The outcomes and prognostic factors of patients with soft-tissue sarcoma.

The present study evaluates the outcomes and prognostic factors in patients with soft-tissue sarcomas of the extremities, trunk, head and neck region. A retrospective study of 104 patients who underwent treatment was conducted on 48 males and 56 females with a mean age of 44.5 years (range, 10-85 years). Seventy-eight patients had high-grade sarcomas and most tumors (89.5 percent) were located at the extremities. One hundred patients were treated by surgery and 51 patients were treated by both surgery and radiation therapy. With the median follow-up time of 24.5 months, local recurrence developed in 26 patients (25 percent) and distant metastasis developed in 29 patients (27.9 percent). The actuarial overall 3-year disease-specific survival rate were 74.2 percent. Multivariate statistical analysis revealed that positive surgical margin and occurrence of distant metastasis were significant predictors for overall survival. Positive surgical margin was the only factor that increased the risk of local recurrence and older age (> or = 60 years) was only the factor that increased the risk of distant metastasis. The results reaffirm the importance of the surgical margin where uncontrolled local disease affects the risk of local failure and disease-specific survival. Occurrence of distant metastasis is associated with older age (> or = 60 years) and decreases disease-specific survival of the patients.

Periacetabular limb salvage for malignant bone tumours.

PURPOSE: To evaluate treatment outcomes in primary malignant periacetabular bone tumour removal and limb salvage with or without bone-graft reconstruction. METHODS: A total of 13 patients were treated for malignant periacetabular bone tumours at Siriraj Hospital, Bangkok, Thailand. The diagnoses were chondrosarcoma (n=8), Ewing's sarcoma (n=2), osteosarcoma (n=1), well-differentiated osteosarcoma (n=1), and malignant giant cell tumour (n=1). 11 patients did not undergo reconstruction following tumour resection; 2 patients received fibular bone grafts bridging the periacetabulum to the remaining sacrum. Adjuvant chemotherapy was administered for high-grade malignant tumours, and postoperative radiation therapy was performed on patients with a closed surgical margin. RESULTS: At a mean follow-up of 24.3 months (range, 8.9-43.9 months), 9 patients remained disease-free, 3 had died of the disease, and one was alive with disease. According to the Musculoskeletal Tumor Society classification system, the mean functional analysis at final follow-up was 68.7%. Patients who underwent internal hemipelvectomy experienced a subsequent leg-length discrepancy ranging from 3 to 10 cm. Four patients had complications (one each for deep wound infection, skin necrosis, seroma, and vascular spasms) and were successfully treated with multiple debridements and appropriate antibiotics. Three patients had local recurrences; one required a classic hemipelvectomy. CONCLUSION: Malignant periacetabular tumours are difficult to manage. Functional results of our patients with no reconstruction or with bone-graft bridging were fair. Patients undergoing internal hemipelvectomy may experience leg-length discrepancies, which can be balanced with shoe lifts.

Prognostic factors for major limb re-implantation at both immediate and long-term follow-up.

We performed a prospective study in 186 patients with a minimum follow-up of two years in order to attempt to predict successful major re-implantation of the upper limb. There were 137 men and 49 women with 24 amputations of the palm, 75 of the wrist, 50 of the forearm, 9 disarticulations through the elbow, and 28 amputations through the upper arm. The degree of injury to the amputated segment and the stump were good predictors of the rate of success and the final outcome. Adequate preservation, contraction of the muscle in the amputated part after stimulation, the level of injury and a smoking habit were fair indicators, but the serum potassium concentration in the amputated segment was the best objective predictor. When it is higher than 6.5 mmol/l 30 minutes after re-perfusion, re-implantation should be avoided. A high systemic venous serum potassium concentration was also found before clinical signs of the re-perfusion syndrome were seen.

Vascular injuries in compound fractures of the leg with initially adequate circulation.

We carried out a randomised, controlled trial in 157 patients who had isolated severe Gustilo type-IIIa and type-IIIb fractures of the metaphysis or diaphysis of the leg to determine the prevalence of vascular injuries and the role of vascular repair. All patients had stable vital signs and clinically adequate circulation in their legs before operation. In a control group of 64 patients we performed conventional surgery with systematic debridement and primary stabilisation of the fractures. In the trial group of 93 patients the major vessels and nerves adjoining the compound fracture were routinely explored and repaired when necessary after the initial procedure. Two of the 28 control patients (7.1%) with type-IIIb compound fractures had signs of inadequate circulation after the first operation. Both had major vascular injuries which were demonstrated at a second procedure. In the trial group, major vascular injuries were found in two of 54 patients (3.7%) with type-IIIa and 11 of 39 patients (28.2%) with type-IIIb compound fractures. Compared with the control group the trial group showed improved results at both the immediate and long-term follow-up. Routine exploration and early repair of injured major vessels of the leg in severe compound fractures gave encouraging results.

The role of allopurinol in digital replantation.

The clinical effects of allopurinol on the attenuation of reperfusion injury in thumb replantations after prolonged ischaemic time were studied in a randomized control trial with a 2-year follow-up. There were 60 patients, in the trial group, and 38 patients in the control group. All were young, healthy labourers who had sharp or locally crushed amputations of the thumb at the proximal phalanx with a total ischaemic time of more than 10 hours. The standard management for thumb replantation was used in these patients, except that 300 mg allopurinol was given orally in the trial group on admission and a further 300 mg for another 5 days. After operation, the trial group had a lower infection rate, and less postoperative pain and chronic swelling than the control group. Recovery of sensation was also better in the trial group.

Clinical results of contralateral C7 root neurotization to the median nerve in brachial plexus injuries with total root avulsions.

This prospective study was carried out to assess motor and sensory recovery after contralateral C7 root to median nerve neurotization in brachial plexus injuries with total root avulsions. The survey was carried out from 1993 to 1995 and the patients were followed up for at least 3 years. There were 96 male patients with ages ranging from 13 to 48 years. All had a unilateral brachial plexus injury with avulsion of all roots. This was confirmed by clinical assessment and exploration. The anterior part of the contralateral C7 root was used for neurotization via a reversed pedicular ulnar nerve graft and the proximal end of the graft was connected to the median nerve. Furthermore, phrenic nerve to suprascapular nerve and spinal accessory nerve (via a sural nerve graft) to musculocutaneous nerve neurotizations were also carried out to obtain shoulder abduction and elbow flexion. At the 3 year follow-up, most patients had encouraging recovery of sensory function in the hand but motor function of the forearm and hand muscles was rather poor. Acceptable motor function was found in only 50 to 60% of the patients who were younger than 18 years.

A post marketing survey on the side-effects of loxoprofen.

A survey study of the efficacy and side-effects of loxoprofen in orthopaedic outpatient clinics was carried out from January 1995 to December 1997. There were 1206 patients (569 males and 637 females) with an average age of 56.4 +/- 14.9 years. The youngest was 43 and the oldest was 79 years. About 36 per cent of the patients had underlying diseases and 31 per cent were receiving other medications as well as loxoprofen. About 91 per cent of the patients were satisfied with loxoprofen in terms of pain control and decreased inflammation. However, 8.4 per cent had side-effects, the most common being GI and CNS disturbances. Some patients (0.24%) had GI bleeding and needed hospitalization. The high risk patients were female older than 60 years who had used loxoprofen continuously for more than 6 weeks. However, we conclude that loxoprofen is an effective NSAID with few side-effects.

Methylcobalamin as an adjuvant medication in conservative treatment of lumbar spinal stenosis.

To find out the clinical effects of methylcobalamin on the conservative treatment of degenerative lumbar spinal stenosis, the study was carried out as a control single blind trial with 2 year follow-up in 152 patients, 68 males and 84 females, whose ages ranged from 55 to 85 years, average 67 +/- 18.1 years. They were randomly allocated into 2 groups, the control group, 82 patients, and the methylcobalamin group, 70 patients. All had classical history, and physical and radiographic findings which confirmed the diagnosis of spinal stenosis. Conventional management, including patient education, physical therapy and medication, were carried out in every patient and in addition methylcobalamin 0.5 mg was given orally three times a day in the methylcobalamin group for 6 months. All patients were followed up periodically for 2 years. Most of the patients in both groups showed improvement but there was no significant difference between the 2 groups in terms of pain improvement and neurological signs, except neurogenic claudication distance which was better in the M-group.

Immediate stabilization of unstable pelvic fractures versus delayed stabilization.

To compare the immediate and long term outcome of immediate stabilization of the unstable pelvic fractures to delayed stabilization with simple external fixation, the study was carried out as a paralell trial with 2 year follow-up. There were 112 patients with 69 males and 43 females who had unstable pelvic fractures. They were allocated randomly into 2 groups. In group 1, 40 patients, conventional management was performed while in group 2, 72 patients, reduction and anterior stabilization of pelvic fractures with a simple external fixator were carried out immediately just after the unstable fractures were detected. Blood transfusion, post operative pain, need of reconstructive surgery of the pelvic fractures and late deformities were less in the group 2. Immediate anterior reduction and stabilization of the unstable pelvic fractures gave encouraging results.

Anterior stabilization in the pubic symphysis separation: a mechanical testing.

Four types of commonly used instruments, 1) external fixation, 2) tension wiring, 3) tension band wiring, and 4) single superior plating, for anterior stabilization of the diastasis pubic symphysis were tested for their mechanical properties under single load to failure in cadaveric pelvis by a universal testing machine. Three directions of loading, transverse tension, vertical tension and saggital compression, were used to test each type of instrumentation. Five specimens of each fixation were used for each direction of testing. The strongest instrumentation was single superior plating. Early mobilization can be advocated in the patient after fixation with this instrument. External fixation could resist transverse and saggital compression load at an acceptable level but not the vertical load. Tension band wiring could better resist vertical load than the other directions. Tensions wiring was the weakest instrumentation and early ambulation should be avoided.

The effects of patellar resurfacing in total knee arthroplasty on position sense: a prospective randomized study.

To find out the improvement of joint position sense after total knee arthroplasty with patellar resurfacing compared to total knee arthoplasty without patellar resurfacing, the study was carried out as a randomised parallel trial in patients who had stage III and IV primary osteoarthrosis of only 1 side of the knee with a 2 year follow-up. Twenty-one patients underwent patellar resurfacing and 26 patients had no patellar resurfacing. Joint position sense was evaluated by the average absolute different angle of the operated knees from the non operated knees which was the asymptomatic knee and acted as the reference knee. Position sense was improved significantly in both groups. However, the patients without patellar resurfacing had better improvement. The patients with patellar resurfacing had better results in terms of anterior knee pain and tenderness. Patellar resurfacing should be used in severe articular cartilage damage, not as a routine operation.

Brachial plexus injury and pain: incidence and the effects of surgical reconstruction.

A prospective study of pain after brachial plexus injury was carried out on 246 patients with at least 2 years follow-up. All of them had closed traction injury from motorcycle accidents. There were 16 females and 230 males aged from 16 to 44 years old. The patients' biodata, onset of pain, characteristics of pain and treatment were recorded. Changes in pain after conservative and operative treatment and the outcome of treatment were analysed. Two hundred and nineteen patients (89%) had significant pain and 182 patients (74%) had severe pain. Most of them had continuous pain with 2 to 20 peaks of severe pain per day. Crushing type of pain was the most common but mixed type of pain caused the most distress. Conservative treatment before surgery could relieve the pain in 39 patients (15.8%). Surgical reconstruction could further relieve the pain in 176 patients (80.36%). However, 21 patients (8.5%) still had severe pain. Improvement in sensory function had more effect on pain reduction than motor function.

Topical analgesics for knee arthrosis: a parallel study of ketoprofen gel and diclofenac emulgel.

The clinical efficacy of the two topical analgesics, ketoprofen hydroalcoholic gel (Fastum gel) and diclofenac emulgel, for osteoarthritis of the knee was studied. There were 85 patients who underwent the trial. They were randomly allocated into 2 groups, the diclofenac group, 42 patients (4 males and 38 females) receiving the diclofenac emulgel at the painfull site four times a day for 4 weeks, and the ketoprofen group, 43 patients (9 males and 34 females) receiving the ketoprofen hydroalcoholic gel four times a day for 4 weeks at the painful knee. Golberg's knee scoring was used to evaluate the patients before the trial, at the end of the first, second and fourth weeks. The ketoprofen group had poorer a score before the trial, however, both groups had improvement in their knee functions, knee score and pain. There was no significant difference between the groups at the end of the study. There was no serious side effect in both groups. Ketoprofen hydroalcoholic gel gave persuasive results in the treatment of knee arthrosis stage I and II.

Recovery of joint position sense after total knee replacement: the effects of soft tissue dissection.

To find out the effect of sharp dissection compared to electrocautery for soft tissue release and balancing in total knee replacement on proprioceptive sense, the study was carried out as a parellel double blind trial with 2 year follow-up. There were 52 patients in the sharp dissection group and 42 patients in the electrocautery group. Position sense of the operated knees was evaluated by the ability to reproduce the same angles as the non operative knees which acted as reference knees. The absolute different angles were used to evaluate the position sense. Before the operation, the patients in both groups had similar biographic data, pathology, and absolute different angles of knee positioning. After the operation, both groups had improvement in knee position sense; however, the sharp dissection group had more rapid improvement in the 1st post operative year. There was no significant difference at the 2 year follow-up.

Introducing the use of a simple nerve stimulator and locator for intraoperative use.

We found that this simple nerve stimulator which gave a direct current of 4.8 volts, 0.1 to 1.5 mA and 2.0 mA pulse of 60 cycles/min using 9 volts dry cells was useful for peripheral nerve surgery. It is cheap and easy to maintain. Surgeons who are interested in this simple nerve stimulator can adopt this idea themselves or can contact the authors.

Clinical efficacy of glycosaminoglycan polysulfate for the treatment of osteoarthritis of the knee joint: a double blind controlled study.

The investigator could not show that administration of glycosaminoglycan polysulfate twice a week, one intra-articular and one intra-muscular injections, was useful for osteoarthritis (stage II) of the knee joint.

Application of problem-based learning in orthopaedic surgery for 5th year medical student at Prince of Songkla University.

Problem-based learning should be continued and extended to more topics. However, the steps and details of the process should be modified to each group of students. The students and tutors should have a period for preparing themselves for the process. The learning media should be improved in quality, quantity and variety to serve almost all of the students.

Malignant peripheral nerve sheath tumor with neurofibromatosis type 1: a 2-case report and review of the literature.

Malignant peripheral nerve sheath tumor is a very rare soft tissue tumor in the general population but there is an increased incidence in patients with neurofibromatosis type 1. Two cases of malignant peripheral nerve sheath tumor associated with neurofibromatosis type 1 whom we were able to follow-up long term are presented. Although wide excision was performed successfully in these patients, they suffered from local recurrence of the tumors shortly after surgery and died with distant metastases. The literature concerning the natural history and the management of this specific condition was reviewed.