segment pedicular fixation with intermediate screws. Methods: Retro- and prospective studies were done of 29 patients with thoracolumbar or lumbar burst fractures who were treated with posterior short segment pedicular fixation. Anterior vertebral body height compression percentage (AVBCP) and local kyphosis were measured and analyzed pre-operatively, post-operatively, and at last follow-up period. All patients were followed up for a minimum of 6 months. Results: The mean immediate post-operative corrections of AVBCP and kyphosis were 24±15% and 14±8° respectively. The mean losses of correction at the last follow-up period were 0% and 2.2° for AVBCP and kyphosis respectively. At last follow-up, there was significant loss of correction of kyphosis (p
New Technique to Improve Subchondral Bone Mechanics in Core Drilling and Bone Graft for Osteonecrosis in Swine Hip Model
(The Thai Journal of Orthopaedic Surgery, 2010-02-09) Cholawish Chanlalit, MD
The mechanical compressive strength of the femoral head after core tract drilling and debridement of subcondral bone to simulate the post-treatment condition of avascular necrosis of the femoral head was studied using the swine hip model. Compressive strength after other treatment methodwas also investigated. This includes ; the group with the use of strut graft only and the group with interference screw supplementation. Twelve swine hips model were use for the study by creating a large void beneath the superior part of femoral head by core tract drilling and subchondral bone debridement technique in area that will usually a common site of subchondral bone destruction from osteonecrosis. The specimens were then randomized into 3 groups, 4 hips for control group (bone debridement alone), 4 hips for strut graft group (with strut graft placed beneath subchondral plate) and the rest 4 hips for experimental interference screw supplementation group. Compressive strength were measured using round indenter compress at the upper mostof femoral head that can collapse subchondral plate to 2 mm. The result show that experimental group have significant higher compressive strengh than the contol and the strut graft group
Six Months Postoperative Outcomes of Carpal Tunnel Release Using a Short Palmar Incision in Lampang Hospital
(The Thai Journal of Orthopaedic Surgery, 2010-02-18) Nutthapong Wongwiwat, MD
Carpal tunnel release is one of the most commonly performed procedures of outpatient surgery in Lampang Hospital. The author studied 42 consecutive patients who underwent a short palmar incision for carpal tunnel release between January and June 2006 in Lampang Hospital. Only 35 patients (40 hands) were included. All operations were carried out under local anesthesia and without tourniquet. The patients were evaluated before and 6 months after surgery using subjective symptoms, physical examination findings and the Boston carpal tunnel questionnaires(BCTQ). The results showed that all symptoms and BCTQ scores decreased significantly (p \< 0.001). Night pain and day pain disappeared in all patients. Numbness was improved with a less score than other symptoms. Tinel’s sign and Phalen’s test were decreased postoperatively(p \< 0.001). The thenar wasting was improved in some patients but no statistical significance was found (p = 0.25). The scar tenderness was found in 3 patients at 6 months follow-up. However, pillar pain occurred in the early postoperative period and completely resolved in 6 months. The average operation time was 10.8 minutes. The average incision length was 15.4 mm. There were no serious complications. In conclusion, carpal tunnel release with a short palmar incision is a simple procedure with no need for specialized instrument. It can be effectively and safely used for the treatment of carpal tunnel syndrome.
Minimally Invasive Open Reduction and Compression Plating for Simple Femoral Shaft Fracture
(The Thai Journal of Orthopaedic Surgery, 2010-02-18) Theerachai Apivatthakakul, MD
Although intramedullary nailing has standardized the management of the femoral shaft fractures, compression plating may offer an alternative for simple femoral shaft fracture that intramedullary nailing is not indicated. From March 2003 to December 2005, the author retrospective study of 14 simple femoral shaft fracture that the intramedullary nailing was contraindicated and treated by the minimally invasive approach for open anatomical reduction and compression plating. The vastus lateralis muscle was split and fracture was exposed only at the area that needed for the reduction. The fracture was maintained by two schanz screws connected with the AO tubular external fixator which were fixed from the anterior cortex of the femoral shaft that provided the space on the anterolateral surface of the bone for the standard compression plating. All fractures united without secondary surgery. The mean time to bony union was 20.4 (range, 16-28) weeks, there was one case of delayed union that healing in 28 weeks. The time to full weight bearing was 14.2 (range, 12-24) weeks. There was no plate failure but one broken screw at 14 week. The average intraoperative blood loss was 185 ml (80-260) and no blood transfusion was required. The results show that this technique is simple, reproducible and effective for the treatment of the simple femoral shaft fractures that require open reduction and compression plating.
Minimal Tourniquet Pressure for Hemostasis: The Effect of the Tightness of Tourniquet Cuff Application
(The Thai Journal of Orthopaedic Surgery, 2010-02-18) Vuth Kaveevorayan, MD
The pneumatic tourniquet is commonly used to establish a bloodless surgical field in extremity surgery. The minimal pressure that can effectively occlude arterial flow has been recommended to minimize the complication due to the excessive pressure. This study was to investigate the effect of the tightness and looseness of tourniquet cuff application to the minimal tourniquet pressure required for effective arterial occlusion of the upper extremity. The study was performed in the non-paid volunteer measured the upper extremity tourniquet inflation pressure under the tightness of tourniquet cuff’s circumference as it was loosen at 0, 1, 2, and 3 cm. in 52 volunteers. Other factors influencing the tourniquet inflation pressure were also recorded. The result shows that the effective tourniquet inflation pressure progressively increased when the tourniquet was loosening in all of the volunteers. Other factors found to have influence on the tourniquet inflation pressure were systolic blood pressure, and arm circumference.
Case Report A Simple Novel Technique to Remove a Bent Kuntscher Nail
(The Thai Journal of Orthopaedic Surgery, 2010-02-18) Sunyarn Neimpoog, MD
We present a simple technique to remove the bent intramedullary femoral nail in 26 year-old man admitted with an abnormally angulated right thigh within 3 days. The patient had a history of broken right femoral shaft at 2 months before this admission and was previously treated with Kuntscher nail fixation by open method. For the operative techniques, the fracture site was exposed using a previous incision. After dissection of soft tissue and periosteum from the fracture site, the authors increased the varus deformity of the femur including the nail inside the medullary canal until the nail formed the “V shape” and extracted the nail simultaneously. A limited corticotomy was conducted to allow more space for the nail to escape. After removal of the bent nail, the fracture was stabilized with a 12 x 360 mm. static interlocking nail (Grosse-Kempf).
Technical Note Minimally Invasive Arthroscopic Acromioclavicular Joint Stabilization
(The Thai Journal of Orthopaedic Surgery, 2010-02-18) Bancha Chernchujit, MD
Techniques for stabilization acromioclavicular joint injuries remain a topic of considerable controversy. The fact that over hundred different surgical procedures for treating complete acromioclavicular separation are noted in the literature indicates that an optimal procedure has not been found for this condition. Pinning across joints was a common method for fixing acromioclavicular joint separation because it is simple and easy to apply. Unfortunately, many complications associated with pinning have been reported such as degenerative acromioclavicular joint disease, breakage and migration of the pins. Simple coracoclavicular cerclage causes anterior subluxation of the distal clavicle with malreduction of the acromioclavicular joint. Also with time, synthetic cerclage material such as wire or Dacron tape can wear through the bone amputating the clavicle or the coracoid. A Bosworth screw or hook plate requires removal of the implant to avoid breakage or bony erosion. Dynamic muscle transfer may allow excessive motion at the acromioclavicular joint and can lead to symptomatic joint instability and arthrosis, especially in older patientsDespite these numerous options of surgical methods, the minimally invasive stabilization of this injury has been rarely reported. The aim of this report is to propose a new technique for stabilization of acromioclavicular joint dislocation using suture anchors with fiberwire tied over a small plate.
Idiopathic Chondrolysis of the Hip: A Case Report and Review of the Literature
(The Thai Journal of Orthopaedic Surgery, 2010-02-18) Nutthapong Wongwiwat , MD
This report is to present a case of idiopathic chondrolysis of the left hip in an 11-year-old girl. The patient had developed contractures of the left hip in the flexed, abducted, and externally rotated position for 8 months before attending the orthopaedic clinic. Radiographic findings revealed concentric with narrowing of the hip joint space. The results of laboratory studies were normal. The patient did not improve with conservative treatment which included; skin traction, physical therapy and medications. A subtotal circumferential capsulectomy and concomitant muscle releases were performed at 8 months later. A subsequent aggressive rehabilitation was continued for 3 weeks. Manipulations of the hip were supplemented during the loss in range of motion. At the time of last follow-up at 4 years and 2 months after surgery, the patient had normal activities at school and home, and she had neither symptoms nor contractures. The radiographs showed reconstitution of joint space and overgrowth of femoral head on the neck. The literature review regards to the etiology, natural history, clinical presentation and treatment options is also discussed.
Overlap Connecting Plate for Treating Facture
(The Thai Journal of Orthopaedic Surgery, 2010-02-19) Wallop Adulkasem , MD
Short segmented and comminuted fractures usually require special implants such as the special long plate or interlocking nailing system for the fixation. These implants or instruments may not be available in most hospital in Thailand or in the developing countries. This paper presents an improvise technique of using the overlap connecting plate to overcome this problem. The method have been successfully applied in fifteen patients who had segmented or comminuted fractures. Seven cases were treated by using condylar plate with broad dynamic compression plate (DCP) for femoral fractures, four were fixed bysmall T-plate with small DCP for distal radius fractures and another four were fixed by using T-plate with narrow DCP for tibial fractures. The operation time and blood loss were not exceed the average of ordinary operating procedure. All fractures were united in 4 months post operation. All patients could have early ambulation or mobilization program post operation and the injured limbs had returned to normal function at the time of final visits.The overlap connecting plate is an alternative method for treating complicated fractures. Special considerations of the method include; minimum of six cortices in each fragment fixation is required, plate must seat well on the bone, the thinner plate should be placed underneath the thicker one, the blade plate should be placed over the normal DCP. The overlap connection plate has been found simple and effective. The instrument and implants are familiar to the surgeon and are available in most hospitals.
Review Article Initial Management of the Injured Elderly
(The Thai Journal of Orthopaedic Surgery, 2010-02-19) Kongkhet Riansuwan, MD
It is well recognized that the proportion of the elderly is increasing. The population who are older than 65 years will become 52 millions by the year 2020. The number may exceed 68 million by the year 2040.1 Many of these elderly will sustain an injury during their lives and trauma in this age group usually relate with higher mortality rate than do in the adult. Except heart disease, cancer, chronic obstructive pulmonary disease (COPD), stroke, diabetes and pneumonia, trauma is the seventh leading cause of death in the geriatric patients. Even though the elderly are less likely to be injured than the younger, the fatal outcome, 28% of all fatal injuries in the United State, are more likely in this age group.2,3 This evidence probably reflects the decreased physical reserves of the elderly due to the physiologic changes of aging, the developed co-morbidities and a lack of understanding of specific treatment by many health care providers.
Idea and Innovation Mobile Spacer for Revision Infected Total Knee Arthroplasty
(The Thai Journal of Orthopaedic Surgery, 2010-02-19) Piya Pinsornsak, MD
Antibiotic spacer is the material that has amajor role in treatment of two-stage exchange arthroplasty in infected total knee replacement. Currently there are two types of antibiotic spacer used, static spacer and mobile spacer. The disadvantage of the static spacer is bone loss from the surface of the articulating femoral condyle and tibial plateau, limitation movement of the knee in the period of stage exchange, and difficult exposure in the second stage reimplantation of the prosthesis. Then the mobile spacer is created to solve these problems. The authors created the mobile spacer molds from silicone to mold the femoral and tibial articulating spacer which do not adhere to the cement and resterilable. The spacer molds are very reproducible, and easily made. These molds can safe the cost for using of the commercial PROSTALAC system which is more expensive than the local made one.
Unreamed Tibial Nailing with Additional Bone Grafting from Tibial Entry Point in the Treatment of Closed and Open Fractures Grade I and II
(The Thai Journal of Orthopaedic Surgery, 2010-02-19) Theerachai Apivatthakakul, MD
Forty two fractures of the tibial shaft (40 patients) were treated by unreamed intramedullary nailing with additional autogenous cancellous bone grafting from the proximal tibial entry point. There were 28 closed fractures and 14 open fractures, 6 cases of grade I and 8 cases of grade II. The fracture was stabilized with a solid static interlocking nail without intramedullary reaming. The bone graft harvested from proximal tibial entry point of the nail was inserted through the additional small incision on the medial side of the tibia in the closed fracture and through the open fracture wound in the open fracture. The mean time for fracture union was 16.3 weeks, the delayed union rate was 2.3%, malunion was 7%. There was no case of nonunion. Locking screw breakage occured in one case and no nail breakage occurred in this study. No additional surgical procedure was performed to promote union. There was one case in open fracture grade II had postoperative complication of deep infection at the fracture. The fracture was treated by irrigation and antibiotics and uneventfully healed in 30 weeks. No donor site hematoma or fracture of the tibial plateau was observed. Un-reamed intramedullary nailing with additional

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