Nuh-uohj.pdf

Message by Editor, UOHJ The journal enters its fifth year since it was launched in 2012 with the inaugural and commemorative issue to celebrate 60 years of excellence in teaching, research and clinical services for National University of Singapore in the Department of Orthopaedics and Hand Surgery. The journal continues to be a forum for teaching residents. This fifth issue carries a large residency teaching section as in previous years. Articles have been contributed by the residents themselves. In addition, the journal features the Professorial Lectures for 2015, Special Awards conferred to Senior Consultants, Undergraduate Teaching Awards and Research Awards. Feature articles include the UOHC Cluster Retreat and the Official Opening Ceremony of our NUH Sports Centre in January 2016. I wish all residents happy reading. Do continue to contribute more articles and to support this journal.

Associate Professor Aziz Nather Editor University Orthopaedics & Hand Journal

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Editorial Board EDITOR Aziz Nather DEPUTY EDITOR (RESIDENT) Francis Wong Keng Lin RESIDENT MEMBERS Bernard Lau Pung Huh Andrew Hong Choon Chiet Sara Tan Shuhui STAFF MEMBERS Low Siew Leng May Siau Joseph Thambiah David Tan Meng Kiat ASSISTANT MEMBERS Jere Low Wenn Chua Chui Wei, Mae Sarah Lim Man Lin Lim Kai Bing, Danson Cao Shuo Tan Wei Ying, Rachel Alyssa Marion Chua Jia Min Low An Yee Foo Tian Yu, Claribel Jamie Chen Li Wen BUSINESS MANAGER Sharona Chang ADVISOR Wong Hee Kit ii

Content MESSAGE BY EDITOR, UOHJ

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EDITORIAL BOARD

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CONTENT PAGE LIST OF STAFF, UOHC

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RESIDENTS OF UOHC

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SPECIAL FEATURE •

Approach to Primary Bone Tumors- A Radiological Approach with X-Rays – Amritpal Singh, Gurpal Singh

CLINICAL ORTHOPAEDICS UPDATE •

Advancement in Treatment Strategy for Metastatic Spine Disease: Can Minimally Invasive Surgery Make a Difference? – Rishi Malhotra, Naresh Kumar

BASIC SCIENCE UPDATE •

The use of Intraoperative Cell-Salvage for Autologous Blood Transfusions in Metastatic Spine Tumour Surgery – Chen Yongsheng, Naresh Kumar

CLINICAL EXAMINATION • Examination of the Diabetic Foot – Andrew Hong, Aziz Nather • Examination of the Elbow – Joel Lim, Dennis Ng HAND CASE DISCUSSION • Missed Scaphoid Fracture – Ryan Yak, David Tan PLANNING & WRITING RESEARCH

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23 25

35 37

41 43 59 63 65 69

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Planning Research – Jamie Kee, Mao Haitong, Aziz Nather

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Writing a Case Report – Zest Ang, Aziz Nather

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PROFESSORIAL LECTURES •

2015 PESI B CHACHA LECTURE Transitions and Transformations in Spine Surgery – Steven D. Glassman

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2015 R W H PHO LECTURE

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The Evolution of Musculoskeletal Oncology as a Specialty – Patrick J Boland •

2015 V K PILLAY LECTURE

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Hip Preservation Surgery:Fact or Fiction – Young-Jo Kim •

2015 N BALACHANDRAN LECTURE

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Principles of Assessment and Management of Paediatric Musculoskeletal Deformities: Techniques Change, but Principles are Forever – Vincent Stephen Mosca SPECIAL AWARDS:

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NUH Emeritus Consultant Award: Prof K Satkunanantham

103

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NUHS Outstanding Mentor Award: Prof Shamal Das De

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TEACHING AWARDS:

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Dr Darren Tay Keng Jin, SGH

107

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Dr Jacqueline Tan Siau Woon, SGH

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Dr Lee Keng Thiam, TTSH

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Dr Chee Yu Han, NUH

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Dr Mark Edward Puhaindran, NUH

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Dr Andy Wee Teck Huat, KTPH

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Dr Arjandas Mahadev, KKH

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Dr Low Boon Yong, CGH

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Dr Gamaliel Tan Yu-Heng, NTFGH

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RESEARCH AWARDS:

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Rob Johnston Award: A/Prof Naresh Kumar

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Best Clinical Poster & Best Poster Presentation Awards: A/Prof Naresh Kumar

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Best of Outside-Europe Award: A/Prof Naresh Kumar

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LIST OF PUBLICATIONS (January to December 2015)

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REPORTS BY UOHC CLINICAL FELLOWS

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UOHC EVENTS:

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UOHC Cluster Retreat January 2016

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UOHC Charity Run and Opening of NUH Sports Centre January 2016

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INSTRUCTIONS TO RESIDENTS

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LIST OF STAFF, UOHC

LIST OF STAFF, UOHC Chairman, UOHC: Professor Wong Hee Kit DEPARTMENT OF ORTHOPAEDIC SURGERY Head:

A/Professor Wilson Wang Ee Jen

University Spine Centre

A/Prof Gabriel Liu Ka Po Prof Wong Hee Kit A/Prof Naresh Satyanarayan Kumar Dr Lau Leok Lim Dr Dennis Hey Hwee Weng Dr John Nathaniel Ruiz

Division of Hip & Knee Division of Paediatric Orthopaedics

A/Prof Wilson Wang Ee Jen Prof K Satkunanantham Asst Prof Lingaraj Krishna Dr Mark Chong Seng Ye Prof James Hui Hoi Po Emeritus Professor Lee Eng Hin Dr Andrew Lim Kean Seng

Division of Shoulder & Elbow

Prof V Prem Kumar Dr Dennis Ng Zhao Wen

Division of Musculoskeletal Trauma

A/Prof Joseph Thambiah Asst Prof Diarmuid Murphy Asst Prof Chee Yu Han Dr Gavin O’ Neill Dr Vinod Kumar Pannirselvam

Division of Musculoskeletal Oncology

Dr Mark Edward Puhaindran Emeritus Professor Robert Pho Wan Heng Dr Gurpal Singh

Division of Foot & Ankle

Prof Shamal Das De A/Prof Aziz Nather Dr Mark Chong Seng Ye Asst Prof Chee Yu Han Dr Ajay Purushothaman Nambiar

Division of Sports Medicine & Surgery

Asst Prof Lingaraj Krishna

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LIST OF STAFF, UOHC Chairman, UOHC: Professor Wong Hee Kit DEPARTMENT OF HAND & RECONSTRUCTIVE MICROSURGERY Head:

Asst Prof Alphonsus Chong Khin Sze



Emeritus Professor Robert Pho Wan Heng A/Prof Aymeric Lim Yu Tang Dr Mark Edward Puhaindran Dr David Tan Meng Kiat Dr Amitabha Lahiri Dr Sandeep Jacob Sebastin Dr Andre Cheah Eu Jin Dr Anthony Foo Tun Lin

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RESIDENTS OF UOHC

Residents of UOHC In January 2016, UOHC has 30 Residents: 22 for Dept of Orthopaedic Surgery 8 for Dept of Hand & Reconstructive Microsurgery

DEPARTMENT OF ORTHOPAEDIC SURGERY Residency Year 1

 

Lau Tze Chun Eugene

  Lee Zhao Jie Joel

Residency Year 2

 Muhammed Yaser

 Lim Zongwei Joel

Tan Shuhui Sara

Amritpal Singh

Hong Choon Chiet (Andrew)

Louis

Residency Year 3

Rishi Malhotra

Hasan

 

 

Wang Ming

Khor Yuet Peng

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Ng Yau Hong

Tan Jiong Hao Jonathan

Residency Year 4

Lau Puang Huh Bernard

Poh Keng Soon

 

Yik Jing Hui (Kevin)

Zubin Daruwalla

Residency Year 5

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Chen Yongsheng

Chua Wei Liang

Han Fucai

Lin Shuxun

Wong Keng Lin Francis

Zackary Chua Kerk Hsiang

DEPARTMENT OF HAND & RECONSTRUCTIVE MICROSURGERY Residency Year 1

Benjamin Seah

Residency Year 2

Jonathan Tay

Dong Xiaoke

Residency Year 4

Janice Liao

Residency Year 5

Lim Jin Xi

Ellen Lee

Renita Sirisena

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Residency Year 6

Soumen Das De

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SPECIAL FEATURE

Approach to Primary Bone Tumours - A Radiological Approach with X-Rays Resident: Amritpal Singh Supervisor: Gurpal Singh Division: Musculoskeletal Oncology, Orthopaedic Surgery

INTRODUCTION Primary bone tumours can be either benign or malignant. Metastasis is a characteristic feature of secondary bone tumours. Malignant tumours are characterized by locally aggressive and destructive behaviour. The behaviour of a tumour is dependent on its size, the differentiation grade and localization. These factors are of decisive importance for the correct therapy. Even benign tumours can behave very aggressively. Most tumours are classified according to the pattern of differentiation and origin. Bone tumours form 0.2% of the human tumour burden. Primary malignant bone tumours make up 1% of all malignant tumours1. The commonest bone tumour however, is still bone metastases. The commonest primary bone tumour is multiple myeloma and osteosarcoma. Patient history and conventional radiographs are the most powerful primary diagnostic tools. Many tumours show typical characteristics and if a malignant lesion is suspected, a biopsy should be carried out. Several quality standards have to be respected when making the biopsy. The approach to malignant tumours is always interdisciplinary. Several biological as well as alloplastic reconstruction techniques exist. The treatment of primary malignant bone tumours requires a lot of experience and should only be done in specialized centres.

Definition, classification and general information Primary bone tumours are derived from mesenchymal and neuroectodermal progenitor cells. They are basically divided into benign and malignant bone tumours. We can classify bone tumours in the following way with some examples: Bone – forming tumours o Osteosarcoma Cartilage forming tumours o Chondrosarcoma Giant Cell tumour Marrow Tumours o Ewing’s sarcoma o Neuroectodermal tumour o Malignant lymphoma of bone o Myeloma Vascular Tumour o Angiosarcoma o Malignant Haemangio pericytoma

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Other Connective tissue tumours o Fibrosarcoma o Liposarcoma o Leiomyosarcoma Secondary malignant tumours of bone o Osteoblastic o Osteolytic o Mixed

EVALUATION History and clinical evaluation is the most important step in the diagnosis of tumours. In general, one should consider primary bone tumours in patients who present before the age of 40 and metastases after the age of 40. Age is the most important clinical clue in differentiating possible bone tumours. Most primary bone tumours are seen in patients. Different tumours also present in different age groups generally as shown in Table 1 below:

Age

0

10

20

30

40

50

Simple Bone Cyst Ewing Sarcoma Chondroblastoma NOF Osteochondroma Fibrous Dysplasia Osteosarcoma Osteoid Osteoma Aneurysmal Bone Cyst Eosinophilic granuloma Giant Cell Tumour Enchondroma Fibrosarcoma Osteoma Parosteal Sarcoma Chondrosarcoma Meyloma Metastases Chordoma Table 1: Specific Tumours by age (Malignant tumours in red and benign tumours in blue)

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It is important to ascertain the following points in the history as they can give a clue to the aggressiveness of the tumour: Pain Swelling History of trauma Neurological symptoms Restriction of movement Other constitutional symptoms

IMAGING MODALITY - The Plain Radiograph The most important factor in the analysis of a potential bone tumour, together with the age of the patient, is the morphology of the bone lesion on a plain radiograph. It can be divided into: Well-defined osteolytic Ill-defined osteolytic Sclerotic It is important to realize that the plain radiograph is the most useful examination for differentiating these lesions. CT and MRI are only helpful in selected cases. In this article we will discuss a systematic approach to the differential diagnosis of bone tumors and tumour-like lesions. The differential diagnosis mostly depends on the review of the conventional radiographs and the age of the patient. The typical sites of the different kinds of lesions on the X-ray are shown in Figure 1 below:

Figure 1: Types of tumours based on bony locations and age

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The abbreviations used in the article are as follows: ABC = Aneurysmal bone cyst CMF = Chondromyxoid fibroma EG = Eosinophilic Granuloma GCT = Giant cell tumour FD = Fibrous dysplasia HPT = Hyperparathyroidism with Brown tumor NOF = Non Ossifying Fibroma SBC = Simple Bone Cyst Differentiating between a diaphyseal and a metaphyseal location is not always easy. Many lesions can be located in both or move from the metaphysis to the diaphysis during growth. Larger lesions tend to expand into both areas. Most bone tumours are osteolytic. The most reliable indicator in determining whether these lesions are benign or malignant is the zone of transition between the lesion and the adjacent normal bone1. Once we have decided whether a bone lesion is sclerotic or osteolytic and whether it has a well-defined or ill-defined margins, the next question should be: how old is the patient? Age is the most important clinical clue. Finally other clues need to be considered, such as a lesion’s localization within the skeleton and within the bone, any periosteal reaction, cortical destruction, matrix calcifications, etc. (Figure 2)

Figure 2: Steps in assessing a radiograph for tumour

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In the table below (Table 2), the morphology of a bone lesion is combined with the age of the patient.

Age

Well-Defined

Ill-Defined

Sclerotic

0-10

EG SBC

EG-Ewing Osteosarcoma Leukemia

Osteosarcoma

10-20

NOF, Osteoblastic Fibrous Dysplasia EG SBC ABC Chondroblastoma CMF

Ewing EG Osteosarcoma

Osteosarcoma Fibrous Dysplasia EG Osteoid Osteoma Osteoblastoma

20-40

Giant CT Enchondroma Chondronsarcoma (Low Grade) Brown Tumour Osteoblastoma

Giant CT

Enchondroma Osteoma Bone Island Parosteal osteosarcoma Healed Lesions (NOF, EG, SBC, ABC, Chondroblasoma)

40 and above

Metastases Myeloma Geode

Metastases Myeloma Chondrosarcoma (High Grade)

Metastases Bone Island

All ages

Infection

Infection

Infection

Table 2: Morphology of bone lesion combined with age of patient

Notice the following: Infections, a common tumour mimic, are seen in any age group. Infection may be well-defined or ill-defined osteolytic, and even sclerotic. EG and infections should be mentioned in the differential diagnosis of almost any bone lesion in patients

Zone of Transition In order to classify osteolytic lesions as well-defined or ill-defined, we need to look at the zone of transition between the lesion and the adjacent normal bone. The zone of transition is the most reliable indicator in determining whether an osteolytic lesion is benign or malignant1. The zone of transition only applies to osteolytic lesions since sclerotic lesions usually have a narrow transition zone.

Small zone of transition A small zone of transition results in a sharp, well-defined border and is a sign of slow growth. A sclerotic border especially indicates poor biological activity. In patients particularly over 40 years, despite benign radiographic features, metastasis or plasmacytoma also have to be considered. 17

Below, two bone lesions with a narrow zone of transition are shown (Figure 3). Based on the morphology this lesion is benign.

Figure 3: Bone cysts seen in the ilium and distal femur with narrow zones of transition

In patients > 40 years, metastases and multiple myeloma are the most common bone tumours. Metastases under the age of 40 are extremely rare, unless a patient is known to have a primary malignancy. Metastases could be included in the differential diagnosis if a younger patient is known to have a malignancy, such as neuroblastoma, rhabdomyosarcoma or retinoblastoma.

Wide zone of transition An ill-defined border with a broad zone of transition is a sign of aggressive growth1. It is a feature of malignant bone tumours. There are two tumour-like lesions which may mimic a malignancy and have to be included in the differential diagnosis. These are infections and eosinophilic granuloma. Both of these entities may have an aggressive growth pattern. Infections and eosinophilic granuloma are exceptional because they are benign lesions which may seem malignant due to their aggressive biologic behaviour. These lesions may have ill-defined margins, but cortical destruction and an aggressive type of periosteal reaction may also be seen. EG almost always occurs in patients. Infections have to be included in the differential diagnosis of any bone lesion at any age. (Figure 4)

Periosteal Reaction A periosteal reaction is a non-specific reaction and will occur whenever the periosteum is irritated by a malignant tumour, benign tumour, infection or trauma. There are two patterns of periosteal reaction: a benign and an aggressive type. The benign type is seen in benign lesions such as benign tumours and following trauma. An aggressive type is seen in malignant tumours, but also in benign lesions with aggressive behaviour, such as infections and eosinophilic granuloma (Figure 4).

Figure 4: Different kinds of periosteal reactions

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Benign Periosteal Reaction Detecting a benign periosteal reaction may be very helpful, since malignant lesions never cause a benign periosteal reaction. A benign type of periosteal reaction is a thick, wavy and uniform callus formation resulting from chronic irritation (Figure 5). In the case of benign, slow growing lesions, the periosteum has time to lay down thick new bone and remodel it into a more normal-appearing cortex.

Figure 5: Benign Periosteal reaction in an osteoid osteoma

Aggressive Periosteal Reaction This type of periostitis is multilayered, lamellated or demonstrates bone formation perpendicular to the cortical bone2. It may be spiculated and interrupted - sometimes there is a Codman’s triangle. A Codman’s triangle refers to an elevation of the periosteum away from the cortex, forming an angle where the elevated periosteum and bone come together. In aggressive periostitis the periosteum does not have time to consolidate.

 

               A    

 

                         B                                                                                                C  

Figure 6: Aggressive periosteal reaction

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Left: Osteosarcoma with interrupted periosteal reaction and Codman’s triangle proximally. (Figure 6A) There is periosteal bone formation perpendicular to the cortical bone and extensive bony matrix formation by the tumor itself.

Middle: Ewing sarcoma with lamellated and focally interrupted periosteal reaction (Figure 6B).

Right: Infection with a multilayered periosteal reaction (Figure 6C). Notice that the periostitis is aggressive, but not as aggressive as in the other two cases.

Cortical Destruction Cortical destruction is a common finding, and not very useful in distinguishing between malignant and benign lesions3,4. Complete destruction may be seen in high-grade malignant lesions, but also in locally aggressive benign lesions like EG and osteomyelitis. More uniform cortical bone destruction can be found in benign and low-grade malignant lesions. Endosteal scalloping of the cortical bone can be seen in benign lesions like FD and low-grade chondrosarcoma.

Figure 7: Cortical Destruction

Figure 7 shows irregular cortical destruction in an osteosarcoma (left) on a background of myositis ossificans. It can be difficult to evaluate such lesions but careful assessment of the X-rays shows cortical destruction of the fibula. Ballooning is a special type of cortical destruction5,6 (Figure 8). In ballooning the destruction of endosteal cortical bone and the addition of new bone on the outside occur at the same rate, resulting in expansion. This ‘neocortex’ can be smooth and uninterrupted, but may also be focally interrupted in more aggressive lesions like GCT.

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Giant cell tumour A locally aggressive lesion with cortical destruction, expansion and a thin, interrupted peripheral layer of new bone. Notice the wide zone of transition towards the marrow cavity, which is a sign of aggressive behaviour. In the group of malignant small round cell tumours which include Ewing’s sarcoma, bone lymphoma and small cell osteosarcoma, the cortex may appear almost normal radiographically, while there is permeative growth throughout the Haversian channels. These tumours may be accompanied by a large soft tissue mass while there is almost no visible bone destruction. Figure 9 shows an Ewing’s sarcoma with permeative growth through the Haversian channels accompanied by a large soft tissue mass. The radiograph does not show any signs of cortical destruction.

Figure 9: Ewing’s Sarcoma

Location within the skeleton The location of a bone lesion within the skeleton can be a clue in the differential diagnosis. Figure 10 shows the preferred locations of the most common bone tumours. In some locations, such as in the humerus or around the knee, almost all bone tumours may be found7.

Figure 10: Locations of tumours within a skeleton

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CONCLUSION The diagnosis and treatment of primary bone tumours requires a lot of experience and an interdisciplinary approach. The conventional X-ray imaging is the most important initial imaging to assess and diagnose bone tumours. It is often indicative and saves unnecessary diagnostic tests and uncertainties for the patient.

REFERENCES 1. Helms CA. Fundamentals of Skeletal Radiology. W.B. Saunders Company. 1995 2. Kransdorf MJ, Sweet DE. Aneurysmal Bone Cyst: Concept, Controversy, Clinical Presentation, and Imaging. AJR 1995; 164: 573-580 3. University of Washington Musculoskeletal Radiology academic section. Lucent Lesions of Bone. In: Online Musculoskeletal Radiology Book. Seattle. 4. University of Washington Musculoskeletal Radiology academic section. Sclerotic Lesions of Bone. In: Online Musculoskeletal Radiology Book. Seattle. 5.

University of Washington Musculoskeletal Radiology academic section. Periosteal Reaction. In: Online Musculoskeletal Radiology Book. Seattle.

6. Miller TT. Bone Tumors and Tumorlike Conditions: Analysis with Conventional Radiography. Radiology 2008; 246(3): 662-674 7.

Mulder JD, Schütte, Kroon HM, Taconis WK. Radiological Atlas of Bone Tumors. Elsevier B.V. Amsterdam. 1993

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CLINICAL ORTHOPAEDICS UPDATE

Advancement in Treatment Strategy for Metastatic Spine Disease: Can Minimally Invasive Surgery Make a Difference? Resident: Rishi Malhotra Supervisor: Naresh Satyanarayan Kumar Division: Orthopaedic Surgery

ABSTRACT Purpose There is evidence in the recent past that there has been major evolution in treatment of metastatic spine disease (MSD) with advent of minimally invasive surgery (MIS). We aimed to discuss evolution of surgical treatment in MSD from open approach to MIS. This will provide sound base for further development and understanding of treatment paradigms in MSD.

Methods Relevant articles were selected using search terms: “minimally invasive surgery”, “surgery”, “metastatic spine disease”, and any of the above terms with “radiotherapy” and “chemotherapy”. We also identified additional articles through hand searches of references.

Results A multidisciplinary team approach including spinal surgeons, medical & radiation oncologists is mandatory as the treatment options are constantly evolving and are of much debate. Current evidence shows best clinical outcomes are achieved by surgery with timely post-operative radiotherapy. To make surgical management an appealing choice in MSD, surgical morbidity needs to be minimized, especially when planning oncological treatment around surgery. MIS approaches have shown encouraging results with early wound healing resulting in early introduction of radiotherapy, reduced intra-operative blood loss and shortened hospital stay, good outcomes in terms of pain reduction and neurological improvement, comparable to open surgery. We also provide our treatment algorithm to operate on patients with MSD, which relies on clinical presentation and radiological appearance of spinal cord compression.

Conclusions Patient’s quality of life can be improved through MIS. Introduction of MIS can be a game-changer in the treatment of MSD due to less peri-operative morbidity and allowing earlier radiotherapy and/or chemotherapy.

Introduction The spine is the most common site for osseous metastasis from systemic neoplasia[1, 2]. Metastatic Spine Disease (MSD) can lead to significant morbidities including pain and neurological deficits. Traditionally, surgery has been indicated in conjunction with medical treatment in specific situations or when radiotherapy and/or chemotherapy have failed. It is also commonly employed in an emergent situation such as rapid neurological deterioration or pathological fracture. (Figure 1) Every opportunity to reduce surgical morbidity in these high-risk patients should be taken. Minimally invasive surgery (MIS) seems to be a logical solution to reducing surgical morbidities in such patients. The use of MIS in MSD is relatively young and revolutionary[3]. Its indications are not yet clearly defined but are evolving[3-5]. 25

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Figure 1: Lateral and AP projections of MIS intervention to bridge across a pathological fracture. Embolisation coils can be seen at the affected vertebral level which is a useful preoperative measure if tumour decompression is also required.

Spine as part of the skeletal system, is the third most common system after lung and liver in the body to which metastasis take place[6]. Symptomatic spinal metastases are identified in only 10% of cancer patients[1, 7] of which 90 to 95% are extradural[8]. The most common primary cancers that metastasize to the spine are of epithelial origin, which include breast (21%), lung (14%), prostate (8%), kidney (5%), and thyroid (3%)[9]. Symptomatic spinal metastases are mostly found in the thoracic region (60 to 80 %) followed by lumbosacral region (15-30%) and the least in cervical region (10-15%)[1, 10, 11, 12]. Symptoms commonly are pain (95%) and neurological disturbance (75-80%)[1, 7, 13, 14]. ‘Spinal instability’ as a consequence of MSD is still poorly understood but is gaining recognition[15, 16]. The most common symptom of instability is pain on movement and when severe, it can render a patient bed-ridden regardless of motor ability[16]. Normal physiological forces such as twisting, bending or loading of the spine aggravate the pain. Whereas the pain can be relieved when the spine is supported and off-loaded, such as when the person is lying down[7, 10, 17].

CURRENT TREATMENT STRATEGIES FOR MSD: Chemotherapy There is little literature on chemotherapy (CTx) effects around surgery for MSD. With anti-vascular endothelial growth factors (e.g. Bevacizumab), 4-6 weeks of gap between surgery and CTx is advised, to reduce antiangiogenesis related wound complications[18- 20]. In the study by Erinjeri et al[21], they reported higher complication rate when chemotherapy was initiated within 14 days of the index surgical procedure (chest wall port). Unfortunately, we have not been able to find similar studies pertaining to spinal surgery. One can extrapolate that wound complications in MSTS can be minimized by adopting minimally invasive techniques which cause less trauma to soft tissue.

Radiotherapy (RTx) RTx as a primary modality is reasonable for patients with MSD without bony collapse or significant neurological deficit[22] and is associated with improvement in local pain, neurological deficit and functional outcome[14], especially in radiosensitive tumours[23]. Although there is no difference in long or short course RTx for MSD in terms of pain improvement[22], longer lower dose regimes resulted in lower local recurrence rate[24]. In contrast 26

to the standard external beam RTx, stereotactic radiosurgery allows more targeted delivery of higher doses to the area of interest and is garnering interest in spinal tumour[7, 25]. With regard to the timing of RTx, preoperative RTx is associated with increased complication rates such as dehiscence, delayed healing and wound infection ranging from 4% to 15.8% [26-28]. Ghogawala et al[29] concluded that preoperative RTx triples the rate of wound complications and RTx within the week prior to surgery carries a wound complication rate of 46%. Post-operative RTx results in better neurological outcome than with pre-operative RTx or RTx alone[29]. However, post-operative RTx should be delayed in order to reduce wound problems. Itshayek et al[30] recommended an interval of at least one week between surgery and radiotherapy[7, 13, 18].

Evolution of Surgery In the traditional posterior decompressive laminectomy for MSD with neurological deficits, access to the anterior tumour is limited by the inability to retract the spinal cord intra-operatively, thereby compromising the effectiveness of surgery. In addition, without instrumented stabilization, this resulted in spinal instability leading to RTx as the favoured treatment for MSD in the past; as laminectomy outcomes in terms of neurological function and pain, were no superior[1, 6, 7, 10, 13, 14, 31]. Newer surgical approaches involving instrumentation with decompression evolved and can provide a stable spine[13]. Furthermore, development of anterior approaches to the spine has enabled substantial tumour debulking from the vertebral body and has led to better neurological outcomes[6, 31]. In the face of technical advancements, there was a need to re-evaluate the role of surgery vis-a-vis RTx.

Surgery versus Radiotherapy The benefits of RTx are limited in established spinal instability, pathological fracture, cord compression secondary to fracture or bone retropulsion and in radioresistant tumours[7]. Thus, these situations are indications for surgical intervention in MSD. Other absolute indications for early decompressive surgery include onset of significant neurological deficit within 24 to 48 hours. Elective surgery may also be undertaken in a patient with a reasonable life expectancy to improve quality of life and relieve troublesome symptoms. However, surgery is usually not considered in patients with less than 3 months life’s expectancy[10]. Witham et al[6] conducted an extensive review to compare RTx and surgery. RTx alone resulted in a mean neurological improvement rate of 36%. More extensive surgical procedures resulted in greater neurological improvements with rates of 42%, 64%, and 75% in laminectomy, laminectomy plus stabilization, and anterior corpectomy plus stabilization respectively. Unfortunately, surgical morbidity, which is in the range of 21-26%[26, 28], correlates positively with the extensiveness of surgical procedure[28] and the use of preoperative radiotherapy[26]. The mean mortality rate for posterior surgery and anterior corpectomy was 5-6% and 10% respectively[6]. Similar operative mortality rates have been observed in recent studies of the last decade[26, 28]. Patchel et al[32] randomized patients with MSD into two arms: RTx alone or surgery followed by RTx. In the surgical group (50 patients), the approach was individualized in order to circumferentially decompress the tumour with stabilization if deemed necessary. RTx was started within 14 days from surgery as per the same protocol for the radiation-only group (51 patients). 84% of the surgery group maintained ambulation for a significantly longer period compared to 57% of the radiation only group. Of those non-ambulant at commencement of treatment, 62% in the surgical group regained ambulation versus 19% in the radiation only group. The surgical group also showed statistically significant advantages in neurological improvement, pain improvement, and maintenance of bowel and bladder control. Median survival was better in the surgical group (126 days vs 100 days) although not statistically significant. Morbidity was higher in the radiation only group, mainly due to complications secondary to prolonged immobilization. Incidentally, this study excluded highly radiosensitive tumours where the results of RTx may be more comparable to surgery. It is still safe to conclude that in acute paraplegia, immediate surgical debulking combined with RTx is superior to RTx alone. A meta-analysis of non-randomized cohorts[31] has echoed the previous results. Surgery was 1.3 times more likely to maintain ambulation and twice as likely to restore ambulation. Pain improvement was seen in 90% of patients who underwent surgery compared to 70% in RTx group. One-year survival in the surgical and RTx group were 12-62% (mean=41%) and 20-28% (mean=24%) respectively. Current evidence shows that best clinical outcomes are achieved by surgery, especially when it is combined with post-operative RTx[6, 31, 32]. This combination, however, is only successful when the two modalities are appropriately timed as the previous studies showed that preoperative RTx[26-29] and post-operative RTx[30] that is too soon after surgery can increase surgical morbidity. 27

To make surgical management an appealing choice in MSD, surgical morbidity needs to be kept as low as possible, especially when planning oncological treatment around surgery. This is where we believe ‘minimally invasive surgery’ (MIS) is successful, by reducing morbidity and allowing earlier introduction of post-operative RTx and CTx. In fact, early introduction of postoperative RTx and CTx (2 weeks post-operation) would lengthen the “honeymoon period” of surgery – i.e. the period after surgical decompression before the residual tumor can reproduce symptoms of cord compression.

Minimally invasive surgery (MIS) Minimally invasive stabilization and decompression is performed using working tubes and percutaneous pedicle screws[33]. Initially introduced for degenerative spine diseases, the technique has evolved rapidly since the late nineties. Minimally invasive approaches have been reported to be as successful as open techniques for lumbar decompression with less disruption of surrounding soft tissue structures, reduced intraoperative blood loss, reduced opioid dependence, shorter hospitalization and earlier return to work[33-37]. However, at one-year post op, there were no differences in clinical or radiological outcomes[35]. Thus MIS can only be shown to be advantageous in the early post-operative period, which is the period of particular interest in MSD patients with limited life expectancy. Complications of MIS and open approaches are compared in a study by Patrick Shih et al[38], which compared 26 open lumbar surgical decompressions with 23 MIS surgical decompressions. It showed that while MIS may be associated with longer operative times, there is decreased blood loss, shorter hospital stays, and decreased requirements for ancillary support services upon discharge[38]. Spinal surgical site infection which has been quoted up to 2% in open surgery[39] has been reduced by nearly 10 times via MIS[40].

Use of MIS for management of MSD Mean blood loss in open surgery for MSD is about 2 litres intra-operatively[43], and the studies that have discussed blood loss during MIS have shown far lower volumes[4, 42, 44, 45]. Our case series on the use of MIS in 27 patients with MSD confirmed the above advantages of reduced blood loss, postoperative morbidity and shorter hospital stays[3]. (Figure 2) Unfortunately, research in the field of MIS is based on several small series as the clinical use of MIS in MSD is still in an early stage of adoption. There are several forms of MIS that have been developed for use in spine surgery. These include cement augmentation techniques, endoscopic procedures, Minimal Access Spinal Surgery (MASS) and minimal invasive instrumentation. (Figure 3) Within the realm of endoscopic procedures, VATS (Video assisted thoracoscopic surgery) enables thoracic spine approaches with lung deflation, while laparoscopic retroperitoneal approaches have been developed to operate on lumbar regions. Posterolateral endoscopic techniques and minimally invasive direct lateral approaches can also be used to achieve lumbar vertebral body decompression. Minimal access surgery uses smaller incisions and the operative microscope to enhance the visual field. This can be employed for thoracotomy or direct posterior approaches to the spine[41].

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Figure 2: Typical 1-2cm incisions in MIS will heal faster than a single large midline incision, especially important in this population of patients who are elderly and affected by metastatic cancer.

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Figure 3: MIS posterior instrumentation - Using image intensifier, Jamshedi needles can be directed into vertebral body via the pedicles and guidewires subsequently used to direct working tubes onto the pedicle entry point. A skin incision is required to permit entry of the tubes and the opening can be sequentially dilated. Through the tubes the pedicle tract can be created and screws inserted.

In 2011, Molina et al[4] published a systematic review of 11 reports in the literature using MIS for MSD. Their main findings were that over 90% of patients achieved pain alleviation and neurological improvement. The largest series of 41 MSD cases by Huang et al[44] reported a 12% excessive bleeding rate (over 2 litres). Thus even MIS technique especially thoracoscopic MIS for MSD can have a significant bleeding risk. The authors[4] also evaluated 6 publications on MASS, involving 59 patients with MSD. They concluded that MIS made possible a hospital stay of a week or less without compromising good clinical results with pain alleviation and neurological improvement in a median of 100% and 95% respectively. Huang et al[45], in their study comparing 29 patients with minimal access thoracic approach to 17 with standard thoracotomy for treatment of thoracic MSD, concluded that only 6.9% of patients in MASS group required ICU admission postoperatively as compared to 88% in standard thoracotomy group. In both groups, 70% of those with paraplegia preoperatively had regained ambulation after surgery, proving that satisfactory outcomes can also be achieved with MASS. Even though the study size is small and non-randomized, the results of both approaches appear comparable but thoracic MASS may reduce the need for ICU stay that is commonly required after standard thoracotomy. Scheufler et al[42] reported a series of 38 patients requiring thoracic extrapleural or abdominal extraperitoneal MIS approach for thoracic lumbar vertebral body replacement, or plate fixations. The extra-coelomic techniques can allow access to the vertebrae with mini-incisions resulting in less pain and less pulmonary complication. These patients were able to start RTx at an average of 10 days post-operatively, much earlier than open cases. None of these patients had surgical site infection or wound break down. Intra-operative blood losses ranged from 220 to 1300ml at an average of 700ml for the MSD cases. Tancioni et al [5] conducted a prospective study of 25 patients with MSD who were treated with MIS posterior decompressive laminectomy and instrumentation. Twenty of these patients also had vertebroplasty. The mean operative time was 160 minutes. In addition, all patients underwent post-operative RTx within 2 weeks. All patients had a pre-operative VAS pain score of 8 or more. Immediate post-operative VAS was reduced to less than 5 in 96%, and at 3 months, all patients had complete remission of back pain. None of the patients had any neurological worsening. Quite notably, the mean hospital stay was 6 days. This study, like ours [3], is one of the larger series we could find on the use of posterior approach MIS for MSD, showing the feasibility of earlier initiation of RTx than traditionally accepted.

Treatment Algorithms The disadvantage of surgery, no matter how effective, is the risk of increased morbidity. We are now striving to reduce the surgical morbidity by utilizing MIS techniques. Evolving from this review, we would like to expand our surgical indications for patients with MSD. We have produced a clinical flow chart (Figure 4) to categorize patients and to aid decision-making. As discussed in this article, rapidly progressive or severe neurological deficits need to be operated on early. Several treatment algorithms have been suggested in the past on how to approach MSD[7, 10, 17]. Most value instability as an important factor but radiological features of impending cord compression are not emphasized.

29

Our proposed guideline (Figure 4) first categorizes patients with symptomatic MSD into 2 neurological groups and then sub-categorizes them according to the presence or absence of radiological features threatening neurology. Thus, neurologically intact patients can be considered for surgery if they have clear indicators of instability or severe symptoms (such as severe pain unresponsive to high doses of opiates). This is regardless of the presence or absence of a threatened cord on imaging. Our other emphasis is that neurological deficit should be surgically approached early in a medically fit patient regardless of instability and sensitivity to oncological treatment. This rationale is based on evidence that early decompression in patients with MSD resulted in better outcomes in preserving neurology and ambulation and improving survival[31, 32]. Since MIS has lower risk of surgical complications, it can allow safer surgery in the ‘grey zone’ of MSD presentations. MIS approach also allows surgery to be considered in patients with poor prognostic scores who may be categorized as ineligible for undergoing open surgery[3]. We strongly feel that promising results will be shown with MIS techniques in future studies. There is no doubt that further and larger studies, preferably comparative, will be required to make MIS the gold standard treatment for MSD for a broad range of indications.

Conclusion We believe that MIS is beneficial in a well-selected group of patients suffering from clinically significant instability with intractable back pain or motor deficits. Our treatment algorithm for symptomatic MSD is suggested as a guideline as these are high risk cases and treatments should be individualized with respect to prognosis, presence of comorbidities, and patients’ choice. We can improve patient’s quality of life through minimally invasive intervention. The introduction of MIS can be a game-changer in the treatment of MSD because it lowers perioperative morbidity and enables earlier radiotherapy and/or chemotherapy. Symptomatic MSD NO NEURO DEFICIT

Radiological compression

RTx/CTx Resistant or Failure

Uncertain histology or sensitivity

NEURO DEFICIT

No Radiological compression

RTx/CTx Sensitive

MIS/open decompression and stabilisation

RTx/CTx after SINS assessme nt

Radiological compression

No Radiological compression

MIS/open decompression and stabilisation ±RTx/CTx

Assess for other pathology

Assess SINS

Consider MIS/open decompression, stabilisation, Biopsy. Or Investigate further ±RTx/CTx

Stable SINS < 7

No Surgery ± RTx/CTx

Indeterminate SINS 7-12

No disabling symptoms

Unstable SINS > 12

Disabling symptoms

MIS stabilisation ±RTx/CTx

Figure 4: Algorithm for Management of Metastatic Spinal Disease

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REFERENCES 1. Jacobs WB, Perrin RG. Evaluation and treatment of spinal metastases: an overview. Neurosurgical focus 2001; 11:e10 2. Hatrick NC, Lucas JD, Timothy AR, Smith MA. The surgical treatment of metastatic disease of the spine. Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology 2000; 56:335-339 3. Kumar N, Zaw AS, Reyes MR, Malhotra R, Wu PH, Makandura MC, Thambiah J, Liu GK, Wong HK. Versatility of percutaneous pedicular screw fixation in metastatic spine tumor surgery: a prospective analysis. Annals of surgical oncology 2015; 22:1604-1611. 4.

Molina CA, Gokaslan ZL, Sciubba DM. A systematic review of the current role of minimally invasive spine surgery in the management of metastatic spine disease. International journal of surgical oncology 2011:598148.

5. Tancioni F, Navarria P, Pessina F, Marcheselli S, Rognone E, Mancosu P, Santoro A, Baena RR. Early surgical experience with minimally invasive percutaneous approach for patients with metastatic epidural spinal cord compression (MESCC) to poor prognoses. Annals of surgical oncology 2012;19:294-300. 6. Witham TF, Khavkin YA, Gallia GL, Wolinsky JP, Gokaslan ZL. Surgery insight: current management of epidural spinal cord compression from metastatic spine disease. Nature clinical practice Neurology 2006; 2:87-94; quiz 116. 7. Sciubba DM, Petteys RJ, Dekutoski MB, Fisher CG, Fehlings MG, Ondra SL, Rhines LD, Gokaslan ZL. Diagnosis and management of metastatic spine disease. Journal of neurosurgery Spine 2010;13:94-108. doi: 10.3171/2010.3.SPINE09202 8. Rose PS, Buchowski JM. Metastatic disease in the thoracic and lumbar spine: Evaluation and management. Journal of the American Academy of Orthopaedic Surgeons 2011; 19:37-46 9. Georgy BA. Metastatic spinal lesions: state-of-the-art treatment options and future trends. AJNR American journal of neuroradiology 2008; 29:1605-1611. doi: 10.3174/ajnr.A1137 10. Bartels RH, van der Linden YM, van der Graaf WT. Spinal extradural metastasis: review of current treatment options. CA: a cancer journal for clinicians 2008; 58:245-259. 11. Agarawal JP, Swangsilpa T, Van der Linden Y, Rades D, Jeremic B, Hoskin PJ. The role of external beam radiotherapy in the management of bone metastases. Clin Oncol (R Coll Radiol) 2006; 18:747-760 12. Willis RA. The Spread of Tumours in the Human Body. Butterworth, London. 1952 13. Heary RF, Bono CM. Metastatic spinal tumors. Neurosurgical focus 2001; 11:e1. 14. Cole JS, Patchell RA. Metastatic epidural spinal cord compression. Lancet neurology 2008; 7:459-466. 15. Fisher CG, DiPaola CP, Ryken TC, Bilsky MH, Shaffrey CI, Berven SH, Harrop JS, Fehlings MG, Boriani S, Chou D, Schmidt MH. A novel classification system for spinal instability in neoplastic disease: an evidencebased approach and expert consensus from the Spine Oncology Study Group. Spine 2010; 35:E12211229. 16. Fourney DR, Frangou EM, Ryken TC, DiPaola CP, Shaffrey CI, Berven SH, Bilsky MH, Harrop JS, Fehlings MG, Boriani S, Chou D. Spinal instability neoplastic score: an analysis of reliability and validity from the spine oncology study group. Journal of clinical oncology: official journal of the American Society of Clinical Oncology 2011; 29:3072-3077. 17. Walker MP, Yaszemski MJ, Kim CW, Talac R, Currier BL. Metastatic disease of the spine: evaluation and treatment. Clinical orthopaedics and related research 2003; S165-175. 31

18. Payne WG, Naidu DK, Wheeler CK, Barkoe D, Mentis M, Salas RE, Robson MC. Wound healing in patients with cancer. Eplasty 2008; 8:e9 19. Bose D, Meric-Bernstam F, Hofstetter W, Reardon DA, Flaherty KT, Ellis LM. Vascular endothelial growth factor targeted therapy in the perioperative setting: implications for patient care. The lancet oncology 2010; 11:373-382. 20. Scappaticci FA, Fehrenbacher L, Cartwright T, Hainsworth JD, Heim W, Berlin J, Kabbinavar F, Novotny W, Sarkar S, Hurwitz H. Surgical wound healing complications in metastatic colorectal cancer patients treated with bevacizumab. Journal of surgical oncology 2005; 91:173-180. 21. Erinjeri JP, Fong AJ, Kemeny NE, Brown KT, Getrajdman GI, Solomon SB. Timing of administration of bevacizumab chemotherapy affects wound healing after chest wall port placement. Cancer 2011; 117:12961301. 22. van der Linden YM, Dijkstra SP, Vonk EJ, Marijnen CA, Leer JW. Prediction of survival in patients with metastases in the spinal column: results based on a randomized trial of radiotherapy. Cancer 2005; 103:320-328. 23. Maranzano E, Latini P. Effectiveness of radiation therapy without surgery in metastatic spinal cord compression: final results from a prospective trial. International journal of radiation oncology, biology, physics 1995; 32:959-967 24. Rades D, Stalpers LJ, Veninga T, Schulte R, Hoskin PJ, Obralic N, Bajrovic A, Rudat V, Schwarz R, Hulshof MC, Poortmans P. Evaluation of five radiation schedules and prognostic factors for metastatic spinal cord compression. Journal of clinical oncology: official journal of the American Society of Clinical Oncology 2005; 23:3366-3375. 25. Gerszten PC, Burton SA, Ozhasoglu C, Welch WC. Radiosurgery for spinal metastases: clinical experience in 500 cases from a single institution. Spine 2007; 32:193-199. 26. Quan GM, Vital JM, Aurouer N, Obeid I, Palussiere J, Diallo A, Pointillart V. Surgery improves pain, function and quality of life in patients with spinal metastases: a prospective study on 118 patients. European spine journal 2011; 20:1970-1978. 27. Pascal-Moussellard H, Broc G, Pointillart V, Simeon F, Vital JM, Senegas J. Complications of vertebral metastasis surgery. European spine journal 1998; 7:438-444 28. Ibrahim A, Crockard A, Antonietti P, Boriani S, Bunger C, Gasbarrini A, Grejs A, Harms J, Kawahara N, Mazel C, Melcher R, Tomita K. Does spinal surgery improve the quality of life for those with extradural (spinal) osseous metastases? An international multicenter prospective observational study of 223 patients. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2007. Journal of neurosurgery Spine 2008; 8:271-278. 29. Ghogawala Z, Mansfield FL, Borges LF. Spinal radiation before surgical decompression adversely affects outcomes of surgery for symptomatic metastatic spinal cord compression. Spine 2001; 26:818-824 30. Itshayek E, Yamada J, Bilsky M, Schmidt M, Shaffrey C, Gerszten P, Polly D, Gokaslan Z, Varga PP, Fisher CG. Timing of surgery and radiotherapy in the management of metastatic spine disease: a systematic review. International journal of oncology 2010; 36:533-544 31. Klimo P, Jr., Thompson CJ, Kestle JR, Schmidt MH. A meta-analysis of surgery versus conventional radiotherapy for the treatment of metastatic spinal epidural disease. Neuro-oncology 2005; 7:64-76. 32. Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, Mohiuddin M, Young B. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 2005; 366:643-648. 33. Guiot BH, Khoo LT, Fessler RG. A minimally invasive technique for decompression of the lumbar spine. Spine 2002; 27:432-438

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34. Adogwa O, Parker SL, Bydon A, Cheng J, McGirt MJ. Comparative effectiveness of minimally invasive versus open transforaminal lumbar interbody fusion: 2-year assessment of narcotic use, return to work, disability, and quality of life. Journal of spinal disorders & techniques 2011; 24:479-484. 35. Ntoukas V, Muller A. Minimally invasive approach versus traditional open approach for one level posterior lumbar interbody fusion. Minimally invasive neurosurgery: MIN 2010; 53:21-24. 36. Rahman M, Summers LE, Richter B, Mimran RI, Jacob RP. Comparison of techniques for decompressive lumbar laminectomy: the minimally invasive versus the “classic” open approach. Minimally invasive neurosurgery: MIN 2008; 51:100-105. 37. Yagi M, Okada E, Ninomiya K, Kihara M. Postoperative outcome after modified unilateral-approach microendoscopic midline decompression for degenerative spinal stenosis. Journal of neurosurgery Spine 2009; 10:293-299. 38. Shih P, Wong AP, Smith TR, Lee AI, Fessler RG. Complications of open compared to minimally invasive lumbar spine decompression. Journal of clinical neuroscience: official journal of the Neurosurgical Society of Australasia 2011;18:1360-1364. 39. Olsen MA, Nepple JJ, Riew KD, Lenke LG, Bridwell KH, Mayfield J, Fraser VJ. Risk factors for surgical site infection following orthopaedic spinal operations. The Journal of bone and joint surgery American volume 2008; 90:62-69. 40. O’Toole JE, Eichholz KM, Fessler RG. Surgical site infection rates after minimally invasive spinal surgery. Journal of neurosurgery Spine 2009;11:471-476. 41. Ofluoglu O. Minimally invasive management of spinal metastases. The Orthopedic clinics of North America 2009; 40:155-168, viii. 42. Scheufler KM. Technique and clinical results of minimally invasive reconstruction and stabilization of the thoracic and thoracolumbar spine with expandable cages and ventrolateral plate fixation. Neurosurgery 2007; 61:798-808; discussion 808-799. 43. Chen Y, Tai BC, Nayak D, Lim JW, Goy RWL, Wong HK, Kumar N. Blood loss in spinal surgery for metastatic disease. A Meta-Analysis. The Journal of bone and joint surgery British volume 2013; 95-B 44. Huang TJ, Hsu RW, Sum CW, Liu HP. Complications in thoracoscopic spinal surgery: a study of 90 consecutive patients. Surgical endoscopy 1999; 13:346-350 45. Huang TJ, Hsu RW, Li YY, Cheng CC. Minimal access spinal surgery (MASS) in treating thoracic spine metastasis. Spine 2006; 31:1860-1863.

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BASIC SCIENCE UPDATE

The Use of Intraoperative Cell-Salvage for Autologous Blood Transfusions in Metastatic Spine Tumour Surgery Resident: Chen Yongsheng Supervisor: Naresh Satyanarayan Kumar Centre: University Spine Centre

INTRODUCTION Intraoperative blood loss is one of the feared problems encountered during surgical management of metastatic spine diseases (MSD). This significant intraoperative blood loss makes surgery for MSD challenging. The vertebral column is the most common site of bony metastasis, accounting for 18,000 new cases in North America yearly1. The most common primary tumor types likely to metastasise to the spine include breast, lung, prostate, kidney, and hematopoietic cancer2. In 2012, our group showed that there is considerable blood loss associated with spinal tumour surgeries, with an average of 2180 ml of blood lost per surgery and the possibility of catastrophic blood loss exceeding 9 L. In addition are many variables, which affect blood loss, such as the type of surgery, patient status (age, comorbidities) and type of tumour. Presently, ‘allogeneic blood transfusion’ (ABT) is the gold standard at most centres worldwide, placing an enormous burden on the limited and precious blood bank resources3. ABT has become safer with better testing yet there remain deleterious effects such as immune system compromise or transfusion-related acute lung injury from its exposure. It has been found that administration of ABT may increase the length of ICU and hospital stays resulting in higher treatment costs4, 5. Despite using measures to minimize the intraoperative blood loss such as preoperative embolization, antifibrinolytic drugs, bipolar electrocautery and haemostatic agents, there is still significant amount of bleeding during surgery for MSD6. The ideal method would be to salvage the lost blood during surgery and reinfuse the same6. Intraoperative cell salvage (IOCS) has emerged as a practical blood replenishment strategy in major spine surgeries, i.e. scoliosis surgery7. Using IOCS, the lost red blood cells during surgery can be salvaged and returned to the patient instead of discarding it6. The cost of transfusion of IOCS blood has been estimated to be less than the cost of banked blood. However, in cancer surgery, the biggest hurdle has been proving the safety of salvaged blood for reinfusion, as there is theoretical concern of reinfusing tumour cells to the patient via salvaged blood. Despite the above fact, evidence has accumulated supporting the use of IOCS in different surgical disciplines6. Other studies provided evidence that if leucocyte depletion filter (LDF) is added, the combination could eliminate all tumour cells from salvaged blood, rendering it safe6. Nevertheless, there remain many controversies among the orthopaedic and spine surgeons worldwide on the use of IOCS in ‘metastatic spine tumour surgery’’ (MSTS).

The evidence for use of iocs-ldf in oncological surgeries outside of orthopaedics and spine surgery In 2014, we published a comprehensive systematic review in the Lancet Oncology6 the latest evidence on IOCS-LDF combination use in oncological surgeries performed outside of orthopaedics and spine surgery. Our systematic review showed that the use of IOCS has been extensively investigated in patients undergoing surgery for gynaecological, hepatobiliary, gastrointestinal, urological, and lung cancers. These articles can be categorised into two groups: non-reinfusion studies and reinfusion studies. Non-reinfusion studies are those in which salvaged blood was not reinfused into patients but was analysed for presence or viability of tumour cells in the processed blood to ascertain the ability of the IOCS machine or LDF filter to remove tumour cells. These studies assess a proof of concept that cell saver machines and LDF can remove tumour cells. In reinfusion studies, salvaged blood was reinfused into patients undergoing oncological surgery and analysed on the basis of clinical outcomes such as survival, tumour recurrence rate, rate of metastasis, and 37

transfusion requirements after a period of follow-up. These studies attempt to establish a proof of value that cell saver machines with or without LDF can remove tumour cells and are safe for patients. Our study identified 23 reinfusion studies involving 1860 patients who had received autologous transfusion of intraoperative salvaged blood and five non-reinfusion studies involving 133 patients who had IOCS without autotransfusion (table). Additionally, we identified two in-vitro experimental studies that primarily assessed the usefulness of LDF in removal of tumour cells from blood. In that review, we found that the use of IOCS consistently reduces ABT requirements in gynaecological, hepatocellular, gastrointestinal, and urological cancer surgery. Empirical evidence from in-vitro studies and several non-reinfusion studies in gynaecological, hepatocellular, urological, and lung cancer surgery has consistently shown that LDF can either completely eradicate tumour cells or greatly reduce the number of tumour cells from blood–tumour cells admixtures or salvaged blood. This evidence provided the proof-of-concept that LDF can effectively remove tumour cells from the blood. Perhaps the strongest evidence in support of IOCS alone or IOCS–LDF use during cancer surgery came from clinical outcome data derived from reinfusion studies. These studies are done on patients who have received IOCS blood during their cancer surgery. The patients were assessed over a period of follow-up (maximum follow-up period up to 5 years), which is long enough to observe tumour recurrence in these patients. All studies showed either equivalent or better results across all clinical outcome parameters studied in the IOCS group, compared with those who did not receive IOCS. Of the five non-reinfusion studies, four showed that no tumour cells could be detected in the salvaged blood after LDF filtration. Only in one study involving 32 patients undergoing orthotopical liver transplantation for hepatocellular carcinoma, two of the 32 samples remained positive for tumour cells—both were cases in which the tumour had ruptured during surgery.

Prospective study on IOCS-LDF use in spine surgery With the above concepts in mind, we undertook a prospective observational study on IOCS-LDF use in spine surgery8. This was a 3-year project which recruited 60 patients who fulfilled the study criterial and were managed surgically with posterior and/or anterior approaches as clinically indicated. Patients selected had known spinal metastasis from known epithelial malignancies, and required spinal surgery for treatment of MSD. During surgery, an IOCS device (Dideco, Sorin Group, Italy) was used to collect blood lost from the operative field. The anticoagulant used was heparin 30,000 units diluted in 1 L of normal saline. To optimize the safety of salvaged blood, Pall RS leucocyte depletion filter (RS1VAE, Pall Corporation, Portsmouth, UK) was used as a final filtration after the blood had been processed by IOCS. Blood samples taken were 3 stages: stage A—from the operative field at the time of maximum tumour manipulation and prior to IOCS processing, stage B— IOCS processed blood prior to LDF filtration, stage C— IOCS-LDF processed blood (Fig. 1). At each stage, 15 ml blood sample was collected which comprised of three separate 5 ml samples taken at slightly different time points to avoid sampling error and provide advantage of replicative sampling. The samples from each stage were combined back to single sample of 15 ml before processing. The samples were processed in pathology laboratory. Each 15 ml samples were centrifuged, treated with RBC lysing agent ‘‘Pharmlyse’’ and centrifuged again three times after addition of phosphate-buffered saline. Bouin’s solution was added to the cell button and re-centrifuged. The sediment recovered was processed as a cell block. Three micron sections were cut from cell block and stained with Hematoxylin and Eosin, as well as cytokeratin immunostains using monoclonal mouse antibodies to high and low molecular weight cytokeratins (AE1/3, MNF116 and CAM5.2) to assess for tumour cells of epithelial origin. These slides were studied by one of two consultant pathologists who were provided full access to information on the histology of the primary tumour and operative notes, but were blinded to the actual stages from which the slides were derived. The advantage of two consultant pathologists was to be able to provide a continuous coverage of services so that the samples could be studied without prolonged storage. They could also consult to each other if there was any ambiguity regarding the slide studies such as cell characteristics. The laboratory method has been employed consistently throughout the study period.

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Figure 1: Stages of blood samples collection during surgery

Over a 3-year study period, 60 patients who fulfilled the inclusion criteria were enrolled and managed surgically with posterior and/or anterior approaches as clinically indicated. Postoperative diagnosis showed giant cell tumours in two cases and infection in two cases; hence, they were excluded. Minimally invasive surgery (MIS) technique was used in another six cases, where blood loss was minimal (\50 ml); leaving 50 participants in the final analysis. The sample size of 50 patients was sufficient for the purposes of proving the hypothesis which we intended to test. There were 29 females and 21 males. The median age of the patients was 60 years (range 36–85 years). The commonest primary tumour in our study was lung, followed by breast. Median blood loss was 550 ml (range 150–3500 ml). Malignant cells of epithelial origin were detected in the samples taken from stage A, i.e. the operative field prior to IOCS processing in 24 out of 50 patients and in the samples from stage B, i.e. IOCS processed blood in 4 out of 50 patients. No viable malignant cells were detectable in any of the blood samples taken from stage C where the salvaged blood was filtered with LDF. Therefore, the proportion of patients with negative tumour cells in the samples taken from operative field (stage A) was 52 % (95 % CI 43–75 %) and that in the samples taken from the transfusion bag post-IOCS processing (stage B) was 90 % (95 % CI 76–97 %). All patients (100 %) had negative tumour cells in the samples, which were processed and filtered with both IOCS and LDF. Proportion tests revealed that there was a significant difference between the proportion of patients with negative tumour cells in stage A and stage C (P<0.01). This significant difference was also observed between stage A and B (P<0.01) as well as stage B and C (P = 0.04). In summary, we found that no malignant cells detectable in any of the samples taken from IOCS-LDF treated salvaged blood (100 % of patients’ filtered salvaged samples were negative for tumour cells). The difference between the proportion of patients with tumour cells negative in blood from operative field and filtered salvaged blood (stages A and C) was significant, showing that the combination of IOCS-LDF is effective in eliminating tumour cells from blood salvaged during MSTS. Our findings were consistent with previous basic evidence studies in various surgical disciplines

Conclusion In conclusion, this review paper challenges the prevailing myth of avoiding IOCS in MSTS or even musculoskeletal tumour surgery because of unsubstantiated concern of tumour dissemination. We have clearly presented evidence which supports the notion that IOCS-LDF is effective in removing tumour cells from blood salvaged during MSTS as similar to oncological surgeries in other disciplines. It is now timely to proceed to clinical trials which will provide more warranted results, which might lead to new approaches in blood management during MSTS and musculoskeletal oncological surgeries.

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REFERENCES 1. Gokaslan ZL, York JE, Walsh GL, McCutcheon IE, Lang FF, Putnam JB, Jr., et al. Transthoracic vertebrectomy for metastatic spinal tumors. J Neurosurg. 1998; 89(4): 599-609. 2. Jacobs WB, Perrin RG. Evaluation and treatment of spinal metastases: an overview. Neurosurg Focus. 2001; 11(6): e10. 3. Blajchman MA, Bardossy L, Carmen R, Sastry A, Singal DP. Allogeneic blood transfusion-induced enhancement of tumor growth: two animal models showing amelioration by leukodepletion and passive transfer using spleen cells. Blood. 1993; 81(7): 1880-2. 4. Hu Y, Fu L. Targeting cancer stem cells: a new therapy to cure cancer patients. American journal of cancer research. 2012; 2(3): 340-56. 5. Blumberg N. Allogeneic transfusion and infection: economic and clinical implications. Seminars in hematology. 1997; 34(3 Suppl 2): 34-40. 6. Kumar N, Chen Y, Zaw AS, Nayak D, Ahmed Q, Soong R, et al. Use of intraoperative cell-salvage for autologous blood transfusions in metastatic spine tumour surgery: a systematic review. The Lancet Oncology. 2014; 15(1): e33-41. 7. Chen Y, Tai BC, Nayak D, Kumar N, Chua KH, Lim JW, et al. Blood loss in spinal tumour surgery and surgery for metastatic spinal disease: a meta-analysis. The bone & joint journal. 2013; 95-B(5): 683-8. 8. Kumar N, Ahmed Q, Lee VK, Zaw AS, Goy R, Wong HK. Are we ready for the use of intraoperative salvaged blood in metastatic spine tumour surgery? European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2015.

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CLINICAL EXAMINATION

Examination of the Diabetic Foot Resident: Andrew Hong Choon Chiet Supervisor: Aziz Nather Division: Foot and Ankle

INTRODUCTION In examining a diabetic foot problem (DFP), the usual method of using “look, feel, move and X-rays” – Apley’s system of examination1 of a hip joint, a knee joint or a spine – may not be appropriate. A system for examining a diabetic foot is: General examination Local examination Assessment for vasculopathy Assessment for sensory neuropathy Assessment for immunopathy

HISTORY TAKING It is important to take a comprehensive medical history.

What is the patient’s profile? Usually in the 5th and 6th decades of life (Nather et al 2007)2. Males and females are equally affected (Nather et al 2007)2.

What is the patient’s socioeconomic status? There is a higher incidence of DFPs in Malays and Indians as compared to other racial groups in Singapore. The incidence in Chinese was significantly lower3. They mainly occur in the lower socioeconomic group. Patient’s education level is usually up to secondary school only. They tend to have a low average monthly household income of less than S$20003.

Where is the pain? Localise the site of the pain: Toe(s) Dorsum of foot Sole of the foot Heel

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Is there vascular claudication? Vascular claudication is pain in the calf muscle when the patient walks a characteristic claudication distance due to inadequate blood flow. The pain disappears when he stops walking. Vascular claudication, a common symptom of ischaemic limb, is not common in DFPs.

Is there rest pain? Rest pain is common in patients with DFPs. It refers to continuous pain in the distal part of limb – toes or forefoot. This continuous, severe and aching pain often stops him from walking and sleeping. The patient usually hangs the leg over the side of the bed. Putting the leg below the level of the heart allows blood to gravitate into the limb and offers some relief of pain. He prefers to sleep in a sitting position rather than lying on bed. Sometimes, the rest pain is so severe that the patient begs for an amputation.

Is there swelling? In cellulitis, the generalised swelling in the foot is associated with redness, warmth and pain (Figure 1). A localized swelling is usually due to an abscess or infection of the underlying bone (osteomyelitis).

Figure 1: Cellulitis

Swelling of a joint with pain on motion of joint is usually due to septic arthritis. This commonly involves the metatarsophalangeal joint and the proximal interphalangeal joint of the foot. Fever, chills and rigors may be present. Elderly patients and patients with diabetes are usually immunocompromised. Thus, usually no systemic response is seen in these patients.

Is there deformity? Clawing of toes may be present due to motor neuropathy. A large swollen foot with deformity is due to Charcot Joint Disease (CJD). CJD can also be bilateral (Figure 2). Deformity can lead to a loss of the arch of the foot and in advanced cases, a rocker bottom foot deformity (Figure 3).

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Figure 2: Bilateral deformed feet due to CJD showing clawing of toes and hallux valgus deformity

Figure 3: Rocker bottom deformity in patient with CJD

Is there an ulcer? An ulcer is a common presenting symptom.

Site of ulcer Localise the site of the ulcer: Dorsum of foot (Figure 4) Sole of foot (Figure 5) Base of 5th metatarsal Lateral malleolus Heel

Figure 4: Ulcer of dorsum of foot showing infection and slough

Figure 5: Ulcer on sole of foot (neuropathic ulcer)

Contents of ulcer Note the colour and smell of the discharge. Staphylococcus aureus:

Thick, brown appearance, little odour

Pseudomonas aeruginosa:

Greenish appearance, rotten fruit smell or “metallic” smell.

Bacteroides fragilis (Anaerobe):

‘Faecal’ smell

Is there gangrene? Identify type of gangrene:

Dry Gangrene (Figure 6)

No superimposed infection

Wet Gangrene (Figure 7)

Superimposed infection

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Figure 6: Dry gangrene of heel

Figure 7: Wet gangrene of big toe

In gangrene, pain is usually felt at junction of dead and living tissues (pain receptors function in living tissue only)

Is there numbness? Look for 1. Degree a. Pins and needles (paraesthesia) b. Increased sensitivity to pain (hyperaesthia) c. Decreased sensitivity to pain (anaesthesia) 2. Duration sensation a. The longer the duration, the higher the incidence of sensory disturbance. 3. Extent of sensory disturbance a. Involving toes only b. Up to mid-foot c. Up to mid-shin d. Up to knees

Does the patient have recent trauma? Trauma is usually sustained at home (eg. when the patient kicks the side of the bed or slips and falls in the bathroom). Often, trauma goes unrecognized because patient has sensory neuropathy.

Has the patient sustained self-inflicted trauma? Cutting of a callosity or digging of a toenail using non-sterile equipment at home.

Does the patient self-medicate? Many patients like to self-medicate. Malays tend to apply coffee powder on their ulcers, Indians apply turmeric and the Chinese apply herbs from Traditional Chinese Medicine to heal their wounds. Such applications can aggravate infections.

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What is the type of footwear worn? Note the type of footwear worn by the patient. Nather, Kathryn and Zameer 20055 found that about 70% of diabetics do not wear shoes outside the house. They only wear slippers. Note the type of slippers worn Japanese slippers put the first web space in jeopardy of friction, leading to ulceration of the first web space. Slippers with dorsal straps and ankle straps lead to ulceration over the ankle and dorsum of foot.

What is the type of diabetes mellitus present? Most patients have Type 2 Diabetes (non-insulin dependent diabetes)2-5.

What is the type of diabetic medication used? Record diabetic medications employed. √ Diabetic diet √ Oral hypoglycaemic agents √ Oral drugs supplemented with insulin injections

Does the patient monitor his diabetes? Record type and frequency of monitoring by patient: √ Urine dipstick √ Capillary blood glucose level monitoring

Does the patient know his HbA1C level? HbA1C level reflects control of diabetes over the last 3 months. In patients with no diabetes, HbA1C is 3.5-5.5%. In patients with diabetes, HbA1C of less than 7% is good.

What are the symptoms of poorly controlled diabetes? The symptoms are polyuria (excessive production and passing of urine), polydipsia (excessive thirst) and polyphagia (excessive desire to eat).

What are the complications of diabetes present? Complications

Symptoms

Cataracts

Impairment of Vision

Diabetic Retinopathy

Damage to retina

Diabetic Nephropathy

Sallow appearance

Diabetic Neuropathy

‘Glove and stocking’ sensory disturbance in feet

Diabetic Vasculopathy

Vascular claudication or rest pain

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What are the co-morbidities present? Hypertension Ischaemic Heart Disease Chronic Renal Failure Cerebrovascular Accident (CVA)

Diabetes + Hypertension Diabetes and hypertension each predisposes the patient to atherosclerosis (hardening of arteries). The combination of diabetes and hypertension causes an increased risk to atherosclerosis or peripheral vascular disease. These patients thus have a greater risk of Below Knee Amputation (BKA).

Diabetes + Renal Failure Diabetes and renal failure each lead to immunocompromisation. The combination of diabetes and renal failure gives a poor prognosis, as the patient is “double-immunocompromised”. In patients undergoing renal dialysis, post-operative bleeding is a common complication leading to haematoma formation. The patient’s wound healing rate is also compromised. In a patient undergoing BKA, the chance of wound healing is only about 50-60%. The patient must be warned about the need for a further operation such as a revision BKA or an Above Knee Amputation (AKA) before the surgeon performs the primary BKA.

Diabetes + CVA The combination of stroke with diabetes is also bad, as severely physically disabled patients have an increased risk to pressure ulceration and bedsores.

What are the risk factors of diabetes? Hypertension Smoking Hyperlipidaemia

What is the functional status of the patient? Is he a walker? Can he walk into the community or is he housebound? Is he wheelchair-bound? Is he bed-ridden?

What is the patient’s occupation? Jobs that put workers under high risks of BKA include taxi drivers, housewives, cooks, manual labourers, and factory workers wearing safety boots. A housewife who cooks is at risk of BKA from hazards in the kitchen. A taxi driver who needs to continually exert pressure on the foot by stepping on the accelerator, brake or clutch may need to change his job to avoid a BKA. A factory worker experiences ulceration from wearing safety boots. He may also require a change of job to avoid a BKA.

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What is the patient’s family history? Is there a family history of diabetes? One or both parents and one or more siblings could have diabetes.

What is the lifespan of parents with diabetes? If the parent died at the age of 88, chances of the patient living to 70 years old or more are good.

Does the patient have a care-giver? Identify the care-giver – spouse, son, daughter-in-law, etc, who can help manage the diabetes or diabetic foot problem (eg. perform daily dressings of the wound).

CLINICAL EXAMINATION Conform to appropriate attire to avoid the risk of spreading infection from one patient to another. Wear o Short-sleeved shirt (or roll up long-sleeved shirt) o Bow tie (or remove long tie) o Remove watch/bracelet Wash hands with Hibiscrub or perform hand rub with alcohol before and after examining the patient. Prepare sterile green towel and gloves.

Position of Patient Ward:

Clinic:

Best to sit beside the bed

Put patient’s foot on stool

Examine foot at eye level.

Sit on chair to examine foot

Figure 8: Position of patient in the ward

Figure 9: Position of patient in the clinic

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General Examination Is the patient ill, anxious or well? Is he febrile? Is he alert or drowsy due to hypoglycaemia or ketoacidosis? Is there acidotic breathing due to ketoacidosis? Is there a sallow appearance due to renal impairment? Is there pallor? (Depress the eyelid and inspect conjunctiva for anaemia.) Is there dehydration? (Ask the patient to stick out his tongue to look for dryness.) Examine the eyes for cataracts. Is patient able to read newspapers? Examine the sclera for jaundice.

Vital Signs Measure blood pressure on both arms o Look for postural hypotension (sudden fall in blood pressure) Record Pulse Rate o Look for tachycardia Record Respiratory Rate o Look for tachypnoea Palpate all pulses in o Carotid, axillary, brachial, radial, ulnar, abdominal aorta, femoral, popliteal, dorsalis pedis and posterial tibial Record findings in the stick diagram:

Legend: ++

Palpable, strong

+

Palpable, weak

-

Not palpable

Figure 10: Stick diagram showing pulses in lower limb

LOCAL EXAMINATION Before starting, wear gloves. Remove dressing and place exposed limb on sterile green towel (Figure 11). After examination, wrap foot in green towel before applying new dressing. Place soiled dressing in plastic bag.

Figure 11: Foot placed on sterile dressing towel for examination

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Inspection Perform local inspection first. Inspect in systematic fashion the following parts of the foot: Toes Toenails Web spaces Dorsum Sole Heel Start with examining toes. End with examination of heel. Other signs include:

Problem Autonomic Neuropathy

Signs Dryness of skin Increased size of one foot (due to CJD)

Deformity

Rocker Bottom Foot Hallux valgus (bunion) Trophic nail changes

Chronic Ischaemia

Shininess of skin Loss of hair Increased pigmentation of the skin

Motor Neuropathy

Clawing of toes Wasting of intrinsic muscles

Examination of an Ulcer Examine the wound using the following protocol. (Figure 12): Site Size Edge o Incised, everted, inverted, ischaemic Floor o Slough, granulation tissue, tendon, capsule Content o Exudate, pus Environment o Cellulitis of adjacent skin

Edge

Floor

Figure 12: Ulcer on dorsum of foot with ischaemic edge. Slough and tendon in floor of ulcer

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Palpation It is important to palpate the foot. Is the redness in the foot cold or hot (indicating ischaemia or inflammation)? Is there underlying induration or abscess? Is there crepitus (indicating gas)? One then proceeds to assess vital components of the Diabetic Foot Triad: Vasculopathy Neuropathy Immunopathy

ASSESSMENT FOR VASCULOPATHY 1. Colour of skin Pink:

Normal

Pale:

Ischaemic

2. Temperature of skin Warm:

Normal

Cold:

Ischaemic

3. Pulp Capillary Refill < 2 seconds: Normal >2 seconds: Ischaemic

4. Palpation of pulses Femoral Pulse: Midway between pubic tubercle and anterior superior iliac spine (the mid-inguinal point) Easiest pulse to feel Politeal Pulse: Flex the knee to a 90° angle. Place both thumbs on either side of tibial tuberosity and the other fingers on the popliteal fossa. Relax the hamstrings. Gently press the popliteal artery against the tibia to feel the pulse. More difficult to feel (deep seated) Dorsalis Pedis Artery: Mid-point of anterior ankle line, between medial malleolus and the lateral malleolus. Drop a line between this point to the first interdigital cleft. The doraslis pedis pulse can be felt one-third down this line from the anterior ankle line. (Point B)

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Figure 13: Palpation of dorsalis pedis artery

Figure 14: Point A: midpoint of line between malleoli, Point B: 1/3 down the line from A to first interdigital cleft.

Posterior Tibial Artery: Place the hip in external rotation, the knee in flexion and the foot in dorsiflexion. The landmarks are: One-third along the line between the tip of the medial malleolus and the Tendo Achilles (Point C) One-third along the line between the tip of the medial malleolus and the point of the heel (Point D)

Figure 15: Palpation for posterior tibial artery

Figure 16: Showing Points C & D

The presence or absence of palpable pulses determines the type of surgery that could be performed.

Buerger’s Test Perform the Buerger’s Test when one or both pulses are not palpable. With the patient supine, raise the lower limb and look for pallor of the sole and toes (Figure 17). Record the vascular angle at which the foot turns pale. A Buerger’s angle of less than 20° indicates severe ischaemia. Normal:

90°

Ischaemia:

15° -30°

Pink Pallor Figure 17: Both feet turning pale at an angle of 30 o

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Pulses 2 pulses palpable

1 pulse palpable

Type of Surgery Distal amputation* can be performed Very good chance of success (70-80%) Distal amputation can be performed Fairly good chance of success Distal amputation should not be performed No chance of success

No pulse palpable

Refer to vascular surgeon Below Knee Amputation should be performed if revascularisation fails *Distal Amputation: Ray, Transmetatarsal, Lisfranc, Chopart, Pirogoff

ASSESSMENT FOR SENSORY NEUROPATHY 1. Pin Prick Test 2. Position Sense Test 3. Vibration Sense Test 4. Monofilament Test

Pin prick test Use a pin (neurotip) to test for pain sensation. Assess the degree of numbness present – increased sensitivity to pain (hyperaesthesia), decreased sensitivity to pain (hypoaesthesia) or complete loss of feeling (anaesthesia)4. Map out extent of the sensory disturbance present: Involve: Toes only Up to forefoot

Figure 18: Pin prick test

Up to mid-shin Disturbance is usually distributed in classical ‘glove and stocking’ distribution.

Position Sense Hold sides of big toe. Move toe up and down (Figure 19 and 20).

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Figure 19: Position sense test, hallux dorsiflexion (up)

Figure 20: Position sense test, hallux plantar flesion (down)

Vibration Sense Use a 128 Hz tuning fork: Place the tuning fork over bony prominence (tip of toe, medial malleolus and tibial crest). Record whether patient feels vibration or not.

Figure 21: Vibration Sense test using 128 Hz tuning fork

Ten-Points Semmes Weinstein Monofilament Test (SWMT) Use a 5.07 Gauge Nylon Monofilament to test for touch sensation.

Method: 1. Apply monofilament gently over each point and press until it buckles (10 gram force) with patient’s eyes closed. (Figure 22) 2. Record “Yes” or “No” for each point. 3. Complete 10 sites of testing (Figure 23)

Figure 22: 10g of force applied until filament bends

Abnormal: 7/10 or fewer sites

Figure 23: 10 sites for SWM testing

Normal: 8/10 or more sites 55

A positive monofilament test is more accurate than pinprick, vibration sense and position sense combined to detect sensory neuropathy6.

ASSESSMENT FOR IMMUNOPATHY Look for: Deep abscess Osteomyelitis Septic Arthritis 1. Start on dorsum of foot. Move interphalangeal joints and metatarsophalangeal joint gently of first ray. 2. Look for pain on movement of joints. Severe pain indicates septic arthritis. 3. Perform deep palpation of the bones in the first ray from distal phalanx, proximal phalanx and metatarsal to tibia (Figure 24). 4. Look for tenderness. 5. Next, palpate ray by ray (2nd, 3rd, 4th and 5th). 6. Press between 1st ray and 5th ray. 7. Repeat deep palpation on sole of foot (Figure 25).

Figure 24: Deep palpation ray by ray: dorsum

Figure 25: Deep palpation ray by ray: sole

Most common joints involved in septic arthritis are metatarsophlangeal joints (MTPJ) and proximal interphalangeal joints of foot (Figure 26). Most common bones involved in osteomyelitis are metatarsals and proximal phalanges.

Figure 26: Septic arthritis involving 4th MTPJ

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In necrotising fasciitis (Figure 27), the underlying skin shows cellulitis. In delayed cases, hemorrhagic blisters are classical.

Figure 27: Necrotising fasciitis, showing haemorrhagic blister of the skin

Signs: Look for severe tenderness and tension of the underlying deep fascia. Look for subcutaneous crepitus

Probe Test: Put a sterile metal probe into the ulcer. If it reaches bone, the bone is osteomyelitic7.

Figure 28: Probe Test

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REFERENCES 1. Solomon L, Warwick DJ, Nayagam S, Apley AG. Apley’s System of Orthopaedics and Fractures. Hodder Arnold 2001; (8) 2. Nather A, Chionh SB, Chan YH, Chew JLL, Lin CB, Neo SH, Sim EY. Epidemiology of diabetic foot problems and predictive factors for limb loss. J Diab Complic 2008; 22: 77-82 3. Nather A, Chionh SB, Wong KL, Koh SQO, Chan YH, Li XY, Nambiar A. Socioeconomic profile of diabetic patients with and without foot problems. Diabetic Foot & Ankle 2010; 1:5523 4. Nather A, Neo SH, Siok BC, Liew SCF, Sim EY, Chew JLL. Assessment of sensory neuropathy in diabetic patients without diabetic foot problems. J Diab Complic 2008; 22: 126-131 5. Stone K, Nather A, Aziz Z, Erasmus A. Footwear in patients with diabetic foot problems. 35th Annual General Meeting of Malaysia Orthopaedic Association 12 May 2005, Miri, Sarawak, Malaysia 6. Sosenko JM, Kato M, Sato R, Bild DE. Comparison of Quantitative Survey Threshold Measures for their Associates with Foot Ulceration in Diabetic Patients. Diabetes Care 1990; 13: 1057-1061 7. Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW. Assessment and management of foot disease in patients with diabetes. N Engl J Med 1994; 331(13): 854-860

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Examination of the Elbow Resident: Joel Louis Lim Supervisor: Dennis Ng Division: Shoulder and Elbow Surgery

INTRODUCTION The elbow is a synovial hinge joint that forms the articulation between the humerus and the radius and ulna. In it, the trochlea of the humerus articulates with the trochlea notch of the ulna and the capitulum of the humerus articulates with the head of the radius respectively. Strictly, the elbow joint only allows flexion and extension of the forearm. Flexion is performed by the brachialis, biceps brachii, bracioradialis and pronator teres muscles, while extension by the triceps and anconeus muscles. Pronation and supination occur at the adjacent proximal radioulnar joint. Its important relations are the median nerve and brachial artery anteriorly; the ulnar nerve and common flexor origin medially; and the common extensor origin laterally. An appreciation of the regional anatomy is vital to understanding the examination of the elbow.

INSPECTION The patient should be adequately exposed for the examination. Ideally, both upper limbs should be exposed entirely for comparison. The patient may be asked to stand with both elbows extended, palms facing forward, in the anatomic position.

Figure 1. Inspection from front, side and back (Left to right)

Start by inspecting the patient’s elbows from the front, side, back and then the inside of each elbow (Figure 1). Look for skin erythema, scars, swelling, deformity and carrying angle. Comparing the size of both elbows is a good way to notice swelling. However, keep in mind that adaptive hypertrophy may be present in certain sportsmen or manual laborers, accounting for a difference in size in the dominant arm. A swollen elbow is almost always held in a semi-flexed position. One of the earliest signs of effusion is the filling out of the hollows superior to the olecranon in a flexed elbow. Localized swellings may be seen around the joint and these include olecranon bursitis and rheumatoid nodules. Skin erythema, in the presence of increased warmth and tenderness may suggest an infective and inflammatory process.

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Inspecting the patient in the anatomic position also allows us to observe the carrying angle of both elbows concurrently. It is approximately 11° in males and more valgus at 13° in females. Unilateral cubitus valgus or varus deformities may be more apparent in this manner. Any departure from normal should be measured with a goniometer.

PALPATION Feel the elbow with the dorsum of your hand to assess for joint temperature relative to the rest of the arm. As mentioned above, increased warmth may be related to infection or an inflammatory process. Locate the olecranon process and the lateral and medial epicondyles. Check that they form an equilateral triangle. Disruption of this triangle suggests elbow subluxation or dislocation. Next, perform deep palpation of the lateral and medial epicondyles. Sharply localized tenderness over the lateral epicondyle indicates tennis elbow, while tenderness over the medial epicondyle may be due to golfer’s elbow or due to tears of the ulnar collateral ligament. Examine the radiohumeral joint by palpating the space between the radial head and the capitulum on the lateral aspect of the elbow. Tenderness, especially on pronation and supination of the forearm, may be present in radial head pathology. Roll the ulnar nerve under your fingers posterior to the medial epicondyle when the elbow is flexed and extended. Thickening of the nerve, or paraesthesia or hyperesthesia distally may be due to compression within the cubital tunnel and may warrant a formal examination of the ulnar nerve. Moving centrally, examine the antecubital fossa by palpating medial and lateral to the biceps tendon. Feel for any abnormal masses in this area. Ranging the elbow from 0° to 20° of flexion may allow deeper examination of this space.

MOVEMENT

Figure 2. Elbow extension, flexion, pronation and supination (Starting top left, clockwise)

There are 4 movements around the elbow (Figure 2). Flexion and extension occur at the elbow joint, while pronation and supination occur at the radioulnar joint. 60

Normal full extension is generally regarded as 0°. However, up to 15° of hyperextension may be normal, especially in women. Hyperextension beyond this limit should prompt the examiner to look for hyper-laxity in other joints. Normal full flexion is at least 145 degrees. Pronation and supination are examined with the patient’s arms and elbows tucked to sides of the body. The starting position for the measurement of these movements is with the patient’s palms facing each other and the radial border of the hand pointing vertically upwards. Pronation is expected to reach 75° and supination 80°. When necessary, accurate measurements should be made with a goniometer. Flexion and extension are measured with the axis at the elbow joint. Pronation and supination can be measured by getting the patient to grasp a pen in his hand. One leg of the goniometer can be aligned against the pen, with the other aligned with the vertical axis.

ACCESSORY TESTS Tennis Elbow (Lateral Epicondylitis) This can be tested by passive stretch tests at the common extensor origin at the lateral epicondyle. First, the patient’s elbow is flexed, the forearm is pronated, and the wrist is flexed. The elbow is then extended. The test is positive when the examiner observes pain at the lateral epicondyle.

Figure 3. Thomsen’s test (Resisted test for Tennis elbow)

Thomsen’s test is an active, resisted test for Tennis elbow (Figure 3). It involves asking the patient to clench the fist and dorsi-flex the wrist, with the elbow in extended and forearm pronated. From this position, the examiner attempts to palmar-flex the first while the patient resists. This test is positive when the patient reports pain over the lateral epicondyle.

Golfer’s Elbow (Medial Epicondylitis) This can be tested by passive stretch tests at the common flexor origin at the medial epicondyle. First, the patient’s elbow is flexed, the forearm is supinated and the wrist is extended. The elbow is then extended. The test is positive when the examiner observes pain at the medial epicondyle.

Figure 4. Resisted test for Golfer’s elbow

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Golfer’s elbow can also be tested against resistance by asking the patient to supinate the forearm and palmarflex the wrist (Figure 4). The examiner should then attempt to dorsi-flex the wrist while the patient resists. This test is considered positive if pain is elicited at the medial epicondyle.

Collateral Ligament Testing The integrity of the lateral and medial collateral ligaments of the elbow should be evaluated by observing for pain or laxity upon applying stress across the ligament. The varus and valgus stress tests are used to assess the lateral and medial collateral ligaments respectively. In both tests, the humerus is held in full external rotation and the forearm supinated. The elbow is held in 20° to 30° of flexion to disengage the olecranon from the olecranon fossa. The lateral collateral ligament is tested by first stabilizing the elbow at its medial aspect with one hand, allowing it to act as a pivot. This is followed by applying a valgus force at the distal forearm with the other hand. The medial collateral ligament is similarly tested by stabilizing the elbow at its lateral aspect with one hand, allowing it to act as a pivot, and applying a valgus force at the distal forearm with the other hand. The tests are considered positive if pain or joint opening is elicited.

Figure 5. Milking Maneuver

The medial collateral ligament can also be assessed with the milking maneuver (Figure 5), which also aims to create valgus stress across the elbow. The arm being tested should be held in front of the patient with the elbow flexed to 90°, the forearm supinated, and the thumb extended. The patient should then reach for the extended thumb with the other hand, passing under the tested elbow, and pull laterally. This creates a valgus stress at the medial collateral ligament of the tested elbow. Pain at the medial collateral ligament origin, instability or subjective apprehension is considered a positive test.

CONCLUSION Knowledge and understanding of the normal anatomy is necessary for a meaningful examination of the elbow. Comparison with the contralateral, asymptomatic side often provides a good benchmark to account for anatomical variants. It is useful to note the patient’s arm dominance as it may affect physical findings and it also has a strong influence on the functional impairment faced by the patient.

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HAND CASE DISCUSSION

Missed Scaphoid Fracture Resident: Ryan Yak Siqi Supervisor: David Tan Meng Kiat Division: Hand and Reconstructive Microsurgery

CASE REPORT A 23-year-old Malay male was seen in a polyclinic after a fall on his outstretched left hand while playing soccer. He complained of radial sided left wrist pain. Orthogonal wrist radiographs revealed no fracture (Figure 1) and he was discharged with analgesia. He re-attended the polyclinic two months later with persistent left wrist pain. At this juncture, a repeat wrist radiograph showed a fracture of the proximal pole of the scaphoid (Figure 2). He was subsequently referred to our department. On physical examination, there was anatomical snuffbox and scaphoid tubercle tenderness. We applied a long thumb spica to immobilize the fracture and arranged for early operative fixation with bone grafting.

Fig 1. Initial radiographs of the left wrist showing no fracture

Fig. 2 Radiograph two months later demonstrating a minimally displaced proximal pole scaphoid fracture with bony resorption at the fracture site and early sclerosis

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The patient underwent a left scaphoid open reduction and internal fixation via a dorsal approach with autologous non-vascularized distal radius bone grafting 10 weeks after the initial injury. Intra-operatively, the proximal pole fracture non-union was debrided and bone graft was packed into the fracture site. The fracture was then fixed using a 3mm x 18mm headless compression screw. Post-operatively there were no complications. The patient was reviewed at one week. The post-operative radiograph showed satisfactory fixation of the scaphoid (Figure 3). Histology of the fracture edges showed fibroconnective tissue, bone and cartilage with reactive change. A scaphoid cast was applied for another 4 weeks before it was converted to a splint and intermittent wrist range of motion was initiated. Subsequent postoperative radiograph at five weeks showed further healing of the fracture (Figure 4).

Fig. 3 Post-operative radiographs at one week showing satisfactory fixation of the scaphoid

Fig. 4 Post-operative radiographs at five weeks showing further healing of the fracture

DISCUSSION The scaphoid is the most commonly fractured carpal bone, accounting for 60-70% of all carpal fractures1. Scaphoid fractures occur frequently in young males engaged in sporting activities, and the mechanism of injury is usually a fall on an outstretched hand2,3. In adults, scaphoid fractures affecting the waist (70%) are the commonest type, followed by distal pole fractures (10-20%), proximal pole fractures (5-10%), and tubercle fractures (5%)4. The diagnosis of a scaphoid fracture is commonly missed. Clinical tests such as anatomical snuffbox tenderness, longitudinal thumb compression, scaphoid tubercle tenderness, and painful ulnar deviation have high sensitivity but low specificity5. Radiographs of the wrist or hand are usually obtained to diagnose the injury. However, only 16-27% of patients with initial negative radiographs have an actual fracture5. The rate of missed scaphoid fractures is estimated at 40%6. To aid in diagnosis, when clinical signs warrant further investigation, proper scaphoid radiograph views should be obtained. These include posterior-anterior (PA) wrist, lateral wrist, posterior-anterior (PA) wrist with an ulnar 66

deviated clenched fist (to position the scaphoid parallel to the film) and 45 degree oblique views4,7. Adjuvant imaging techniques may be required to diagnose scaphoid fractures. Computed tomography (CT) is useful for pre-operative planning and identification of non-unions, and has a sensitivity of 94% and a specificity of 96%. Magnetic resonance imaging (MRI) has a sensitivity of 98% and a specificity of 99%, and is helpful in detecting avascular necrosis (AVN) of the proximal pole (as evidenced by low signal intensity on T1 and T2 images)8. In view of the challenge of making accurate and early diagnoses, the classical treatment for suspected scaphoid fractures is the application of a long thumb spica to immobilize the wrist for two weeks. This is followed by serial examination and radiographs, with the belief that the delay allows for bony resorption adjacent to the fracture site, making the fracture visible9. In our institution, we advocate early referral to a hand surgeon after immobilization to follow up on such injuries. A missed diagnosis of a scaphoid fracture and subsequent delayed treatment often leads to complications. AVN is common in proximal pole fractures, with rates estimated between 13-50%10. The more proximal the fracture, the higher the risk of AVN11. Other complications include non-union, mal-union and carpal instability. Late scaphoid non-union may cause bony collapse, which results in “humpback” deformity. Chronic untreated scaphoid non-union predictably progresses to arthritic change, in what is termed “scaphoid non-union advanced collapse” (SNAC). Physicians should therefore maintain a high index of suspicion when evaluating any patient with traumatic radial sided wrist pain.

Fig 5. Showing blood supply of scaphoid

The scaphoid has two main vascular pedicles; volarly the distal third is supplied by the superficial palmar branch of the radial artery and dorsally, the dorsal carpal branch supplies the waist. The proximal pole is supplied via retrograde intraosseous blood vessels. Proximal pole fractures are at particular risk of nonunion and avascular necrosis because of their small size, tenuous blood supply, intra-articular location, and the relatively large moment arms across the fracture site. In our institution, we advocate that proximal pole fractures should be treated operatively due to the risk of non-union and AVN. An open dorsal technique as described by Matti was utilized for ease of access to the proximal pole fracture and bone grafting from the distal radius when the fracture is displaced or requires bone grafting. Alternatively, in early presenting minimally displaced proximal pole fractures, a dorsal mini-open or percutaneous screw fixation may be feasible. Our patient’s fracture was fixed with a compression screw as it has been shown that rigid screw fixation has superior results to Kirschner wiring for unstable non-unions12.

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CONCLUSION Scaphoid fractures can be easily missed as initial radiographs may be negative or a complete scaphoid series may not have been performed. Patients with a suspected scaphoid fracture should be immobilized in a long thumb spica cast for two weeks and re-evaluated by a hand surgeon. The penalty for missing this injury is high for the patient, as irreversible long term complications such as osteonecrosis and non-union may develop, causing significant pain and disability. Patients with a proximal pole fracture are especially prone to such complications due to the vascularity of the scaphoid. Such fractures should be operatively managed. The choice of surgical access and the need for a vascularized versus non-vascularized bone graft depend on the fracture location, configuration and presence of non-union and/or osteonecrosis.

REFERENCES 1. Hove LM. Epidemiology of scaphoid fractures in Bergen, Norway. Scand J Plast Reconstr Surg Hand Surg 1999; 33(4): 423-6 2. Van Tassel DC, Owens BD, Wolf JM. Incidence Estimates and Demographics of Scaphoid Fracture in the U.S. Population. The Journal of Hand Surgery 2010; 35(8): 1242-1245 3. Duckworth AD, Jenkins PJ, Aitken SA, Clement ND, Court-Brown CM, McQueen MM. Scaphoid fracture epidemiology. J Trauma Acute Care Surg 2012; 72(2): E41-5 4. Shenoy R, Pillai A, Hadidi M. Scaphoid fractures: variation in radiographic views - a survey of current practice in the West of Scotland region. Eur J Emerg Med 2007; 14(1): 2-5 5. Mallee WH, Henny EP, van Dijk CN, Kamminga SP, van Enst WA, Kloen P. Clinical Diagnostic Evaluation for Scaphoid Fractures: A Systematic Review and Meta-Analysis. The Journal of Hand Surgery 2014; 39(9): 1683-1691.e2. 6. Nguyen Q, S Chaudhry, R Sloan, I Bhoora, C Willard. The clinical scaphoid fracture: early computed tomography as a practical approach. Ann R Coll Surg Engl 2008; 90(6): 488-91 7. Bohler L,Trojan E, Jahna H. The results of treatment of 734 fresh, simple fractures of the scaphoid. J Hand Surg Br 2003; 28(4): 319-31 8. Yin ZG., Zhang JB, Kan SL, Wang XG. Diagnosing suspected scaphoid fractures: a systematic review and meta-analysis. Clin Orthop Relat Res 2010; 468(3): 723-734 9. Linscheid RL, Cooney WP, Dobyns JH. Scaphoid fractures and nonunion, in The wrist: diagnosis and operative treatment. Mosby. 1998: 385-430. 10. Adams JE, SP Steinmann. Acute scaphoid fractures. Orthop Clin North Am 2007; 38(2): 229-35, vi. 11. Buijze GA, Ochtman L, Ring D. Management of Scaphoid Nonunion. The Journal of Hand Surgery 2012; 37(5): 1095-1100 12. Merrell GA, Wolfe SW, Slade JF iii, Treatment of scaphoid nonunions: Quantitative meta-analysis of the literature. The Journal of Hand Surgery 2002; 27(4): 685-691

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PLANNING & WRITING RESEARCH

Planning Research Authors: Kee Xiang Lee Jamie, Mao Haitong Supervisor: Aziz Nather Division: Foot and Ankle Surgery

CHOOSING A SUITABLE SUPERVISOR “The first timer must not be thrown into the deep end of the swimming pool. He might just drown! ... He should have the guidance of a good supervisor.” - Professor P Balasubramaniam - Department of Orthopaedic Surgery, NUS

!

From the very start of any research project, a suitable supervisor should be present to provide guidance. A good mentor should be: 1. An experienced clinician and keen researcher – This places him in a good position to identify significant clinical issues meriting investigation. He can provide sound advice to the resident on the subject of his research project. 2. Innovative and able to think outside of the box 3. Committed to mentoring the resident – A young, inexperienced researcher should not be left to fend for himself.

SOURCING A “WINNING IDEA” The most important part of planning is deciding on a “winning” project. The topic must be novel. The results of the research should have a significant clinical impact on medical practice. For this, we need an experienced clinician with a keen eye for choosing the right topic. One example would be the concept of procuring stem cells from the filtrate bag of the Reamer Irrigator Aspirator (Figure 1) by G. Cox, D. McGonagle, S. Boxall, C. Buckley, E. Jones, and PV. Giannoudis. This paper, titled “The Reamer-Irrigator-Aspirator (RIA): A Harvester of Mesenchymal Stem Cells (MSCs)1”, was published in 2011 in the Journal of Bone and Joint Surgery.

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Figure 1: Reamer Irrigator Aspirator

Reamer Irrigator Aspirator Aspirated contents pass through the filter, which traps bony particles. The effluent then flows into the “waste bag”. The Filtrate Bag contains large numbers of MSCs. The effluent is potentially usable for the clinical transplantation of MSCs, without going through cell expansion in the laboratory. Expansion of cell requires two weeks in the laboratory. Studies show that Passage 2 cells from this effluent could differentiate into osteogenic, adipogenic, and chrondrogenic lines. This is a revolutionary clinical find, which may well change the practice of Tissue Engineering. There is one other novel idea that has not been explored by the authors. The effluent is also potentially a rich source of growth factors Platelet-rich plasma has been obtained by centrifugation of blood from the buffy coat layer. (Nather et al.)2 By the same token, centrifugation of the effluent will give a good yield of PRP. This could also be explored, and PRP could be an additional clinical application from the RIA.

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In choosing the research topic, one must ask the following questions: What is important about your project? – Your research should be useful. It should aim to contribute to clinical practice. What is new about your project? – The topic must be original. If there has been previous work done on the topic, your research should seek to offer an angle that has not yet been addressed by others. Is the idea viable? – The research should be able to be conducted in the facilities available to the researcher. Will the costs fit within the budget given? – The researcher should estimate the budget costs to make sure that it is within the budget allocated for the research. Can the project be completed in time? – Time is a very important factor. The planning must take into account the time needed to complete the project. Many projects are left uncompleted due to insufficient time allocated.

Planning Ahead: Do you have enough time?

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In vivo animal experiments studying the biology of healing of tendons, cartilage, and bone require at least 2 to 3 years for completion. In vitro biomechanical studies on cadavers or on animals require less time. It is possible to complete within a 1 to 1 1/2 year frame. With clinical studies, the time required is generally less than animal experiments.

WRITING YOUR OBJECTIVES After selecting the research topic, one should first write clearly the detailed objectives of the study.

FORMULATING YOUR HYPOTHESIS One should formulate the hypothesis being studied. A hypothesis is a speculation which will be either proved or disproved according to the evidence. It has to be testable, and has to be formulated early on in the planning stage.

REVIEWING LITERATURE Research must never be done in a vacuum. One should not assume a specific clinical problem to have never been researched before. A thorough review of all literature on the problem should be performed to ensure the topic is a novel one.

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How to Review Literature

! Figure 2: The general process of the Literature Review

Reviewing literature is an art to be mastered. It must be extensive. This process involves the following stages (Figure 2): Procurement of articles Reading and critical analysis of articles Ranking of articles based on relevance Summarising the salient points of each article Filing of articles for future reference

Appraising Articles with 10 Questions The following 10 questions should be asked when critically analyzing a research article3. 1.

Is the study question relevant? The study should address the topic that you are researching on and add to what is already known about that subject.

2.

Does the study add anything new? While most papers may not make a substantive new contribution to existing knowledge, research papers that make an incremental advance can also be of value. For instance, an article may increase the validity of previous research by replicating its findings. It may also extend original findings to new populations of patients or clinical context.

3.

What type of research question is being asked? Identifying the specific research question addressed by the article is the most fundamental step in article analysis. There are generally two kinds of clinical research questions: questions about the effectiveness of treatment and questions about the frequency of events such as incidence of diseases.

4.

Was the study design appropriate for the research question? Meta-analysis of Randomised Controlled Trials (RCTs) and individual RCTs are most suitable for studies that answer questions about effectiveness. Meanwhile, observational studies are the most appropriate for questions about the frequency of events.

5.

Did the study methods address the most important potential sources of bias? The bias may be a random error attributed to chance. Alternatively, it may be a systematic bias that is inherent in the study methods.

6.

Was the study performed according to the original protocol? If a study deviates from the planned protocol, its validity or relevance can be affected. A failure to recruit the planned number of participants, for instance, reduces the power of the study to demonstrate significant findings. Other possible deviations include changes to inclusion and exclusion criteria, employed techniques and duration of follow-up.

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7.

Does the study test a stated hypothesis? The study hypothesis should be identified before the study is conducted. The study may otherwise be prone to false positive findings. In addition, check that all data relevant to the stated study objectives have been reported, and that selected outcomes have not been omitted.

8.

Were the statistical analysis performed correctly? All quantitative research articles should explain the tools used in the statistical analysis and the rationale for them. The approach to dealing with missing data and the statistical techniques applied should be specified. Additionally, patients lost in follow-up and missing data should be clearly identified.

9.

Do the data justify the conclusions? The conclusions should be reasonable based on the data collected. Make sure that no overemphasis is placed on statistically significant findings that in reality are differences too small to be of clinical value.

10. Are there any conflicts of interest? Examples of such conflicts include receipt of salary or consultation fees from the company that has sponsored the research, patents related to the research, and industry funding for educational events, travels or gifts. Most journals require authors to declare any potential conflicts of interest. It is up to the reader to decide if the declared factors are significant enough to influence the validity of the study’s findings.

Ranking Articles According To Type Of Research Each article should be ranked according to several factors, namely the: type of article, type of journal, year published, and institution of authors.

Type of article Systematic reviews, meta-analyses, and RCTs tend to be the most objective studies with the least potential for bias. They also provide the strongest evidence (Figure 3 and Table 1). Multi-centre studies provide more significant results than single-centre studies.

Figure 3: Ranking of studies4

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Level

Type of Study

Level 1a

Systematic review (with homogeneity) of RCTs

Level 1b

Individual RCT (with narrow coincidence interval)

Level 1c

All-or-none studies

Level 2a

Systematic review (with homogeneity) of cohort studies

Level 2b

Individual cohort study (including low quality RTC, e.g. <80% follow-up)

Level 2c

‘Outcomes’ research; ecological studies

Level 3a

Systematic reviews (with homogeneity) of case-control studies

Level 3b

Individual case-control study

Level 4

Case series (and poor quality cohort and case-control studies)

Level 5

Expert opinion without explicit critical appraisal, or based on physiology, bench research or ‘first principles’ Table 1: Hierarchies of evidence for questions of therapy, prevention, etiology5

Type of journal Articles published in high impact, internationally refereed journals are more significant than those published in regionally or locally refereed journals (Table 2). It is also better if the journal is specialized in the particular field of medicine you are researching.

Ranking

Type of Journal

1

Tier 1 Internationally Refereed Journal

2

Tier 2 Internationally Refereed Journal

3

Regionally Refereed Journal

4

Locally Refereed Journal Table 2: Journal rankings

Year Published Articles published recently should be procured.

Institution of Authors The international standing of the authors’ institution should also be taken into account.

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PRELIMINARY WRITE-UP OF DISCUSSION AND INTRODUCTION Based on the literature review, one first begins to design a discussion on the topic. This will include evidence for and against the hypothesis. The references in support or against the hypothesis must be appropriately quoted. This is best done immediately after the completion of the literature review, when ! both the ideas and facts are still fresh in the mind. The literature review and subject discussion are the most tedious to finish in the writing of the article. Possessing a completed discussion before one embarks on the research project will be very useful in writing the final manuscript several months later. Once the discussion has been written, one can then select the information that can best be used for the introduction. The introduction summarises what is known on the topic and what is not. It ends with the objectives of the study. !

A Useful Procedure to Follow 1. Write objectives clearly. 2. Formulate hypothesis. 3. Review literature. 4. Plan discussion. 5. Plan introduction.

CONSIDERING ETHICS One must always bear in mind ethical considerations when designing a research project. This is true for all types of research: clinical, cadaveric, or otherwise. All research projects submitted to the National Medical Research Council in Singapore must first be evaluated and approved by the Ethics Committee before it can be approved for funding by the Council.

STATISTICAL PLANNING It is essential to involve a statistician early in one’s project. This is especially true when one is designing a prospective clinical study. What a statistician can do: Advise on the size of the study population to be adopted for the project to be clinically significant Decide how to select a representative sample after enumerating all variables that could influence the results Evaluate and determine the statistical significance of the results, upon completion of the study (Figure 4)

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Figure 4: A normal curve can be used to determine the statistical significance of experimental results.

BRAINSTORMING RESEARCH Upon completion of the initial research proposal, it should be presented at departmental level for detailed discussion and constructive criticism. Based on the feedback obtained, the research proposal should be rewritten and presented to the department again. Repeat discussions allow problems unanticipated by both the researcher and the supervisor to be raised. Be it work at the proposal stage, on-going work, or completed research, residents should present their research to the department for peer review every 3 months. If possible, research should be presented at International Research Meetings so as to obtain feedback from a wider, international pool.

PILOT STUDY

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A pilot study is an essential small scale preliminary study conducted in order to evaluate feasibility, time, cost, adverse events, and effect size (statistical variability). It is a method to predict an appropriate sample size and improve upon the study design prior to performance of a full-scale research project i. Using a pilot study, one can find out all the practical problems that will arise. Such problems include:

For clinical reviews: Mechanism of recall for patients Clinic space to conduct the review

For cadaveric research: Shortage of proper surgical instruments Lack of storage facilities for proper dissection of cadavers in cadaveric research. 78

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For animal experimentation: Anaesthesia for the animals Operative technique Post-operative care of the animals Lack of proper surgical instruments The research protocol can then be written to fully address the problems surrounding the project, based on the pilot. The pilot study is especially important for animal experimentation. The pilot study has to show that the research project can run smoothly, without any major problems. Only then is the researcher ready to embark on the final writing up of the research proposal for a full-scale research project application.

RESEARCH GROUPS A research group consists of 3 to 4 Principal Investigators (PI) sharing similar research interest, e.g. tissue engineering. One PI may be interested in the effect of MSCs on bone, the other on cartilage, and the third on tendons. It is strategic for them to team up to brainstorm regularly. They may have bioengineers dealing with scaffolds, and tissue engineering specialists dealing with cell culture and growth factors. By forming a research group, experienced gained in one tissue may be beneficial to the PI dealing with another tissue. Each PI should ideally possess a research grant and have a research fellow employed to work for the project.

1. Research Fellow A research fellow is very useful for conducting a research project, especially when the PI is a clinician heavily involved in patient work. The research fellow is available to do the research project on a full-time basis. He can run the clinical trials on patients or perform the animal experiments for basic research. The fellow is responsible for planning and coordinating the research project. He performs all the documentation for the research and analyses all the results obtained. He is also responsible for writing up the article to be produced from the project, including literature search, discussion, etc. He will produce progress reports and final reports, as well as run all administration required. His work should also involve writing up future research grant application. To engage a research fellow, the PI should have a grant of $250,000 or more. A research fellow (Post-doctorate PhD) will require at least $60,000 per annum. Do not wait until a big grant (e.g. BMRC, NMRC, A*STAR) is obtained before hiring a fellow. One must think out of the box. Two to three clinicians can group up to hire a PhD fellow for their research by contributing $2000 monthly each. The research fellow can write up the application for research grant and run the research project efficiently for the group. This is a good investment. The group can produce good research work with a full-time research fellow.

2. Residents The group can also include residents keen to pursue research. This is a win-win situation as both the consultants and residents obtain great satisfaction from the publications arising from the research. The resident will benefit from research to advance his career whilst the consultant may get the promotion he desires.

3. Students Junior College (JC) students who have completed A levels (in November), whilst waiting for medical university enrolment, can also be recruited into the research group. The senior author employs 4 JC students full-time for 5 months each year from January to May as research assistants. 79

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8th Research Team 2012

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9th Research Team 2013

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10th Research Team 2014

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REFERENCES 1. Cox G, Mcgonagle D, Boxall S, Buckley C, Jones E, Giannoudis PV. The Reamer-Irrigator-Aspirator (RIA) – A Harvester Of Mesenchymal Stem Cells (MSCs). J Bone Joint Surg 2012; 94B: 455-455 2. Dasde S, Manohara R, Nather, A. Platelet-Rich Plasma in Orthopaedic Surgery: Basic Science and Clinical Applications. In: Nather A, Bone Grafts and Bone Substitutes: Basic science and clinical applications. World Scientific. New Jersey. London. Singapore. 2005: 387-40 3. Young JM, Solomon MJ. How to critically appraise and article. Nat Clin Pract Gastroenterol Hepatol 2009; 6(2): 82-91 4. Bhandari M, Joensson A. Clinical Research for Surgeons. Thieme Medical. 2008: 39 5. Hemingway P, Brereton N. What is a systematic review? Hayward Medical Communications. 2009

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Writing a Case Report Author: Ang Yi Yen Zest Supervisor: Aziz Nather Division: Foot and Ankle Surgery

WHAT IS A CASE REPORT? Case reports represent the oldest and most familiar form of medical communication. Given the unpredictable and challenging nature of medicine, many medical students will have come across a patient who has not been a textbook case. The patient may have had an unusual presentation, strange new pathology, or unforeseen reaction to a medical intervention. Since the time of Hippocrates from 460 B.C. to 370 B.C., medical case histories have been documented to advance the base of knowledge in clinical medicine. Famous case studies have also helped shape the way we view health and disease1-3. In medicine, a case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports may contain a demographic profile of the patient, but usually describe an unusual or novel occurrence worth knowing. Some case reports also contain a literature review of other reported cases. Case reports are often accompanied by photos or figures that give readers the chance to make their own decisions about whether the diagnosis was correct4.

WHAT IS THE PURPOSE OF A CASE REPORT? However, some argue that case reports are increasingly irrelevant as Medicine takes a slant to become more evidence-based. Many medical journals have stopped publishing case reports. The rarity of cases targets only a specialised few, and hence case reports contribute little to everyday medical practice. Their anecdotal nature lacks the scientific rigour of large, well-conducted studies, and they have therefore fallen down the hierarchical ladder of medical evidence (Table 1)5.

Category I

Evidence from at least one properly randomised controlled trial

Category II-1

Evidence from well designed controlled trials without randomisation

Category II-2

Evidence from well designed cohort or case-control analytic studies, preferably from more than one centre or research group

Category II-3

Evidence from multiple case series with or without intervention or dramatic results in uncontrolled experiments

Category III

Opinions of respected authorities, based on clinical experience, descriptive studies, and case reports, or reports of expert committees. Table 1: Level of evidence

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Nonetheless, case reports still have a role to play in furthering medical knowledge and education in the following ways:

Quick form of communication between scientists Case reports are published quickly in comparison to randomized control trials6, allowing for rapid and short communication between clinicians. They are also less costly and time-consuming compared to large-scale research7.

Provide new insights Because remarkable and atypical cases are less likely to be published, case reports permit discovery of new diseases and unexpected effects (adverse or beneficial) as well as the effectiveness of new surgical or treatment methods. They describe important scientific observations otherwise missed or undetected in clinical trials. They therefore play an important role in medical education, by bringing to light new diseases, anomalous patient behaviour, unexpected effects of drugs and their method of administration, and even different techniques to treating typical conditions8. They therefore provide many new ideas in medicine9.

Giving an all rounded understanding of an illness Randomized clinical trials usually only inspect one variable or very few variables. They rarely reflect the full picture of a complicated medical situation. Conversely, the case report can detail many different aspects of the patient’s medical situation (e.g. patient history, physical examination, diagnosis, psychosocial aspects, followup)6. Different areas of medical education such as physiology, pathology, pharmacology, and anatomy are brought together in case reports. This helps students and doctors develop a more holistic approach to patients. Case reports also are useful in other ways (Figure 1):

Figure 1: Other benefits of Case Report

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CHOOSING THE TOPIC FOR A CASE REPORT Be attentive and constantly look out for novel cases when on ward rounds or during clinic sessions. Should you not know what constitutes a good case report topic, refer to a senior doctor for advice. They may also have cases that you can help research and write on. Case reports can be on the following content10: a. An unexpected association between diseases or symptoms, or between 2 illnesses thought to be mutually exclusive b. An unexpected event in the course of observing or treating a patient. c. Findings that shed new light on the possible pathogenesis of a disease or an adverse effect. d. Unique or rare features of a disease. e. Unique diagnostic or therapeutic approaches. f. An unrecognized link between 2 diseases thought to be mutually exclusive g. A positional or quantitative variation of the anatomical structures. h. Adverse response to therapies i. Unusual side effects or interactions i. Shed new light on pathogenesis j. Illustration of a new theory k. Question regarding a current theory l. Personal impact m. Uncommon observations n. Unexpected presentation o. Emerging disease p. Unusual combination of events or conditions that cause confusion q. Unexpected association r. Variation in the disease process

GATHERING INFORMATION FOR YOUR CASE REPORT To establish a credible and validated case, amass information from varied and credible sources.

1. Perform a literature search for your case Before you begin, perform a literature search on similar cases to collate information to give you varied perspective and set you in the right direction. Review relevant scientific publications: abstracts, original science, review articles, as well as relevant reference textbook articles. Medical database such as PubMed, Ovid, or Medline can be used to check if there have been any similar cases; this helps you gauge how rare your case is. To keep yourself organized, make a reference list of the articles to refer to as you write your case presentation. To do so, assemble case information and literature reviews into a file, then assign each article a reference number to form a list. Write a report with references to the indexed articles.

2. Liase with doctors in charge Discuss the case report with senior doctors in charge, not just to gain their permission, but also to obtain their guidance and advice. 84

Approach clinicians of other specialties who are involved in the care of the patient. This allows you to substantiate your case with detailed patient information such as: Case history Hospital progress notes Lab reports o X-rays o Pathology reports Discharge summaries Outpatient progress notes

3. Gain consent It is of utmost importance that the advancement of science does not occur at the expense of the rights of the patient11. Patient confidentiality must be preserved even when writing the case report. Information that identifies a patient should not be published, and informed consent should be obtained if there is any possibility of patient confidentiality being breached. During the consent process you must explain why you wish to share their case with others, the risks and benefits of doing so, and answer any questions the patient may have. Get the help of a senior if you require it.

4. Selecting the right journal Always begin with the end in mind. Define your target audience by finding 3-4 suitable journals, taking into consideration the following Audience Field Impact factor Likelihood for publication After selecting the right journal, review previous samples of published case reports from the journal for exemplary models to follow. Always review the “Instructions for Authors” from the journal chosen before beginning to write, which vary between journals. Journals typically specify what content has to be covered, the word limit for each section, the number of tables and figures used and the number of references citedi. For example, BMJ has the following criteria12 (Table 2):

Authorship

Maximum 4

Summary

Max 150 words

Images

To be submitted in colour and in the following formats: jpg, tiff, gif, PowerPoint and eps.

Competing interests

Compulsory to declare any financial gain or personal rivalry Table 2: Instructions for BMJ

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WRITING THE CASE REPORT Do a quick rough 1st draft of the following sections in the order below. √ Case √ References √ Introduction/background √ Discussion √ Abstract (normally easier to write after completing the main body of text as you would be more familiar with the contents of the case) √ Title

Title The title should be informative and accurate. It should also be succinct, to effectively convey the essence of the case report. The title should also include the words “case report”, and three to five key words. This facilitates retrieval with electronic searching.

Abstract The abstract is typically required by most journals when submitting a case for publication. The abstract is the “face” of the report—it is indexed by most electronic databases and is what represents your case in searches. Hence, it is important to include key words throughout the abstract, so that your article can be more easily found during searches. Reviewers and judges rate a case report’s merit based on the abstract. Your abstract is a summary of the following: The objectives of the report Case presentation o Diagnosis o Intervention (diagnostic, therapeutic or preventive) o Outcome Understanding and implications Keep your abstract within the word limit as determined by the relevant journal.

Introduction As this constitutes the beginning of the essay, the introduction must capture the interest of the reader. Present the relevance of your article to entice busy physicians to take an interest in your report. The introduction should not exceed 3 paragraphs. You should include the following in your introduction: An overview of the medical condition A single sentence describing the patient’s condition Rationale for reporting the case, adequately substantiated Justify why the case report is novel and deserving of mention, supported by references. 86

o Previously unreported? o A new pattern? o Previously unsuspected relationship? o Unusual diagnosis, prognosis, therapy, harm? Contextual information required for readers to better understand the text

Case presentation Your case presentation should succinctly list out information pertaining to the patient’s case—mention only important information, and leave out superfluous data like normal vital signs and other irrelevant patient information to avoid confusing readers. Case presentations should cover the following13: Medicine 3 months prior to the study, to eliminate any possibility of aftereffects. All records of the patient’s diet, as food can interfere with the pharmacologic effect of the drugs. Always suspect food allergy first before the possibility of drug allergy. o One or two images to engage your reader Ensure your case presentation is relevant and thorough enough such that readers without background knowledge will be able to infer a conclusion.

Discussion The discussion is the most important section in which you value add to what was provided in the patient information. Reviewers will be interested in the evidence proving your case is rare. Hence, the discussion should centre on why the case is different or unique, such as unprecedented revelations in disease progression, therapy and treatment outcomes. Give the learning points of the case, as well as alternative justifications and novel hypotheses about a condition. Review why certain decisions were made and extract lessons14. Evaluate the case’s validity, accuracy and distinctiveness with respect to an extensive supply of already-published literature. Establish a casual relationship between findings and results from other case studies, and validate its credibility on a scale. Do include supplementary parts such as tables, figures, graphs and illustrations, which provide essential data and enhance flow and clarity of the article. Draw recommendations and conclusions on how future clinical practice will be affected based on the features of the case. Be sure to substantiate your case.

Patient’s perspective The patient should share his or her perspective or experience whenever possible. This provides deeper insight on the symptoms of the illness in question and preempts doctors on the signs to look out for15.

Conclusion The conclusion should be brief and end with a key take-home message. It should also include evidence-based and justified recommendations to clinicians or scientists, and clearly state the future prospects and likely effects on the medical world.

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References Do not be tempted to give a lot of references—remember that more is not always better as there are space limitations. To be sure, check “Instructions for Authors” provided by the journal receiving your case report. Select your sources wisely by using credible databases like PubMed, Jstar and Medscape. Avoid referencing abstracts.

Authors’ contributions Authors make substantial and consequential contributions to the case report. Before you begin, you should decide on authorship and determine who you would want to work with. The first author typically contributes the bulk of the writing, and should be listed first. Subsequent authors should be listed in order of contribution. The senior author, typically the instigator of the case report, should be listed last. It is compulsory for all co-authors to have given approval on the manuscript prior to submission.

PUBLISHING YOUR CASE REPORT As case reports rank low on the evidence scale, most journals these days are reluctant to publish case reports. However, the vastness of cyberspace has allowed for the development of a new breed of medical journals. A number of new online journals such as BMJ Case Reports, Cases Journal, the Journal of Medical Case Reports, Radiology Case Reports, and the Journal of Dermatological Case Reports, allow for the publication and dissemination of notable case reports16. Although still in their infancy, these journals have the potential to act as large case banks that allow doctors to search for cases similar to ones that may be puzzling them, to help guide in their management.

SUMMARY OF APPROACH TO WRITING A CASE REPORT 1. Identify a patient with an interesting case 2. Do a background literature search 3. Pin point a key take home message to convey from the case 4. Select the appropriate journal for publishing 5. Obtain instructions on writing from journal 6. Select your authors 7. Perform a second, more specific literature search of specific journals 8. Assemble case information and literature reviews into a file 9. Assign each article a reference number to form a list 10. Write a report with references to the indexed articles 11. Check spelling and grammar 12. Ask a consultant to proofread for you 13. Submit manuscript with cover letter providing personal details (address, phone and fax numbers, email address). Signatures of co-authors are normally required as well. 14. If article is not accepted by journal, obtain reviewer’s comments. 88

15. Perform one or two revisions based on reviewers’ comments given 16. Submit article to second journal17. The following is a checklist for a Case Report Write-up:

Checklist Due date is___ Number of copies needed. Is ___

1. Abstract Introduction and objective Case report Discussion Conclusion

2. Introduction Describe the subject matter State the purpose of the case report Provide background information Provide pertinent definitions Describe the strategy of the literature review and provide search terms Justify the merit of the case report by using the literature review Introduce the patient case to the reader Make the introduction brief and less than three paragraphs

3. Patient case presentation Describe the case in a narrative form Provide patient demographics (age, sex, height, weight, race, occupation) Avoid patient identifiers (date of birth, initials) Describe patient’s complaint List the patient’s present illness List the patient’s medical history List the patient’s family history List the patient’s social history List the patient’s medication history before admission and throughout the case report Ensure that the medications history includes herbals, vaccines, depot injections and non prescription medications and state that the patient was asked for this history List each drug’s name, strenght, dosage form, route and date of administration Verify the patient’s medication adherence Provide renal and hepatic organ function data in order to determine the appropriateness of medication dosing regimens List the patient’s drug allergy status, including the name of the drug (brand or generic) and date and type of reaction List the patient’s adverse drug reaction history and the dates of reaction Provide pertinent serum drug levels and include the time of each level taken and its relationship to a dose Provide the patient’s dietary history 89

Provide pertinent findings on physical examination Provide pertinent laboratory values that support the case Provide the reference range for laboratory values that are not widely known or established List the completed diagnostic procedures that are pertinent and support the case Paraphrase the salient results of the diagnostic procedures Provide photographs of histopathology, roentgenograms, electrocardiograms, skin manifestations or anatomy as they relate to the case Obtain permission from the patient to use the patient’s photographs or follow institutional guidelines Provide the patient’s event in chronological order Ensure a temporal relationship Ensure a causal relationship Ensure the patient case presentation provides enough detail for the reader to establish the case’s validity

4. Discussion Compare and contrast the nuances of the case report with the literature review Explain or justify the similarities and differences between the case report and the literature List the limitations of the case report and describe their relevance Confirm the accuracy of the descriptive patient case report Ensure a temporal relationship Ensure a causal relationship Report the validity of the case report by applying a probability scale such as the Naranjo nomogram Summarize the salient features of the case report Justify the uniqueness of the case Draw recommendation and conclusions

5. Conclusion Provide a justified conclusion Provide evidence-based recommendations Describe how the information learned applies to one’s own practice List opportunities for research Ensure that this section is bref and does not exceed one paragraph

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REFERENCES 1. Kyle RA. Multiple myeloma: an odyssey of discovery. Br J Haematol 2000; 111: 1035-1044 2. Heller S. Freud a to z. John Wiley & Sons Inc. 2005 3. Schiller F. Paul Broca: Founder of French anthropology, explorer of the brain. Oxford University Press. 1992 4. Graf J. Handbook of Biomedical Research Writing: The Clinical Case Report. Hanyang University. 2008 5. Centre for Evidence Based Medicine. Website. 2014 6. Yitschaky O, Yitschaky M, Zadik Y. Case report on trial: Do you, Doctor, swear to tell the truth, the whole truth and nothing but the truth?. J Med Case Reports 2011; 5(1): 179 7. Guyatt G, Rennie D, Meade MO, Cook DJ. User’s Guide to the Medical Literature: A Manual for EvidenceBased Practice. American Medical Association Press. 2002 8. Mason RA. The case report – An endangered species?. Anaesthesia 2001; 56: 99-102 9. Vandenbroucke JP. In defense of case reports and case series. Ann Intern Med 2001; 134: 330–334 10. Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, et al. Current methods of the US Preventive Services Task Force: a review of the process. Am J Prev Med 2001; 20: 21-35 11. Cohen H. How to write a patient case report. Am J Health Syst Pharm 2006; 63: 1888-1892 12. Levine SB, Stagno JS. Informed consent for case reports: The ethical dilemma of right to privacy versus pedagogical freedom. J Psychother Pract Res 2001; 10: 193-201 13. The BMJ. Instructions for Authors. BMJ Case Reports. 14. Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D. The CARE Guidelines: Consensus-based Clinical Case Reporting Guideline Development. Journal of Medical Case Reports 2013; 53(10): 1541-1547 15. Chelvarajah R, Bycroft J. Writing and publishing case reports: the road to success. Acta Neurochir (Wien) 2004; 146(3): 313-316 16. Saleem MA, Macdonald RL. Cerebral aneurysm presenting with aseptic meningitis: a case report. J Med Case Reports 2013; 7: 244 17. Anwar R, Kabir H, Botchu R, Khan SA, Gogi N. How to write a case report. Student BMJ 2004; 12: 45-88 18. Brodell RT. Do more than discuss that unusual case. Write it up!. Postgraduate Medicine 2000; 108(2): 1920.

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PROFESSORIAL LECTURES

“Transitions and Transformations in Spine Surgery” 2015 Pesi B Chacha Lecture Date: 7 January 2015 Venue: NUHS Tower Block Auditorium The Pesi. B Chacha Lectureship was established in October 2012 in honour of Dr. Pesi B Chacha, a pioneer in orthopaedic surgery. It recognizes his contributions to the University and orthopaedic community. The lecturer is a renowned orthopaedic surgeon and academic from overseas.

ABOUT THE SPEAKER !

Dr. Steven Glassman is Professor of Orthopaedic Surgery at the University of Louisville, Kentucky, USA. He was the immediate past President of the Scoliosis Research Society. Dr. Glassman’s work has focused on patient based outcomes and cost effectiveness for Spinal Surgery. He has written extensively on the treatment of Adult Scoliosis, and on the role of Biologics in Spine Fusion. Dr. Glassman has 173 publications and 142 presentations in various national and international conferences. Steven D. Glassman MD

SYNOPSIS OF LECTURE This presentation examines critical milestones in the development of Spinal Surgery over the last 20 years. In particular, attention is paid to those advances in surgical technology, surgical decision making and outcome assessment which have proven transformational, as well as some notable failures. Finally, it discusses how this history informs and impacts potential future advances in Spinal Surgery.

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“The Evolution of Musculoskeletal Oncology as a Specialty” 2015 R W H Pho Lecture Date: 15 July 2015 Venue: NUHS Tower Block Auditorium The R W H Pho Lectureship was established in 2004 in honour of Dr. R W H Pho (Emeritus Professor). It recognizes his commitment to the training and development of Musculoskeletal Oncology and Microsurgery in Singapore and the region. The lecturer invited is a prominent member in the field of Musculoskeletal Oncology.

ABOUT THE SPEAKER Dr. Boland is an Orthopaedic Oncologist and the Director of Education of the Orthopaedic Surgery Fellowship Programme at the Department of Orthopadic Surgery of Memorial Sloan Kettering Cancer Center in New York, USA.

Patrick J Boland,

! MD, FRCS(I), FRCS

Dr. Boland specialises in the management of malignant and benign tumours of the bones, including those of the spine and pelvis, and in soft tissue sarcomas of the extremities. He also has special training in limb salvage surgery — the removal of limb cancer while preserving a functional extremity. He has extensive experience in the treatment of primary and metastatic spine tumours. Over the years, he has developed a special interest in the management of tumours of the sacrum. Dr Boland is involved in extensive research activities, including on-going clinical research in sacral tumors and in the assessment of quality of life in patients with metastatic bone cancer.

SYNOPSIS OF LECTURE Like Professor Robert Pho, many scientists and physicians have made major contributions to the establishment of Musculoskeletal Oncology as a specialty in Medicine. The contributions of many were not recognized during their life time, indeed some were even ridiculed. This presentation intends to highlight some of seminal events and pay tribute to outstanding individuals who helped lead us to where we are today.

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“Hip Preservation Surgery: Fact or Fiction” 2015 V K Pillay Lecture Date: 14 April 2015 Venue: NUHS Tower Block Auditorium The V K Pillay Lecture was established in 2004 in honour of Dr. V K Pillay, a pioneer in orthopaedic academics. The lecturer is a renowned orthopaedic surgeon and academic from overseas.

ABOUT THE SPEAKER Dr. Kim is an Associate Professor of Orthopaedic Surgery at Harvard Medical School. He is the Director of the Child and Young Adult Hip Preservation Programme and the Fellowship Director of Paediatric Orthopaedic Surgery at Boston Children’s Hospital and the Chair of the Core Curriculum Committee of the Paediatric Orthopaedic Society of North America.

!

Young-Jo Kim MD, PhD

In 2012, Dr. Kim also served as the Director of the POSNA One Day Course delivered by the Paediatric Orthopaedic Society of North America and the Co-Director of the AAOS Femoro-acetabular Impingement Symposium of the American Academy of Orthopaedic Surgeons. In 2013, Dr. Kim was the Co-Director of the AAOS Hip Joint Preservation Skills Course conducted by the American Academy of Orthopaedic Surgeons.

Dr. Kim’s current clinical efforts focus on devising innovative treatment strategies for and understanding the role of abnormal mechanics in the development of premature osteoarthritis. He has published 101 articles for international peer-reviewed journals and written 18 book chapters. In addition, Dr. Kim received the Korean National Honour Award conferred by the Republic of Korea in 1984.

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SYNOPSIS OF LECTURE Much of hip osteoarthritis is caused by hip deformity such as acetabular dysplasia and femoro-acetabular impingement. Recent advances in surgical techniques including osteotomy and arthroscopy have allowed us to correct the deformity with minimal morbidity. The techniques are effective in relieving the clinical symptoms but whether or not we truly preserve the joint is unclear. Recent evidence supporting the role of these conditions in the development of hip osteoarthritis and possible alteration of osteoarthritis development with surgical intervention will be discussed.

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“Principles of Assessment and Management of Paediatric Musculoskeletal Deformities: Techniques Change, but Principles are Forever” 2015 N Balachandran Lecture Date: 15 October 2015 Venue: Grand Copthorne Waterfront Hotel The N Balachandran Professorship in Paediatric Orthopaedics was established in 2007 in memory of Prof N Balachandran, one of the pioneers of Orthopaedics in Singapore. The aim of the Professorship is to build up Singapore’s expertise and capability in the area of Paediatric Orthopaedics. The lecturer is a renowned orthopaedic surgeon from the United States.

ABOUT THE SPEAKER Dr. Mosca is Professor of Orthopaedics at the Department of Orthopaedics and Sports Medicine in University of Washington School of Medicine.

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Dr. Mosca is currently the Chief of Foot and Ankle Service and the Chief of Limb Deficiency Clinic at Seattle Children’s Hospital. He also functions as the Director of Paediatric Orthopaedic Surgery Fellowship and the Director of the International Paediatric Orthopaedic Programme at Seattle Children’s Hospital.

Vincent Stephen Mosca MD

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Dr. Mosca has to his credit, 34 articles in international peer-reviewed journals. He also wrote a book entitled “Principles and Management of Paediatric Foot and Ankle Deformities and Malformations”. In addition Dr. Mosca has contributed 18 book chapters in other books.

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SPECIAL AWARDS

NUH Leadership Award

Emeritus Consultant Award

Professor K Satkunanantham

is Senior Consultant at the Department of Orthopaedics at the National University Hospital (NUH). He specialises in knee disorders. Prof Satku graduated from the National University of Singapore (NUS) in 1974 and joined the University as a lecturer in 1978. He has contributed more than 40 years in service. He is one of the early pioneers in arthroscopy, ligament reconstruction and joint replacement surgery and has published more than 60 peer-reviewed publications, delivered more than 40 guest lectures regionally and internationally, presented more than 100 conference papers and published more than 10 chapters in books. He was Head of the Department of Orthopaedic Surgery at the NUS Yong Loo Lin School of Medicine and NUH from 2001 to 2003, as well as Clinical Director, NUH from 1997 to 1999 and Vice-Chairman, Medical Board, NUH from 2000 to 2001. During his tenure as head of the department, he started the VK Pillay and Robert Pho Lectureships. He has also been active in professional matters, and has served as Master, Academy of Medicine from 2002 to 2004, President, Singapore Orthopaedic Association in 1993 and Chairman, Chapter of Surgeons, Academy of Medicine from 1994 to 1995. Appointed Director of Medical Services (DMS), Ministry of Health in April 2004, Prof Satku held the appointment for 10 years, till December 2013. During this period, he was also Chairman of the Specialist Accreditation Board and Registrar of the Singapore Medical Council. For his numerous contributions, he was awarded the Public Administration Medal (Gold) and the Meritorious Service Medal on National Day in 2009 and 2014 respectively.

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NUHS Leadership Award

Outstanding Mentor Award

Professor Shamal Das De

In his 34 years as a teacher in the Department of Orthopaedic Surgery at the NUS Yong Loo Lin School of Medicine (NUS Medicine), Prof Das De introduced and was involved in a number of teaching initiatives. He was the Undergraduate Director of the Department from 1985 to 2013. He was a member of the Curriculum Review Exsamination Committee (CREC) at the NUS from 1991 to 1996 and the chief co-ordinator of the Year Three to Year Five curriculum for the then Faculty of Medicine. He also held a secondary appointment as the Chief of the Emergency Medicine Department (EMD) at the NUH from 1991 to 1993. Together with Associate Professor Shirley Ooi, his then registrar, he introduced a teaching programme in the department. Some of his teaching accolades include: the “Best Tutor Award” in 1998, the “Teaching Excellence Award” (NUS Medicine) in 2001, Certification of Commendation (Dean’s Office, NUS Medicine) in 2012 and 2014, and the “Role model of the Class of 2012 and 2014”. He is also the chairman of the Orthopaedic Master of Medicine examination committee and examiner for undergraduate and postgraduate examinations in Singapore and Malaysia, including the FRCS Orthopaedics (Edinburgh). He was Chairman of the University Faculty Promotion and Tenure Committee (FPTC) at the NUS and was a member of the University Promotion and Tenure Committee (UPTC) till June 2012. Prof Das De has also made numerous contributions to the field of Orthopaedic Surgery, with a special interest in hip, knee and foot and ankle surgery. He has authored over 90 scientific research articles and contributed to 18 book chapters and delivered over 290 conference papers, posters and guest lectures locally and internationally. He is on the editorial board of two journals and is a reviewer of numerous local and international prestigious journals. Currently Head of the Foot and Ankle Division and Senior Consultant of the Hip and Knee Division in the Orthopaedic Department, Prof Das De also holds a number of administrative duties at the National University Hospital. His many contributions and strong leadership in clinical education in the National University Health System and Singapore over the last 34 years make Professor Shamal Das De a truly Outstanding Mentor. 104

TEACHING AWARDS

Awardees Dr Darren Tay Keng Jin Department of Orthopaedic Surgery

Dr Jacqueline Tan Siaw Woon Department of Hand Surgery

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Adjunct Assoc Prof Lee Keng Thiam Department of Orthopaedic Surgery

Dr Chee Yu Han Department of Orthopaedic Surgery

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Dr Mark Edward Puhaindran Department of Hand & Reconstructive Microsurgery

Dr Wong Lee Yuen Receiving on behalf of Dr. Andy Wee Teck Huat

Dr Andy Wee Teck Huat Department of Orthopaedic Surgery

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Dr Reuben Soh Receiving on behalf of Adjunct Assoc. Prof. Arjandas Mahadev

Adjunct Assoc Prof Arjandas Mahadev Department of Orthopaedic Surgery

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Clinical Assoc Prof Low Boon Yong Department of Orthopaedic Surgery

Adjunct Assoc Prof Gamaliel Tan Yu-Heng Department of Orthopaedic Surgery

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RESEARCH AWARDS

Rob Johnston Award 26th Annual Scientific Meeting of the Australian Spine Society 10-12 April 2015, Canberra, Australia

“Evaluation of the scoring systems & prognostic factors in patients with spinal metastases from lung cancer”.

Assoc Prof Naresh Satyanarayan Kumar

INTRODUCTION The decision for operative treatment of patients with spinal metastases is dependent on the patient’s predicted survival, and this is currently predicted by systems such as the Tokuhashi, Tomita, Bauer and Oswestry scores. However, the best system for predicting survival of patients with spinal metastases specifically from lung cancer has yet to be evaluated. The high incidence of spinal metastases from lung cancer and improved survival of patients treated with tyrosine kinase inhibitor therapy warrants investigation of the accuracy of these scoring systems.

METHODS 180 patients with spinal metastases from lung cancer treated at our institution between May 2001 and August 2012 were studied. 51 of these patients underwent operations for their spinal metastases while 129 received other non-operative modalities of treatment. The primary outcome measure was survival time from the time of diagnosis of spinal metastases. Potential prognostic factors of survival included within the various scoring systems, amongst others, were examined. Predicted survival according to the four scoring systems was compared with actual survival. Potential prognostic factors were investigated using Cox regression analyses. Kaplan-Meier survival estimates and Log-rank tests were conducted for all scoring systems, and their predictive values were determined using post-estimation.

RESULTS Cancer type (p<0.001), EGFR status (p=0.005), Karnofsky Performance Status (p≤0.015), palsy (p≤0.001) and visceral metastases (p<0.001) are significant predictors of survival. The absolute score of all four scoring systems was significantly associated with actual survival, although this significance did not extend to their different prognostic subgroups, except the Oswestry Spinal Metastasis Risk Index. Predictive values were 0.48, 0.38, 0.50 and 0.32 for Tokuhashi, Tomita, Bauer and Oswestry scores respectively. 115

CONCLUSION Current scoring systems used to predict survival of patients with spinal metastases from lung cancer are inadequate. As lung cancer histology appears prognostic, a new scoring system incorporating these factors should be considered, to account for increased survival gained from the use of more targeted lung cancer therapy.

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Best Clinical Poster Award 42nd Annual Meeting of the International Society for the Study of the Lumbar Spine (ISSLS) 8-12 June 2015, San Francisco, USA

& Best Poster Presentation Award Pacific and Asian Society of Minimally Invasive Spine Surgery (PASMISS) in Daejeon, Korea 12-14 November 2015

Metastatic spine tumour surgery: “A comparative study of minimally invasive approach using percutaneous pedicle screws fixation versus open approach.”

Assoc Prof Naresh Satyanarayan Kumar

PURPOSE To investigate and compare the outcomes of open and minimally invasive surgery (MIS) approach in patients with symptomatic metastatic spine disease (MSD), who underwent posterior spinal stabilization and/or decompression.

MATERIALS AND METHODS We prospectively analyzed data on patients undergoing surgery for MSD in our institution. We included 22 patients who underwent posterior surgery using MIS and other 22 patients using open approach. Preoperative, 117

intraoperative and postoperative data were collected and Generalized Linear Model was exploited to estimate the effect of MIS on outcomes, adjusting potential confounders.

RESULTS All patients showed improvement in pain and neurological status. Within 2 weeks of the operative procedure, significant pain relief (VAS score ≤ 2) was seen in 17 patients in MIS group and 12 patients in open group. T test revealed significant difference between preoperative and postoperative mean VAS score in MIS as well as open group. All patients in 2 groups showed neurological improvement in postoperative period. Full normal function (Frankel score E) was achieved in 82% of patients in MIS group compared to 54% in open group postoperation. Kruskal-Wallis analysis showed a significant difference in Frankel score between pre-operation and post-operation in MIS group (P< 0.01). Independent ambulation was observed within 3 months of surgery in 88% in MIS group as compared to 64% in open group. This difference, however, was not significant. A significant increase in the amount of blood loss was associated with more levels of decompression and larger number of screws inserted. In multivariate analysis, the amount of blood loss was significantly lower (537ml less) in MIS group than open group. A significant difference in time to start radiotherapy from index surgery was observed between MIS and open group. Both univariate and multivariate analysis showed that patients in MIS group could start radiotherapy 7 days earlier than those in open group. Operative time, duration of hospital stay and time to initiate chemotherapy were also favourable in MIS group though the difference was not statistically significant.

CONCLUSION MIS in MSD have shown promising results for patients suffering from clinically significant instability, back pain or motor deficits. The introduction of MIS can be a game-changer in treatment of MSD due to less peri-operative morbidity and allowing earlier radiotherapy and/or chemotherapy.  

Best Poster Presentation Award at the PASMISS in Daejeon, Korea

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Best of Outside-Europe Award EUROSPINE 2015 in Copenhagen, Denmark 2-4 September 2015 The Best of Outside Europe award was given to A/Prof Naresh Kumar for the best podium presentation of the top 5 papers of the conference Europsine 2015.

The Spine Society of Europe

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LIST OF PUBLICATIONS

1. Rai, B; Chatterjea, A; Lim, Z X H; Tan, T C; Sawyer, A A; Hosaka, Y Z; Murali, S; Lee, J J L; Fenwick, S A; Hui, J H; Nurcombe, V; Cool, S M. Repair of Segmental Ulna Defects using a β-TCP Implant in Combination with a Heparan Sulfate Glycosaminoglycan Variant. Acta Biomaterialia. 2015; 28: 193-204.

2. Saran, Kushagra; Shi, Pujiang; Ranjan, Shashi; Goh, James C H; Zhang, Yong. A Mouldable Putty Containing Silk Fibroin Yolk Shell Particles for Improved Haemostasis and Bone Repair. Advanced Healthcare Materials. 2015; 4 (3): 432-445.

3. Yik, J H; Sebastin, S J; Bigliardi, P; Lingaraj, K. Pyoderma Gangrenosum Mimicking Early Acute Infection Following Total Knee Arthroplasty. Annals of the Academy of Medicine. 2015; 44 (4): 150-151.

4. Kumar, Naresh; Zaw, Aye Sandar; Reyes, Ma Ramona; Malhotra, Rishi; Wu, Pang Hung; Makandura, Milindu Chanaka; Thambiah, Joseph; Liu, Gabriel Ka Po; Wong, Hee-Kit. Versatility of Percutaneous Pedicular Screw Fixation in Metastatic Spine Tumor Surgery: A Prospective Analysis. Annals of Surgical Oncology. 2015; 22 (5): 1604-1611.

5. Ng, Dennis Z W; Lee, Kevin B l. Unipolar versus Bipolar Hemiarthroplasty for Displaced Femoral Neck Fractures in the Elderly: Is There a Difference? Annals of the Academy of Medicine, Singapore. 2015; 44 (6): 197-201.

6. Singh, Gurpal; Han, Fucai; Kaki, Ratnakar Rao; Shen, Liang; Nathan, Saminathan Suresh. Does Limited Tourniquet Usage in Primary Total Knee Arthroplasty Result in Better Functional Outcomes? Annals of the Academy of Medicine, Singapore. 2015; 44 (8): 302-306.

7. Kumar, Krishna; Makandura, Milindu; Leong, Nicholas J J; Gartner, Louise; Lee, Chin Hwee; Ng, Dennis Z W; Tan, Chyn Hong; Kumar, V Prem. Is the Apprehension Test Sufficient for the Diagnosis of Anterior Shoulder Instability in Young Patients without Magnetic Resonance Imaging (MRI)? Annals of the Academy of Medicine, Singapore. 2015; 45 (5): 178184.

8. Hey, Hwee Weng; Wong, Keng Lin; Long, Ai Sha; Hee, Hwan Tak. Single-Level Anterior Corpectomy with Fusion versus 2-Level Anterior Cervical Decompression with Fusion: A Prospective Controlled Study with 2-Year Follow-Up using Cages for Fusion. Annals of the Academy of Medicine, Singapore. 2015; 45 (5): 188-190.

9. Johandi, Faisal; Tang, Zhihao; Sebastin, Sandeep Jacob; Chew, Winston Y C. Use of the Sole Flap to Convert an Above Knee Amputation to a Below Knee Amputation in Trauma. Annals of the Academy of Medicine, Singapore. 2015; 45 (5): 191-193.

10. Hey, Hwee Weng Dennis; Sng, Weizhong Jonathan; Lim, Joel Louis Zongwei; Tan, Chuen Seng; Gan, Alfred Tau Liang; Ng, Jun Han Charles; Kagda, Fareed H Y. Interpretation of Hip Fracture Patterns using Areal Bone Mineral Density in the Proximal Femur. Archives of Orthopaedic and Trauma Surgery. 2015; 135 (12): 1647-1653.

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11. Pek, Chong Han; Lim, Jane; Ng, Hui Wen; Lee, Han Jing; Ong, Wei Chen; Foo, Anthony Tun Lin; Lim, Chwee Ming; Thong, Mark; Sebastin, Sandeep Jacob; Lim, Thiam Chye. Extensive Necrotizing Fasciitis after Fat Grafting for Bilateral Breast Augmentation: Recommended Approach and Management. Archives of Plastic Surgery. 2015; 42 (3): 365-367.

12. Abraham, Vineet Thomas; Tan, Bryan H M; Kumar, V Prem. Systematic Review of Biceps Tenodesis: Arthroscopic versus Open. Arthroplasty Epub. 2015.

13. Chen, Yongsheng; Chua, Kerk Hsiang Zackary; Singh, Amritpal; Tan, Jun Hao; Chen, Xi; Tan, Shi Hui; Tai, Bee Choo; Lingaraj, Krishna. Outcome of Single-Bundle Hamstring Anterior Cruciate Ligament Reconstruction using the Anteromedial versus the Transtibial Technique: A Systematic Review and Meta-Analysis. Arthroscopy. 2015; 31 (9): 17841794.

14. Hey, Hwee Weng Dennis; Hee, Hwan Tak. Open and Minimally Invasive Transforaminal Lumbar Interbody Fusion: Comparison of Intermediate Results and Complications. Asian Spine Journal. 2015; 9 (2): 185-193.

15. Peh, P; Lim, N S; Chee, Min Ling Stella; Park, H C; Liao, S; Chan, Casey. Simultaneous Delivery of Highly Diverse Bioactive Compounds from Blend Electrospun Fibers for Skin Wound Healing. Bioconjugate Chemistry. 2015; 26 (7): 1348-1358.

16. Goonasekera, Chandhi S; Jack, Kevin S; Bhakta, Gajadhar; Rai, Bina; Luong-Van, Emma; Nurcombe, Victor; Cool, Simon M; Cooper-White, Justin J; Grøndahl, Lisbeth. Mode of Heparin Attachment to Nanocrystalline Hydroxyapatite Affects its Interaction with Bone Morphogenetic Protein-2. Biointerphases. 2015; 10 (4): 04A308.

17. Zhang, Tianting; Wen, Feng; Wu, Yingnan; Goh, Graham Seow Hng; Ge, Zigang; Tan, Lay Poh; Hui, James Hoi Po; Yang, Zheng.

Cross-Talk between TGF-Beta/SMAD and Integrin Signalling Pathways in Regulating Hypertrophy of Mesenchymal Stem Cell Chondrogenesis under Deferral Dynamic Compression. Biomaterials. 2015; 38: 72-85.

18. Loh, Jing L; Wong, Keng L; Hwang, Stephen; Shen, Liang; Murphy, Diarmuid P; Daruwalla, Zubin J. Orthopedic Asymmetry and Clavicle Length. Clinical Anatomy. 2015; 28 (8): 964.

19. Anitha, D; Das De, Shamal; Sun, Khong Kok; Doshi, Hitendra K; Lee, Taeyong. Improving Stability of Locking Compression Plates through a Design Modification: A Computational Investigation. Computer Methods in Biomechanics and Biomedical Engineering. 2015; 18 (2): 153-161.

20. Toh, Wei Seong; Foldager, Casper Bindzus; Hui, James Hoi Po; Olsen, Bjorn Reino; Spector, Myron. Exploiting Stem Cell-Extracellular Matrix Interactions for Cartilage Regeneration: A Focus on Basement Membrane Molecules. Current Stem Cell Research & Therapy Epub. 2015.

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21. Kumar, Naresh; Ahmed, Qasim; Lee, Victor K M; Zaw, Aye Sandar; Goy, Raymond; Wong, Hee Kit. Are We Ready for the Use of Intraoperative Salvaged Blood in Metastatic Spine Tumour Surgery? European Spine Journal Epub. 2015.

22. Hong, Choon Chiet; Nashi, Nazrul; Kuan, Win Sen; Teh, Jing Wen Daniel; Tan, Ken Jin. Forklift-Related Crush Injuries of the Foot and Ankle. Foot & Ankle International. 2015; 36 (7): 806-811.

23. Ling, Ling; Camilleri, Emily T; Helledie, Torben; Samsonraj, Rebekah M; Titmarsh, Drew M; Chua, Ren Jie; Dreesen, Oliver; Dombrowski, Christian; Rider, David A; Galindo, Mario; Lee, Ian; Hong, Wanjin; Hui, James H; Nurcombe, Victor; van Wijnen, Andre J; Cool, Simon M. Effect of Heparin on the Biological Properties and Molecular Signature of Human Mesenchymal Stem Cells. Gene Epub. 2015.

24. Hong, Choon Chiet; Liu, Ka Po Gabriel. A Rare Case of Multiregional Spinal Stenosis: Clinical Description, Surgical Complication, and Management Concept Review. Global Spine Journal. 2015; 5 (1): 49-54.

25. Lee, Jonathan; Wee, Sheena; Gunaratne, Jayantha; Chua, R J E; Smith, Raymond A A; Ling, Ling; Fernig, David G; Swaminathan, Kunchithapadam; Nurcombe, Victor; Cool, Simon M. Structural Determinants of Heparin-Transforming Growth Factor-β1 Interactions and their Effects on Signalling. Glycobiology. 2015; 25 (12): 1491-1504.

26. Satku, Mala; Puhaindran, Mark Edward; Chong, Alphonsus Khin Sze. Characteristics of Fingertip Injuries in Children in Singapore. Hand Surgery. 2015; 20 (3): 410-414.

27. Manohara, Ruben; Sebastin, Sandeep Jacob; Puhaindran, Mark Edward. Post Traumatic Avascular Necrosis of the Proximal Carpal Row - A Case Report. Hand Surgery. 2015; 20 (3): 466-470.

28. He, Min; Gan, Aaron Wei Tat; Lim, Aymeric Yu Tang; Goh, James Cho Hong; Hui, James Hoi Po; Chong, Alphonsus Khin Sze. Bone Marrow Derived Mesenchymal Stem Cell Augmentation of Rabbit Flexor Tendon Healing. Hand Surgery. 2015; 20 (3): 421-429.

29. Tan, Jun Hao; Liu, Gabriel; Ang, Priscilla. A Rare Complication of Tongue Laceration following Posterior Spinal Surgery using Spinal Cord Monitoring: A Case Report. Indian Journal of Anaesthesia. 2015; 58 (6): 773-775.

30. Han, Fucai; Peter, Luke; Lau, Eugene Tze Chun; Thambiah, Joseph; Murphy, Diarmuid; Kagda, Fareed Husain Yusuf. Reamer Irrigator Aspirator Bone Graft Harvesting: Complications and Outcomes in an Asian Population. Injury. 2015; 46 (10): 2042-2051.

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31. Liu, Gabriel; Muhammed, Yaser; Tao, Hu; Wong, Hee-Kit. Cell Saver Filtering of Extravasated RhBMP-2 after Degenerative Scoliosis Reconstruction. Interdisciplinary Neurosurgery: Advanced Techniques and Case Management. 2015; 2 (2): 83-85.

32. Wong, Keng Lin; Peter, Luke; Liang, Shen; Shah, Siddharth; Johandi, Faisal; Wang, Wilson. Changes in Dimensions of Total Knee Arthroplasty Anterior Knee Dressings during Flexion: Preliminary Findings. International Journal of Orthopaedic and Trauma Nursing. 2015; 19 (4): 179-183.

33. Kumar, Naresh; Kumar, A; Shah, Siddharth M; Shah, Sambhav P. Annulo-Nucleoplasty using Disc-FX in the Management of Lumbar Disc Pathology: Early Results. International Journal of Spine Surgery Epub. 2014.

34. He, Ronghan; Hu, Xuefeng; Tan, Hark Chuan; Feng, Jason; Steffi, Chris; Wang, Kun; Wang, Wilson. Surface Modification of Titanium with Curcumin: A Promising Strategy to Combat Fibrous Encapsulation. Journal of Materials Chemistry B. 2015; 3 (10): 2137-2146.

35. Lee, C H; Kumar, Naresh; Moon, K Y; et al. Which One is a Valuable Surrogate for Predicting Survival between Tomita and Tokuhashi Scores in Patients with Spinal Metastases? A Meta-Analysis for Diagnostic Test Accuracy and Individual Participant Data Analysis. Journal of Neuro-Oncology. 2015; 123 (2): 267-275.

36. Lee, Wei Ting; Murphy, Diarmuid; Kagda, Fareed; Thambiah, Joseph. Proximal Femoral Locking Compression Plate for Proximal Femoral Fractures. Journal of Orthopaedic Surgery. 2015; 22 (3): 287-293.

37. Koo, Kevin; Pang, Khang Chiang; Wang, Wilson. Total Knee Arthroplasty in a Patient with a Fused Ipsilateral Hip. Journal of Orthopaedic Surgery and Research. 2015; 10 (1): 127.

38. Koh, Bryan T H; Tan, J H; Ramruttun, Amit Kumarsing; Wang, Wilson. Effect of Storage Temperature and Equilibration Time on Polymethyl Methacrylate (PMMA) Bone Cement Polymerization in Joint Replacement Surgery. Journal of Orthopaedic Surgery and Research. 2015; 10 (1): 178.

39. Daruwalla, Zubin J; Huq, Sumon S; Wong, Keng L; Nee, Pei Y; Murphy, Diarmuid P. “Publish or Perish” - Presentations at Annual National Orthopaedic Meetings and their Correlation with Subsequent Publication. Journal of Orthopaedic Surgery and Research. 2015; 10 (1): 58.

40. Sia, Wei Tee; Xu, Germaine Guiqin; Puhaindran, Mark Edward; Tan, Bien Keem; Cheng, Mathew Hern Wang; Chew, Winston Yoon Chong. Reconstruction of Extensive Soft-Tissue Defects with Concomitant Bone Defects in the Lower Extremity with the Latissimus Dorsi-Serratus Anterior-Rib Free Flap. Journal of Reconstructive Microsurgery. 2015; 31 (6): 407413.

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41. Nashi, Nazrul; Hong, Choon Chiet; Krishna, Lingaraj. Residual Knee Pain and Functional Outcome following Total Knee Arthroplasty in Osteoarthritic Patients. Knee Surgery, Sports Traumatology, Arthroscopy. 2015; 23 (6): 1841-1847.

42. Kortelainen, Jukka; Al-Nashash, Hasan; Vipin, Ashwati; Thow, Xin Yuan; All, Angelo. The Effect of Anaesthesia on Somatosensory Evoked Potential Measurement in a Rat Model. Laboratory Animals Epub. 2015.

43. Ling, Ling; Tan, Si Kee; Goh, Ting Hwee; Cheung, Edwin; Nurcombe, Victor; van Wijnen, Andre J; Cool, Simon M. Targeting the Heparin-Binding Domain of Fibroblast Growth Factor Receptor 1 as a Potential Cancer Therapy. Molecular Cancer. 2015; 14 (1): 136.

44. Daruwalla, Z J; Huq, S S; Wong, K L; Nee, P Y; Leong, K M; Pillay, K R; Murphy, D P. Hip Fractures, Preceding Distal Radius Fractures and Screening for Osteoporosis: Should we be Screening Earlier? A Minimum 10-Year Retrospective Cohort Study at a Single Centre. Osteoporosis International Epub. 2015.

45. Kumar, V Prem. Bipolar Posterior Deltoid Transfer for Massive Rotator Cuff Tears: A Report on 2 Patients. Plastic and Reconstructive Surgery - Global Open. 2015; 3 (5): e390.

46. Okolicsanyi, Rachel K; Camilleri, Emily T; Oikari, Lotta E; Yu, Chieh; Cool, Simon M; van Wijnen, Andre J; Griffiths, Lyn R; Haupt, Larisa M. Human Mesenchymal Stem Cells Retain Multilineage Differentiation Capacity including Neural Marker Expression after Extended In-Vitro Expansion. PLOS One. 2015; 10 (9): e0137255.

47. All, Angelo H; Gharibani, Payam; Gupta, Siddharth; Bazley, Faith A; Pashai, Nikta; Chou, BinKuan; Shah, Sandeep; Resar, Linda M; Cheng, Linzhao; Gearhart, John D; Kerr, Candace L. Early Intervention for Spinal Cord Injury with Human Induced Pluripotent Stem Cells Oligodendrocyte Progenitors. PLOS One. 2015; 10 (1): e0116933.

48. Salunke, Abhijeet Ashok; Chen, Yongsheng; Tan, Jun Hao; Chen, Xi; Foo, Tun-Lin; Gartner, Louise Elizabeth; Puhaindran, Mark Edward. Intramuscular Schwannoma: Clinical and Magnetic Resonance Imaging Features. Singapore Medical Journal. 2015; 56 (10): 555-557.

49. Hong, Choon Chiet; Han, Fucai; Decruz, Joshua; Pannirselvam, Vinodhkumar; Murphy, Diarmuid. Intramedullary Compression Device for Proximal Ulna Fracture. Singapore Medical Journal. 2015; 56 (2): e17-e20.

50. Thambiah, Matthew Dhanaraj; Nathan, Sahaya; Seow, Branden Zx; Liang, Shen; Lingaraj, Krishna. Patient Satisfaction after Total Knee Arthroplasty: An Asian Perspective. Singapore Medical Journal. 2015; 56 (5): 259-263.

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51. Chua, Weiliang; Kong, Chee Hoe; Murphy, Diarmuid Paul. Male Orthopaedic Surgeons and Anaesthetists: Equally Good at Estimating Fluid Volumes (and Changing Light Bulbs) but Equally Poor at Estimating Procedure Duration. Singapore Medical Journal. 2015; 56 (5): 264267.

52. Lee, Wei Ting; Liu, Gabriel; Thambiah, Joseph; Wong, Hee Kit. Clinical Outcomes of Single-Level Lumbar Artificial Disc Replacement Compared with Transforaminal Lumbar Interbody Fusion in an Asian Population. Singapore Medical Journal. 2015; 56 (4): 208-211.

53. Hey, Hwee Weng Dennis; Tan, Jun Hao; Tan, Chuen Seng; Tan, Hsi Ming Bryan; Lau, Puang Huh Bernard; Hee, Hwan Tek. Subsequent Vertebral Fractures Post Cement Augmentation of the Thoracolumbar Spine. Does it Correlate with Level-Specific Bone Mineral Density Scores? Spine Epub. 2015.

54. Wang, Ming; Abbah, Sunny Akogwu; Hu, Tao; Moon Lam, Raymond Wing; Toh, Soo Yein; Liu, Tong; Cool, Simon; Bhakoo, Kishore; Li, Jun; Hong Goh, James Cho; Wong, Hee-Kit. Polyelectrolyte Complex Carrier Enhances Therapeutic Efficiency and Safety Profile of BMP-2 in Porcine Lumbar Interbody Fusion Model. Spine. 2015; 40 (13): 964-973.

55. Hu, T; Abbah, S A; Ming, W; Toh, S Y; Lam, W M; Naidu, M; Bhakta, G; Cool, S; Bhakoo, K; Li, J; Goh, J; Wong, H K. Novel Protamine-Based Polyelectrolyte Carrier Enhances Low Dose rhBMP-2 in Posterolateral Spine Fusion. Spine. 2015; 40 (9): 613-621.

56. Hu, Tao; Abbah, Sunny Akogwu; Toh, Soo Yein; Wang, Ming; Lam, Raymond Wing Moon; Naidu, Mathanapriya; Bhakta, Gajadhar; Cool, Simon; Bhakoo, Kishore; Li, Jun; Goh, James ChoHong; Wong, Hee-Kit. Bone-Marrow Derived Mesenchymal Stem Cells Assembled with Low Dose BMP-2 in a Three-Dimensional Hybrid Construct Enhances Posterolateral Spinal Fusion in Syngeneic Rats. Spine Epub. 2015.

57. Nather, Aziz; Soegondo, Sidartawan; Adam, John M F; Nair, Harikrishna K R; Zulkilfly, Ahmad Hafiz; Villa, Martin Anthony A; Tongson, Luinio S; Chua, Soo Yeng Benjamin; Wijeyaratne, Mandika; Somasundaram, Noel; Mutirangura, Pramook; Chuangsuwanich, Apirag. Best Practice Guidelines for ASEAN Plus: Management of Diabetic Foot Wounds. Sri Lanka Journal of Diabetes Endocrinology and Metabolism. 2015; 5: 1-37.

58. Samsonraj, Rebekah M; Rai, Bina; Sathiyanathan, Padmapriya; Puan, Kia Joo; Rötzschke, Olaf; Hui, James H; Raghunath, Michael; Stanton, Lawrence W; Nurcombe, Victor; Cool, Simon M. Establishing Criteria for Human Mesenchymal Stem Cell Potency. Stem Cells. 2015; 33 (6): 1878-1891.

59. Bazley, Faith A; Liu, Cyndi F; Yuan, Xuan; Hao, Haiping; All, Angelo H; De Los Angeles, Alejandro; Zambidis, Elias T; Gearhart, John; Kerr, Candace. Direct Reprogramming of Human Primordial Germ Cells into Induced Pluripotent Stem Cells. Stem Cells and Development. 2015; 24 (22): 2634-2648.

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60. Tan, Si Heng Sharon; Lau, Bernard Puang Huh; Khin, Lay Wai; Lingaraj, Krishna. The Importance of Patient Sex in the Outcomes of Anterior Cruciate Ligament Reconstructions: A Systematic Review and Meta-Analysis. The American Journal of Sports Medicine Epub. 2015.

61. Hong, Choon Chiet; Lee, Wei Ting; Tan, Ken Jin. Osteomyelitis after TightRope(®) Fixation of the Ankle Syndesmosis: A Case Report and Review of the Literature. The Journal of Foot and Ankle Surgery. 2015; 54 (1): 130-134.

62. Hong, Choon Chiet; Tan, Ken Jin; Lahiri, Amitabha; Nather, Aziz. Use of a Definitive Cement Spacer for Simultaneous Bony and Soft Tissue Reconstruction of Mid- and HindFoot Diabetic Neuroarthropathy: A Case Report. The Journal of Foot and Ankle Surgery. 2015; 54 (1): 120125.

63. Han, Fucai; Daruwalla, Zubin J; Shen, Liang; Kumar, V Prem. A Prospective Study of Surgical Outcomes and Quality of Life in Severe Foot Trauma and Associated Compartment Syndrome after Fasciotomy. The Journal of Foot and Ankle Surgery. 2015; 54 (3): 417-423.

64. Lee, Ellen Y; Karjalainen, Teemu V; Sebastin, Sandeep J; Lim, Aymeric Y T. The Value of the Tender Muscle Sign in Detecting Motor Recovery after Peripheral Nerve Reconstruction. The Journal of Hand Surgery 40 (3): 433-437.

65. Vipin, Ashwati; Kortelainen, Jukka; Al-Nashash, Hasan; Chua, Soo Min; Thow, Xinyuan; Manivannan, Janani; Astrid; Thakor, Nitish V; Kerr, Candace L; All, Angelo H. Prolonged Local Hypothermia Has No Long-Term Adverse Effect on the Spinal Cord. Therapeutic Hypothermia and Temperature Management. 2015; 5 (3): 152-162.

66. Neo, Puay Yong; Tan, Daryl Jian-An; Shi, Pujiang; Toh, Siew Lok; Goh, James ChoHong. Enhancing Analysis of Cells and Proteins by Fluorescence Imaging on Silk-Based Biomaterials: Modulating the Autofluorescence of Silk. Tissue Engineering Part C: Methods. 2015; 21 (2): 218-228.

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REPORTS BY UOHC CLINICAL FELLOWS

Trauma Fellowship Fellow : Dr Prem Haridas Menon Supervisor : A/Prof. Joseph Thambiah Period : 19th March 2014 – 18th March 2015 “Good Exposure to a wide range of Musculoskeletal trauma cases/Joint Replacement Surgeries/Arthroscopic Procedures.”

Hip & Knee Fellowship Fellow : Joyce Gonzales Garcia Supervisor : A/Prof Wilson Wang Period : 3rd March 2014 – 2nd March 2015 “The training program stays current with the latest trends and innovations in the field of hip and knee surgery.” “(Supervisor) provides meaningful information in decision-making that helps in the preparation for a patient or surgery … (has) excellent ability to explain and teach.”

Fellow : Dr Vivek Sharma Supervisor : Prof Shamal Das De Period : 8th August 2014 – 7th February 2015 “Good surgical skills, plenty (of) supervised hands-ons, dedicated teaching sessions.” “Its been a marvellous trip thru hip and knee with added on foot and ankle experience.”

Fellow : Dr Vaibhav Jain Supervisor : Prof Shamal Das De Period : 22nd Jan 2015 – 21st July 2015 “I delightfully say that this programme is very good and very useful.” “It is a great learning experience for me.”

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Fellow : Dr Ramakant Kumar Supervisor : Dr Lingaraj Krishna Period : 17th October 2014 – 16th April 2015 “Very good exposure to different types of hip and knee cases” “(Supervisor always) ready to answer queries at any time” “(Supervisor) gives fellows adequate time to interact with patients in the Outpatient Department.”

Fellow : Dr Saumitra Goyal Supervisor : Dr Lingaraj Krishna Period : 6th April 2015 – 5th October 2015 “Dr Lingaraj is an excellent mentor with great surgical skills… He is prompt to identify which areas/potential of candidate can flourish and encourages him to do so.” “NUH allows exposure to a different setting of healthcare service where one can learn to strive for excellence, not compromise on care or cut corners but aim to achieve (the) best and provides generous care to patients.”

University Spine Centre Fellowship Fellow : Dr Reyes Ma. Ramona Banting Supervisor : Prof Wong Hee Kit Period : 15th May 2014 – 14th May 2015 “The weekly Spine Division rounds offer a very good avenue for discussing cases and learning salient points on how best to manage patients.” “All the spine consultants and assistant consultants are very professional.” “They are very kind and generous with sharing their knowledge, are easily approachable and willing to discuss cases.”

Fellow : Dr Wang Zhen Supervisor : Prof Wong Hee Kit Period : 24th November 2014 – 23rd May 2015 “The time allocated enables trainees to learn and digest the essential concept and surgical techniques that the program has to offer.” “The supervisor is an expert on his subjects and clearly very dedicated to teaching and training.”

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Fellow : Dr Prakash Sitoula Supervisor : A/Prof Gabriel Liu Period : 23rd February 2015 – 22nd May 2015 “The more important aspect of training was the development of thought process and decision-making for care of patients with spine problems which was enhanced by being actively involved in clinics and discussing the options with the professors.” “The spine meetings on Thursdays were excellent learning place where all preops and postops were discussed.” “There is so much to learn from all three professors we were tagged with during the fellowship.”

Fellow : Dr Madhu Kiran Yarlagadda Supervisor : A/Prof Naresh Kumar Period : 4th May 2015 – 3rd November 2015 “Variety of procedures & exposure excellent” “Department teaching and working environment excellent” “Definitely yes (would recommend this training programme to others)”

Fellow : Dr Li Feng Supervisor : Dr Hey Hwee Weng Period : 8th June 2015 – 7th December 2015 “All is excellent, enjoyable and fruitful…” “The supervisor is friendly and conscientious.”

Sports Medicine Fellowship Fellow : Dr Siddharth Sharma Supervisor : Prof V P Kumar Period : 27th August 2014 – 26th February 2015 “Supervisor has keen interest in teaching and facilitates trainee to reach his potential level.” “He keenly observes and makes necessary corrections during learning of trainee to make sure his skills reach excellence.” “Supervisor is very passionate to bring excellence in teaching.” 135

Fellow : Dr Vineet Thomas Abraham Supervisor : Prof V P Kumar Period : 23rd February 2015 – 22nd August 2015 “It was an excellent training programme.” “Got to see a variety of cases and thus will definitely help in my practice when I go back home.” “The tips learnt from him (Prof V P Kumar) are valuable.”

Fellow : Dr Arindam Mukherjee Supervisor : Dr Bryan Tan Period : 18th May 2015 – 17th November 2015 “Good mentorship, ample hands on training, good academic teaching programme” “Dr Bryan Tan is an excellent orthopaedic surgeon with great arthroscopic skills. He is also a fantastic clinician, knowledgeable and keeps himself up-to-date. Always keen to teach and helping out getting over my pitfalls.”

Paediatric Orthopaedics Fellowship Fellow : Dr Soumya Paik Supervisor : Prof James Hui Period : 15th September 2014 – 14th March 2015 “It is a complete exposure of advanced learning and teaching for me.” “A true supervisor – guided me in all difficulties during any time (day/night), very friendly to discuss any topic even for the minor issues, scrutinized all my work positively to deliver proper teaching, gave vision of world in my field and finally promoted me to (the) next level.”

Fellow : Dr Mazen Mohamed Ibrahim Ibrahim Supervisor : Prof James Hui Period : 6th April 2015 – 24th August 2015 “The program was versatile for the level of training as my mentor started by defining the points of weakness of the trainee and this was considered during my training.” “The level of supervision was graduated over the period of the fellowship: started from high level of supervision which gives the trainee confidence towards the end of the training period.”

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UOHC EVENTS

UOHC Cluster Retreat 2016 Organized by University Orthopaedics, Hand and Reconstructive Microsurgery Cluster 23 January 2016 Contributed by: Jamie Chen Li Wen

INTRODUCTION The University Orthopaedics, Hand and Reconstructive Microsurgery Cluster Retreat was held on 23 January 2016 at the Grand Copthorne Waterfront Hotel.

ADDRESS BY PROFESSOR WONG HEE KIT Chairman, University Orthopaedics, Hand and Reconstructive Microsurgery Cluster In his opening address, Professor Wong Hee Kit, Chairman of UOHC, outlined the achievements made by the cluster since 2015, as well as challenges that the cluster would continue to face in the upcoming year. Areas in which progress had been made included increasing arthroplasty load, improving staff welfare and interaction, and tackling research mentorship challenges faced by junior staff. The challenge for the future is to remain competitive, and to continue to provide specialist services and expertise not available in other hospitals. 139

TALK BY DR ALPHONSUS CHONG Head and Senior Consultant, Department of Hand and Reconstructive Microsurgery In delivering his talk on “Vision 2020 and Beyond”, Dr Alphonsus Chong reiterated that some of the goals for NUH included becoming one of Asia’s leading Academic Health System’s by 2020 and one of the world’s leading Academic Health Systems by 2030, and moving towards a more integrated national healthcare system.

“I like this idea that Singapore is actually very good at developing its own answers for its own unique problems. … I am pretty confident that we can find a good way forward for our cluster, for our hospital, as well as for Singapore, even though there isn’t a clear map for what we need to do.” - Dr Alphonsus Chong

ADDRESS BY ASSOCIATE PROFESSOR WILSON WANG Head and Senior Consultant, Department of Orthopaedic Surgery Associate Professor Wilson Wang, Head of Department of Orthopaedic Surgery addressed the staff on the directions for the department in the coming years.

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ADDRESS BY DR ALPHONSUS CHONG Head and Senior Consultant, Department of Hand and Reconstructive Microsurgery Dr Alphonsus Chong, Head and Senior Consultant of the Department of Hand and Reconstructive Microsurgery, also deliberated on the directions for the department to achieve its goals.

PROGRAMME

Time 8.30a.m

Topics

Topics

Registration and Breakfast

8.50a.m

Introduction – Challenges and Future Directions

Prof Wong Hee Kit

9.00a.m

Vision 2020 and Beyond

Dr Alphonsus Chong

9.10a.m

Future Direction for Department of Orthopaedic Surgery

A/Prof Wilson Wang

9.20a.m

Future Direction for Department of Hand and Reconstructive Microsurgery

Dr Alphonsus Chong

9.30a.m

Breakout Session Discussion

11.00a.m

Presentation by Breakout Groups

12.15p.m

Lunch

1.30p.m

UOHC Research Grant – Pitch for Fund 2016

2.30p.m

Progress Update of UOHC Research Awards 2014 -2015

3.30p.m

Employee Climate Survey

Dr Diarmuid Murphy/ Tan Teck Chong

4.00p.m

Tea Break

4.30p.m

Award of UOHC Pitch for Fund 2016

Prof Wong Hee Kit

4.40p.m

Summary and Closing Message

Prof Wong Hee Kit

4.50p.m

Group Picture End of UOHC Retreat 2016

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BREAKOUT DISCUSSIONS Staff members were divided into four groups for breakout session discussions. These groups are: Clinical Direction, Research Direction, Education Direction, and UOHC Nursing Direction.

Breakout Discussion on Research Direction

Breakout Discussion on UOHC Nursing Direction

Breakout Discussion on UOHC Clinical Direction

Breakout Discussion on Undergraduate Education Direction

Breakout Discussion on Postgraduate Education Direction

After the breakout discussions, each group presented their conclusions from the morning’s discussions.

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Presentation on Direction for Research by Dr Sandeep Jacob Sebastin

Presentation on Direction for Clinical Service by Dr Mark Chong

Presentation on Direction for Undergraduate Education by A/Prof Naresh Kumar

Presentation on Direction for Postgraduate Education by Dr Dennis Hey

Presentation on Direction for Nursing

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UOHC RESEARCH GRANT- PITCH FOR FUNDS Pitch for Funds 2016 The following research proposals were presented: “Efficacy of a smartphone application and motivational interviewing on physical activity levels in patients with type 2 diabetes mellitus” o Presenter: Dr Wang Mingchang o Supervisor: Assistant Professor Lingarah Krishna “Impact of L5-S1 interbody fusion on iliac screw strain in lumbopelvic constructs” o Presenter: Dr Muhammed Yaser Hasan o Supervisor: Associate Professor Gabriel Liu “A prospective, randomised, controlled, evaluator-blinded study to compare a hyaluronan-based scaffold (Hyalofast®) with microfracture (MFX) in comparison to microfracture alone in the treatment of articular knee cartilage defects” o Presenter: Dr Mark Chong o Supervisor: Associate Professor Wilson Wang

Pitch for Funds Presentation by Dr Muhammed Yaser Hasan

Pitch for Funds Presentation by Dr Wang Mingchang

Pitch for Funds Presentation by Dr Mark Chong

The judges for the UOHC Pitch for Funds 2016 were Professor Wong Hee Kit, Associate Professor Wilson Wang, Dr Alphonsus Chong, and Professor Shamal Das De. All three research proposals were awarded the UOHC Research Grant 2016. 144

Progress Update – Pitch for Funds 2014 and 2015 Winners of the UOHC Research Grant from previous years updated the cluster on the progress made in their research projects.

Pitch for Funds Progress Update by Dr Lai Kah Weng

Pitch for Funds Progress Update by Dr Rishi Malhotra

Pitch for Funds Progress Update by Dr Zachary Chua

Pitch for Funds Progress Update by Dr Francis Wong

EMPLOYEE CLIMATE SURVEY Dr Diarmuid Murphy and Mr Tan Teck Chong subsequently carried out the Employee Climate Survey for 2016.

Employee Climate Survey Presentation by Dr Diarmuid Murphy (left) and Mr Tan Teck Chong (right)

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NUH Sports Centre Official Opening 22 January 2016 Contributed by Jere Low

The NUH Sports Centre was officially opened on 22nd January 2016 by Ms Grace Fu, Minister for Culture, Community and Youth. The Centre was established with the aim of promoting sport and exercise – essential components of a healthy lifestyle. It will serve as an integrated facility providing quality holistic and multidisciplinary clinical care for the management of sports-related medical conditions.

0745 – 0845 NUH GRAND ROUND: THE FUTURE OF PLAY

Mr Lim Teck Yin, CEO of Sport Singapore, with A/Prof Wilson Wang, Head of Orthopaedic Surgery, and Dr Lingaraj Krishna, Director of NUH Sports Centre

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The day kicked off with a presentation on sport in Singapore at the NUH Grand Round titled “The Future of Play”. The invited speaker, Mr Lim Teck Yin, CEO of Sport Singapore, captured the attention of audience members as he engaged them in a discussion on how we could further enhance access and opportunity to play sport as we move beyond SG50.

Mr Lim Teck Yin CEO, Sport Singapore

By illustrating how playing host to the recent SEA Games and ASEAN Para Games has brought us closer together as one Singapore, Mr Lim highlighted the intrinsic value of sport to us - not just as individuals, but as a nation. Stressing, however, that the full power of sport has thus far been under-leveraged, he shared Sport Singapore’s long-term master-plan “Vision 2030: Live Better through Sport”, which aims to nurture a more inclusive society and enhance the quality of life in Singapore through sport.

Synopsis In 2015, Singapore celebrated 50 years of achievement and we were honoured by the opportunity to host the 28th SEA Games and 8th ASEAN Para Games as part of the year-long celebrations. These two major festivals of sport brought people out to play. They cheered our athletes, they sang our national anthem with gusto, they came with family and friends for a day out; and many went away inspired. Team Singapore – the athletes, the village, and the country delivered. It was obvious to many that sport has an intrinsic value to Singapore. But perhaps it has been under-leveraged? In 2012, Sport Singapore (then known as the Singapore Sports Council) and the then MCYS released a long term master-plan, Vision 2030: “Live Better through Sport”, after wide-ranging public consultation. What emerged from the conversations with people from different walks of life was the conviction that we could leverage sport to develop our youth, our people and our organizations. We could also nurture a more inclusive society, and enhance the quality of life in Singapore through sports. The steady increase in sports participation since the early 2000s gives weight to this belief. Beyond SG50, what should we do to further enhance access and opportunity to play sport? Also, what should we do to improve the quality of participation for all ability levels during our lifetime? How do we design sport to realise its value for individuals, families, organizations and institutions, and the nation? “The Future of Play” is an element of an ongoing discourse on “The Future of Us”. How can we entrench the national narrative concerning sport to the extent that it features prominently as one of our priorities?

Dr Lingaraj Krishna introducing Mr Lim Teck Yin

Mr Lim Teck Yin delivering his presentation

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Dr Lingaraj Krishna presenting a token of appreciation to Mr Lim Teck Yin

0845 – 0915 UOHC ANNUAL CHARITY RUN

All of us together!

Our energetic participants then set off on a 1.7 km charity run to raise funds for the National University Health System (NUHS) Fund, which extends help to patients in financial hardship.

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Preparing for the run

Ready, Set, Go!

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Our participants in action!

Staying hydrated after the run

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0915 – 0945 NUH SPORTS CENTRE OFFICIAL Opening The run was followed by the opening ceremony of the NUH Sports Centre, which commenced upon the arrival of Guest-of-Honour, Ms Grace Fu, Minister for Culture, Community and Youth.

Arrival of our Guest-of-Honour Ms Grace Fu, Minister for Culture, Community and Youth

The ceremony began with a welcome address by Dr Lingaraj Krishna, Director of NUH Sports Centre, who introduced the newly-opened Centre and shared its aims and objectives.

Dr Lingaraj Krishna delivering his welcome address

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Thereafter, there was a cheque presentation for the funds raised during the charity run. In total, $73,000 was raised for the NUHS Fund. This will be channelled towards providing assistance to patients in financial hardship.

Prof Wong Hee Kit, Chair of UOHC, presenting the cheque to Prof John Wong, Chief Executive of NUHS

A plaque was then unveiled by Ms Grace Fu to commemorate the occasion.

Guest-of-Honour Ms Grace Fu unveiling the commemorative plaque

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Ms Fu was then given a tour of the newly-opened Sports Centre by Dr Krishna. Participants were also subsequently invited to tour the Centre’s facilities.

Ms Grace Fu touring the NUH Sports Centre

0945 –1400 GAMES & FOOD CARNIVAL

Our staff at the carnival

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The day ended on a high note as participants were treated to an array of food and games at our carnival.

Games and food stalls

Our sponsors

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INSTRUCTIONS TO RESIDENTS

Instructions to Residents The University Orthopaedics and Hand Journal welcomes abstracts that contribute to orthopaedic knowledge. Contributions will include extended abstracts from award winning papers, published articles and work in progress from residents and medical students. Full articles from invited authors will also be published.

STRUCTURED ABSTRACT When submitting your contribution, it is essential to follow the following instructions: 1) Contributions will be accepted in the form of a structured abstract. 2) Each abstract should not exceed one A4-sized page for a published article, a research award paper or work in progress. 3) The manuscript must be typed, with spacing of 1.15pt and at least one inch margin on both sides and bottom. On the first page, please provide the title of article, name(s) of author(s) and name of department and institution in which the work was done. 4) Please prepare the abstract using the following structured format: a. Objective b. Methodology c. Results d. Conclusion 5) For a letter to editor, a review article or a case report, the abstract need not be structured. References need not be included.

FULL ARTICLE (upon invitation only) The manuscript must be typed using similar instructions as in the abstract. This should include illustrations/figures, tables and references. The article should not exceed 7 A4-sized pages, including illustrations and tables.

Illustrations/Figures All illustrations will be published in black and white. Please insert the illustration(s) in the appropriate section of the manuscript.

Legend Supply a caption for each illustration. Use Arabic numerals to number the figures consecutively as they appear in the text.

Tables Type each table and its title in the appropriate section of the manuscript. Use Arabic numerals to number the tables as they appear in the text.

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References Number the references consecutively in the order in which they are first mentioned in the text. Use the form of references and title of journals abbreviated according to the style used in Index Medicus. List all authors. Examples of correct forms of references are:

Journal Pho RWH, Levack B, Satku K, A Patradul. Free vascularised fibula graft in the treatment of congenital pseudoarthritis of tibia. J Bone Joint Surg 1985; 67B: 64-70

Corporate Author Pennsylvania Orthopaedic Surgery. Traumatic dislocation of the hop in children, final report by Scientific Research Committee. J Bone Joint Surg 1968; 43B: 38-42

Books Schneider FR. Orthopaedics in emergency care. The CV Mosby Co. St Louis. 1980 Ochi Mitsuo, Mori Ryuji. Research in Knee Surgery – Cartilage, Ligament and Meniscus. In: Nather A, Research Methodology in Orthopaedics and Reconstructive Surgery. World Scientific. New Jersey. London. Singapore. Hong Kong. 2002: 595-624

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