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

i
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 i

EDITORIAL BOARD ii

CONTENT PAGE

LIST OF STAFF, UOHC 1

RESIDENTS OF UOHC 5

SPECIAL FEATURE 11

• Approach to Primary Bone Tumors- A Radiological Approach with X-Rays – Amritpal 13

Singh, Gurpal Singh

CLINICAL ORTHOPAEDICS UPDATE 23

• Advancement in Treatment Strategy for Metastatic Spine Disease: Can Minimally 25

Invasive Surgery Make a Difference? – Rishi Malhotra, Naresh Kumar

BASIC SCIENCE UPDATE 35

• The use of Intraoperative Cell-Salvage for Autologous Blood Transfusions in 37

Metastatic Spine Tumour Surgery – Chen Yongsheng, Naresh Kumar

CLINICAL EXAMINATION 41

• Examination of the Diabetic Foot – Andrew Hong, Aziz Nather 43

59
• Examination of the Elbow – Joel Lim, Dennis Ng

HAND CASE DISCUSSION 63

• Missed Scaphoid Fracture – Ryan Yak, David Tan 65

PLANNING & WRITING RESEARCH 69

• Planning Research – Jamie Kee, Mao Haitong, Aziz Nather 71

• Writing a Case Report – Zest Ang, Aziz Nather 82

PROFESSORIAL LECTURES 93

• 2015 PESI B CHACHA LECTURE 95

Transitions and Transformations in Spine Surgery – Steven D. Glassman

 • 2015 R W H PHO LECTURE 96

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

• 2015 V K PILLAY LECTURE 97

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

• 2015 N BALACHANDRAN LECTURE 99

Principles of Assessment and Management of Paediatric Musculoskeletal Deformities:

Techniques Change, but Principles are Forever – Vincent Stephen Mosca

SPECIAL AWARDS: 101

• NUH Emeritus Consultant Award: Prof K Satkunanantham 103

• NUHS Outstanding Mentor Award: Prof Shamal Das De 104

TEACHING AWARDS: 105

• Dr Darren Tay Keng Jin, SGH 107

• Dr Jacqueline Tan Siau Woon, SGH 107

• Dr Lee Keng Thiam, TTSH 108

• Dr Chee Yu Han, NUH 108

• Dr Mark Edward Puhaindran, NUH 109

• Dr Andy Wee Teck Huat, KTPH 109

• Dr Arjandas Mahadev, KKH 110

• Dr Low Boon Yong, CGH 111

• Dr Gamaliel Tan Yu-Heng, NTFGH 111

RESEARCH AWARDS: 113

• Rob Johnston Award: A/Prof Naresh Kumar 115

• Best Clinical Poster & Best Poster Presentation Awards: A/Prof Naresh Kumar 117

• Best of Outside-Europe Award: A/Prof Naresh Kumar 119

LIST OF PUBLICATIONS (January to December 2015) 121

REPORTS BY UOHC CLINICAL FELLOWS 131

UOHC EVENTS: 137

• UOHC Cluster Retreat January 2016 139

• UOHC Charity Run and Opening of NUH Sports Centre January 2016 146

INSTRUCTIONS TO RESIDENTS 155

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 A/Prof Wilson Wang Ee Jen

Division of Paediatric Orthopaedics
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

3
 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

4
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

    Lee Zhao Jie Joel  Muhammed Yaser Rishi Malhotra
Eugene Hasan  

Residency Year 2

 Lim Zongwei Joel Tan Shuhui Sara   Wang Ming

Louis

Residency Year 3

Amritpal Singh Hong Choon Khor Yuet Peng

Chiet (Andrew)

7
 Ng Yau Hong Tan Jiong Hao
Jonathan

Residency Year 4

Lau Puang Huh Poh Keng Soon Yik Jing Hui Zubin Daruwalla
 
Bernard (Kevin)

Residency Year 5

Chen Yongsheng Chua Wei Liang Han Fucai

Lin Shuxun Wong Keng Lin Zackary Chua

Francis Kerk Hsiang

8
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

9
 Residency Year 6

Soumen Das De

10
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

13
 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 60
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)

14
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

15
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

16
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

EG-Ewing
EG
0-10 Osteosarcoma Osteosarcoma
SBC
Leukemia
NOF, Osteoblastic Fibrous
Dysplasia Osteosarcoma
EG Ewing Fibrous Dysplasia
10-20 SBC EG EG
ABC Osteosarcoma Osteoid Osteoma
Chondroblastoma Osteoblastoma
CMF

Giant CT Enchondroma
Enchondroma Osteoma
Chondronsarcoma Bone Island
20-40 Giant CT
(Low Grade) Parosteal osteosarcoma
Brown Tumour Healed Lesions (NOF, EG,
Osteoblastoma SBC, ABC, Chondroblasoma)

Metastases
Metastases
Myeloma Metastases
40 and above Myeloma
Chondrosarcoma Bone Island
Geode
(High Grade)

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

18
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

19
 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.

20
Figure 8: Ballooning
 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

21
 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

22
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
 ! !
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 anti-
angiogenesis 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].

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.

28
 ! !

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 NEURO DEFICIT

Radiological compression No Radiological Radiological compression No Radiological

compression compression

RTx/CTx Uncertain RTx/CTx MIS/open decompression Assess for other pathology

Resistant histology Sensitive and stabilisation
or Failure or ±RTx/CTx
sensitivity

MIS/open RTx/CTx Assess

decompression and after SINS
stabilisation SINS
assessme
nt

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

Stable Indeterminate Unstable

SINS < 7 SINS 7-12 SINS >
12

No Surgery No Disabling MIS stabilisation

± RTx/CTx disabling symptoms ±RTx/CTx
symptoms

Figure 4: Algorithm for Management of Metastatic Spinal Disease

30
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10. Bartels RH, van der Linden YM, van der Graaf WT. Spinal extradural metastasis: review of current treatment
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12. Willis RA. The Spread of Tumours in the Human Body. Butterworth, London. 1952

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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 evidence-
based approach and expert consensus from the Spine Oncology Study Group. Spine 2010; 35:E1221-
1229.

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
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17. Walker MP, Yaszemski MJ, Kim CW, Talac R, Currier BL. Metastatic disease of the spine: evaluation and
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19. Bose D, Meric-Bernstam F, Hofstetter W, Reardon DA, Flaherty KT, Ellis LM. Vascular endothelial growth
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20. Scappaticci FA, Fehrenbacher L, Cartwright T, Hainsworth JD, Heim W, Berlin J, Kabbinavar F, Novotny W,
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32
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33
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.

38
 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.

39
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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.

40
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

43
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).

Figure 2: Bilateral deformed feet due to CJD showing Figure 3: Rocker bottom deformity in patient with CJD
clawing of toes and hallux valgus deformity
44
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 Figure 5: Ulcer on sole of foot

showing infection and slough (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

45
 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.

46
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

47
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.

48
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

49
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
50
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 Signs

Autonomic Neuropathy Dryness of skin

Increased size of one foot (due to CJD)

Deformity Rocker Bottom Foot
Hallux valgus (bunion)

Trophic nail changes

Shininess of skin
Chronic Ischaemia
Loss of hair
Increased pigmentation of the skin

Clawing of toes
Motor Neuropathy
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 Edge Floor
Content
o Exudate, pus
Figure 12: Ulcer on dorsum of foot
Environment
with ischaemic edge. Slough and
o Cellulitis of adjacent skin tendon in floor of ulcer

51
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)

52
 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° Pink

Ischaemia: 15° -30° Pallor

Figure 17: Both feet turning

pale at an angle of 30 o

53
 Pulses Type of Surgery

Distal amputation* can be performed

2 pulses palpable
Very good chance of success (70-80%)

Distal amputation can be performed

1 pulse palpable
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
Figure 18: Pin prick test
Up to forefoot
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).

54
 Figure 19: Position sense test, Figure 20: Position sense test, hallux
hallux dorsiflexion (up) 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 Figure 23: 10 sites for SWM testing
filament bends

Abnormal: 7/10 or fewer sites 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

56
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

57
 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

58
 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.

59
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

61
Golfer’s elbow can also be tested against resistance by asking the patient to supinate the forearm and palmar-
flex 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.

62
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

65
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 post-
operative 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.

67
 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

68
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.

71
 !
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.

72
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?

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.

73
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.

74
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

75
 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)

Expert opinion without explicit critical appraisal, or based on physiology, bench research or
Level 5
‘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.

76
 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)

77
 !
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

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
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
 !

8th Research Team 2012

9th Research Team 2013

10th Research Team 2014

80
 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

81
 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

Evidence from well designed cohort or case-control analytic studies, preferably from more
Category II-2
than one centre or research group

Evidence from multiple case series with or without intervention or dramatic results in
Category II-3
uncontrolled experiments

Opinions of respected authorities, based on clinical experience, descriptive studies, and case
Category III
reports, or reports of expert committees.

Table 1: Level of evidence

82
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, follow-
up)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

83
 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
Compulsory to declare any financial gain or personal rivalry
interests

Table 2: Instructions for BMJ

85
 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.

87
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

90
 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 Evidence-
Based 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): 19-
20.

91
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.

! !

95
 “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.

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
Patrick J Boland,
extensive research activities, including on-going clinical research in sacral tumors and in
! MD, FRCS(I), FRCS 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.

! !

96
 “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.

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
Young-Jo Kim
Skills Course conducted by the American Academy of Orthopaedic Surgeons.
MD, PhD
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.

! !

97
 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.

! !

98
 “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.

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.

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
Vincent Stephen
Deformities and Malformations”. In addition Dr. Mosca has contributed 18 book
Mosca chapters in other books.
MD

! !

99
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.

103
   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

107
 Adjunct Assoc Prof Lee Keng Thiam
Department of Orthopaedic Surgery

Dr Chee Yu Han
Department of Orthopaedic Surgery

108
 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

109
 Dr Reuben Soh
Receiving on behalf of Adjunct
Assoc. Prof. Arjandas Mahadev

Adjunct Assoc Prof

Arjandas Mahadev
Department of Orthopaedic Surgery

110
Clinical Assoc Prof Low Boon Yong
Department of Orthopaedic Surgery

Adjunct Assoc Prof

Gamaliel Tan Yu-Heng
Department of Orthopaedic Surgery

111
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.

116
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 post-
operation. 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

118
 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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119
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): 178-
184.

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.

123
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.

124
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.

125
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.

126
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.

127
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.

128
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 Hind-
Foot 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 Cho-
Hong.

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.

129
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.”

133
 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.”

134
 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.”

136
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.

140
 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 Topics Topics

8.30a.m 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

Future Direction for Department of Hand and Reconstructive

9.20a.m Dr Alphonsus Chong
Microsurgery

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

Dr Diarmuid Murphy/
3.30p.m Employee Climate Survey
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

141
 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.

142
 Presentation on Direction for Research Presentation on Direction for Clinical Service
by Dr Sandeep Jacob Sebastin by Dr Mark Chong

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

Dr Wang Mingchang by Dr Muhammed Yaser Hasan

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.

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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 Pitch for Funds Progress Update by
Dr Lai Kah Weng Dr Rishi Malhotra

Pitch for Funds Progress Update by Pitch for Funds Progress Update by
Dr Zachary Chua 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 multi-
disciplinary 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

147
 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.

148
Preparing for the run

Ready, Set, Go!

149
 Our participants in action!

Staying hydrated after the run

150
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

151
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

152
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

153
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

154
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.

157
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

158