Fractures of the acetabulum

                   Fractures of Acetabulum

                                      Dr KS Dhillon

Anatomy

The acetabulum is a deep, cup-shaped, hemispherical depression, directed downward, lateralward, and forward.Three bones of the pelvis, namely the ilium, ischium and the pubic bone contribute to the formation of the acetabulum. A little less than two-fifths is contributed by the ilium, a little more than two-fifths by the ischium, and the remaining fifth by the pubic bone. The pubic bone lies anteriorly, the ilium superiorly and the ischium posteroinferiorly. It has six principal components, the  anterior column, posterior column, anterior wall,   posterior wall, acetabular dome or roof and the medial wall.

The posterior column is composed of the quadrilateral surface, posterior wall, dome, ischial tuberosity and the greater/lesser sciatic notches. The anterior column is composed of anterior ilium, anterior wall, dome, iliopectineal eminence and the lateral superior pubic ramus.

The roof of the acetabulum is the thick, weight bearing portion and forms a separate fragment in bicolumnar fractures. The thin quadrilateral plate forms the medial wall or the floor of the acetabulum.

The acetabulum is bounded by an uneven rim, which is thick and strong above, and to it is attached the glenoid labrum which deepens the surface for articulation. Below it, there is a deep notch, the acetabular notch, which is continuous with a circular non-articular depression, the acetabular fossa, at the bottom of the cavity. This depression contains a mass of fat. The notch is converted into a foramen by the transverse ligament; through which nutrient vessels and nerves enter the joint. The margins of the notch give attachment to the ligamentum teres. The rest of the acetabulum is covered with a curved articular surface, the lunate surface, for articulation with the head of the femur.
The mean lateral inclination of the acetabulum is between 40 to 48 degrees and the mean anteversion is between 18 to 21 degrees.

Classification of acetabular fractures

The most widely used classification of acetabular fractures is that by Judet and Letournel. According to this classification fractures of the acetabulum are broadly divided into 2 categories: elementary fractures and associated fractures. There are 5 elementary and 5 associated fracture patterns. The associated fractures are composed of a combination of at least two of the elementary fracture patterns.

Elementary fractures involve a single wall, involve a single column, or are purely transverse. The simplest elementary fractures are two-part fractures.

Associated fracture patterns have at least three major fracture fragments and include a posterior column fracture with a posterior wall fracture, a transverse fracture with a posterior wall fracture, an anterior column fracture with a posterior hemitransverse fracture, a T-type transverse fracture, and associated both-column fractures.

The wall fractures can be divided into two types: the anterior wall fractures and the posterior wall fractures. The transverse fractures can be divided into three types: the transverse fracture, the T- shaped fracture and the transverse with posterior wall fracture. The column fractures can be divided into five types: posterior column, anterior column, posterior column with posterior wall, both columns and anterior column with posterior hemitransverse fractures [1].

Out of the 10 fracture patterns, 90% of acetabular fractures that occur are one of following five types: associated both-column, T-type, transverse, transverse with posterior wall, and elementary posterior wall fractures [2,3]. Often the acetabular fractures do not fit perfectly into one of the fracture patterns in the classification scheme [4].

Radiography

An anteroposterior view and left and right Judet views are required for evaluation of acetabular fractures. Judet views are the obturator oblique view (fig 1) which shows profile of obturator foramen and also shows the anterior column and posterior wall, and the iliac oblique view (fig 2) shows profile of involved iliac wing and it shows the posterior column and anterior wall.

The radiographic landmarks of the acetabulum include the iliopectineal line (anterior column), ilioischial line (posterior column), anterior wall, posterior wall, teardrop, weight bearing roof and the Shenton's line.

CT scan 

A CT scan is now considered a gold standard in management of patients with acetabular fractures. It helps in identification of the fracture pattern orientation, and definition of fragment size and orientation. Marginal impaction, articular gaps and step offs can be identified with a CT scan.
Loose bodies in the joint can be seen with CT scan.

Treatment of acetabular fractures

Nonoperative treatment

Indications for nonoperative treatment include:

• Undisplaced fractures and minimally displaced fractures (<2mm displacement).
• Displaced fractures where a large portion of the acetabulum remains intact and the femoral head remains congruent with the acetabulum.
• Moderate displacement of a both-column fracture and the patient presents late (>3 weeks after injury).
• Small posterosuperior-wall fractures with a stable hip joint and a congruent reduction.
• A posterior-wall injury that is minimally displaced or nondisplaced.
• If surgery is contraindicated

Surgery would be contraindicated in patients with:

• Severe systemic illness or secondary multiorgan failure due to polytrauma
• Systemic infections or sepsis
• Local infection
• Extreme  osteoporosis
• Severe comminution with preexisting arthrosis would be a relative contraindication.

Nonoperative treatment includes:

• Resuscitation of the patient - Basic or advanced life support where necessary.
• Diagnosis - After patient has been stabilized a clinical and radiologic diagnosis is established.
• Treatment of other life-threatening injuries such as head, chest, abdominal, or other injuries.
• Urgent reduction of associated dislocation is carried out. Posterior dislocations are managed by gentle close reduction on an emergency basis. Central fracture-dislocations are treated by skeletal traction applied to an upper tibial or lower femoral pin. 

For patients with undisplaced and minimally displaced fractures, protected weight bearing for 6-8 weeks is usually recommended.  DVT prophylaxis is usually recommended in patients who are immobilized or are slow to slow to mobilize.

Indications for open reduction and internal fixation include [5,6] :

• Injury less than 3 weeks old
• Patient physiologically stable
• Good soft-tissue coverage
• no local infection
• More than 2 mm displacement of roof 
• Unstable fracture pattern 
• Marginal impaction
• Intra-articular loose bodies
• Irreducible fracture-dislocation
• Intact roof-arc angle less than 30°
• Fractures that have a medial roof-arc angle of 45° or less
• Anterior roof-arc angle of 25° or less
• Posterior roof-arc angle of 70° or less across the weight bearing part of the acetabulum. 
• Vascular injury or sciatic palsy after a closed reduction

The fractures can be approach anteriorly by the ilioinguinal, iliofemoral or the modified stoppa approach. The Kocher-Langenbeck approach can be used for posterior fractures and an extended iliofemoral combined approach for both anterior and posterior fractures.

Outcome of management of acetabular fracture

The outcome after undisplaced and minimally displaced fractures treated conservatively is invariably good. The outcome of treatment of significantly displaced fractures which require open reduction and internal fixation can vary widely. There is a strong correlation between the accuracy of reduction
and the clinical outcome. Accurate reduction with restoration of articular congruence is associated with good clinical outcome [7]. Incongruent reduction correlates strongly with a poor outcome [8]. Excellent results can be achieved even when the reduction is poor, provided that the step or gap is outside the weight-bearing region [9].

A significant negative impact on outcome is seen in patients with simple posterior column fractures and T-shaped fractures. Patients with a combined posterior wall traumatic dislocation and sciatic nerve palsy also fare badly. The outcome is also poor when the acetabular fracture are associated with injury to the femoral head  [10-13].

Deo et al [14] reported good to excellent results in 74% of 79 patients they treated who had acetabular fractures. Early operation and an anatomical reduction was associated with good outcome and poor outcome was seen in patients who had delayed surgery, and in patients where there was failure to achieve or maintain reduction, and in patients who had femoral head damage at the time of injury.

Matta JM [15] published the outcome of treatment of 262 displaced acetabular fractures in 259 patients. The patients were treated with open reduction and internal fixation (ORIF) within 3 weeks after injury. This review was carried out at a mean follow-up of 6 years. Anatomical reduction was achieved in 71% of cases. Greater fracture complexity, age > 40 years, and a longer interval between injury and surgical reduction were  bad prognostic factors which were significantly associated with a decreased rate of anatomical reduction and poorer outcome. The results were excellent in 40%, good in 36%, fair in 8%, and poor in 16% of the patients.The overall clinical results were excellent / good for 76% of patients.

There was neurological injury (2 sciatic nerve injury and 1 femoral nerve injury and 6 peroneal nerve injury) in 3% of the cases. Wound infection occurred in 13 hips (5%), extraarticular in 5 hips and intraarticular in 8 hips. Progressive femoral head wear was seen 13 cases (5%). Osteonecrosis of the femoral head occurred in 8 hips (3%). Subsequent operations included a total hip replacement in 6% of the cases and an arthrodesis in 2% of the patients.

Gänsslen et al [16] in a study 135 patients with both column fractures of the acetabulum found that 69.8% of those with anatomically reconstructed hip joints had no or mild postoperative pain and a good or excellent result at a mean follow up of 54.6 months. Arthritic changes were seen in 17.5% of the patients and joint failure in a further 25.4% of the patients. Joint failure was usually seen in patients with concomitant femoral head lesion and significant preoperative articular fragment displacement.

Briffa et al [7] reported the outcome of treatment of 161 of the 257 patients who had surgical fixation of acetabular fractures at a minimum of 10 years follow up. The result were excellent in 47%, good in 25%, fair in 7% and poor in 20% of the patients.

They had a high infection rate of 11%, of which 6% were deep infection, despite the use of prophylactic antibiotics. They had a 12.5% incidence of sciatic nerve palsy, a 1.8% obturator and a 14.3% incidence of lateral femoral cutaneous nerve palsy.

There were no cases with pulmonary embolism and no cases with deep vein thrombosis. There was a 10.5% incidence of heterotopic ossification. The incidence of posttraumatic osteoarthritis was 38% in this series, which is higher than the  26.6% reported by Giannoudis et al [17] in their 2005 meta analysis.

The incidence of AVN of the femoral head was 11.8% and the incidence of total hip replacement was 16% in the Briffa et al series.

The 10 years survivorship of total hip replacement (THR) in patients with prior acetabular fracture is markedly inferior and is more frequently associated with serious complications when compared with patients undergoing THR for primary osteoarthritis or AVN. Morison et al [18] carried out a retrospective case-control study which compared the outcome of THR in patients with previous acetabular fractures, with the outcome in patients who received a THR for primary osteoarthritis or AVN. They found that the average time to revision of the THR in patients with previous acetabular fractures was 8 years as compared to 13 years in patients without acetabular fracture who had THR. The primary cause for revision in both cohorts was loosening of the acetabular component. There was no difference in revision rates in patients who had conservative or surgical treatment for the acetabular fractures. The primary cause for revision in both cohorts was loosening of the acetabular component.

Patients undergoing THR who had previous acetabular fractures were more likely to develop serious complications such as infection, dislocation, and acetabular loosening and heterotopic ossification. The infection rates were 7% in patients with previous acetabular fractures as compared to 0% in the cohort without previous acetabular fractures. The dislocation rates were 11% in patients with previous acetabular fracture as compared to 3% in the other cohort and heterotopic ossification was seen in 43% and 16% of the patients respectively, in the two cohorts.

Romness and Lewallen [19] did a retrospective study of 55 primary total hip arthroplasties, in 53 patients with a history of previous acetabular fracture, with a mean follow up of 7.5 years and they found radiographic loosening of the acetabular component in 52.9% of the patients and symptomatic loosening in 27.5% of the patients. The revision rates at a mean follow up of 7.5 years was 13.7%.
Weber et al [20] reported revision rates of 22% for aseptic loosening at 10 years follow up, in patients who had a THR for arthrosis from previous acetabular fractures.

Conclusion

Standard AP and oblique obturator and iliac views of the acetabulum are necessary when an acetabular fracture is suspected. CT scan is now gold standard for a workup in the management of acetabular fractures.

Good long term results can be expected for undisplaced and minimally displaced acetabular fractures treated nonoperatively.

The clinical outcome for operatively treated patients are generally good, with acceptable complication rates. Good to excellent results have been reported in about 76% of the patient.
Loss of joint congruency with an intraarticular step-off of more than 2mm leads to increased rates of secondary osteoarthritis. Post traumatic osteoarthritis has been reported in 26% to 38% of the patients. The reported incidence of AVN of the femoral head is about 11.8% and the incidence of total hip replacement in patients with acetabular fractures is about 16%. The survivorship of THR in patients with acetabular fractures is lower than in patients who have THR for primary OA or AVN by about 5 years at 10 years follow up. Revision rates of 22% for aseptic loosening at 10 years follow up have been reported in patients who had a THR following acetabular fractures.

 References

1. Saterbak AM, Marsh JL, Turbett T, et al. Acetabular fractures classification of Letournel and Judet—a systematic approach. Iowa Orthop J  1995; 15: 184–96.
2. Brandser E, Marsh JL. Acetabular fractures: easier classification with a systematic approach. AJR 1998; 171:1217–1228.
3. Durkee NJ, Jacobson J, Jamadar D, Karunakar MA, Morag Y, Hayes C. Classification of common acetabular fractures: radiographic and CT appearances. AJR 2006; 187:915–925.
4. Lawrence DA, Menn K, Baumgaertner M and Haims AH. Acetabular Fractures: Anatomic and Clinical Considerations. American Journal of Roentgenology. 2013;201: W425-W436. 10.2214/AJR.12.10470.
5. Matta JM, Mehne DK, Roffi R. Fractures of the acetabulum. Early results of a prospective study. Clin Orthop Relat Res. 1986 Apr. (205):241-50. 
6. Olson SA, Bay BK, Chapman MW, Sharkey NA. Biomechanical consequences of fracture and repair of the posterior wall of the acetabulum. J Bone Joint Surg Am. 1995 Aug. 77 (8):1184-92.
7. Briffa N, Pearce R, Hill AM, Bircher M. Outcomes of acetabular fracture fixation with ten years' follow-up. J Bone Joint Surg Br. 2011 Feb;93(2):229-36. doi: 10.1302/0301-620X.93B2.24056.
8. Murray MM, Zurakowski D, Vrahas MS. The death of articular chondrocytes after intra-articular fracture in humans. J Trauma 2004;56:128-31.
9. Starr AJ, Watson JT, Reinert CM, et al. Complications following the “T extensile” approach: a modified extensile approach for acetabular fracture surgery: report of forty-three patients. J Orthop Trauma 2002; 16:535-42.
10. Matta JM, Mehne DK, Raffi R. Fractures of the acetabulum: early results of a prospective study. Clin Orthop 1996;205:241-50.
11. Moed BR, Yu PH, Gruson KI. Functional outcomes of acetabular fractures. J Bone Joint Surg [Am] 2003;85-A:1879-83.
12. Murphy D, Kaliszer M, Rice J, McElwain JP. Outcome after acetabular fracture: prognostic factors and their inter-relationships. Injury 2003;34:512-17.
13. Mears DC, Velyvis JH, Chang CP. Displaced acetabular fractures managed operatively: indicators of outcome. Clin Orthop 2003; 407:173-86.
14. Deo SD, Tavares SP, Pandey RK, El-Saied G, Willett KM, Worlock PH. Operative management of acetabular fractures in Oxford. Injury. 2001 Sep;32(7):581-6.
15. Matta JM. Fracture of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am. 1996; 78 (11): 1632 – 1645.
16. Gänsslen A, Frink M, Hildebrand F, Krettek C. Both column fractures of the acetabulum: epidemiology, operative management and long-term-results. Acta Chir Orthop Traumatol Cech. 2012; 79(2):107-13.
17. Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H. Operative treatment of displaced fractures of the acetabulum: a meta-analysis. J Bone Joint Surg [Br] 2005;87-B:2-9.
18. Morison Z, Moojen DJ, Nauth A, Hall J, McKee MD, Waddell JP, Schemitsch EH. Total Hip Arthroplasty After Acetabular Fracture Is Associated With Lower Survivorship and More Complications. Clin Orthop Relat Res. 2016 Feb;474(2):392-8. doi: 10.1007/s11999- 015-4509-1.
19. Romness DW, Lewallen DG. Total hip arthroplasty after fracture of the acetabulum. Long-term results. J Bone Joint Surg Br. 1990 Sep; 72(5):761-4.
20. Weber M, Berry DJ, Harmsen WS. Total hip arthroplasty after operative treatment of an acetabular fracture. J Bone Joint Surg Am. 1998 Sep;80(9):1295-305.

Racism in Malaysia

                        Racism in Malaysia

                                      Dr KS Dhillon

“All human beings are born free and equal in dignity and rights…”
         (Universal Declaration of Human Rights, 1948)

What is racism?

The Cambridge English Dictionary defines racism as “the belief that people's qualities are influenced by their race and that the members of other races are not as good as the members of your own, or the resulting unfair treatment of members of other races” [1].

Without doubt racism is a global reality. It is a global hierarchy of human superiority and inferiority which has been politically, culturally and economically produced and reproduced for centuries by certain sections of society. People belonging to the superior race enjoy access to, human rights, civil rights, women rights and/or labor rights as well as to material resources, and social recognition. Those belonging to the inferior race are considered subhuman or non-human and their humanity is questioned and negated. Those of the inferior race are denied their human and other rights, as well as material resources and social recognition [2].

Colonial histories in different parts of the world at different times have constructed racism along racial markers such as color, ethnicity, language, culture and/or religion. Since colonial times, color racism, the so called white supremacy, has been the dominant marker of racism in most parts of the world including the USA.

When the skin color is the same and cannot be used as a marker then the religious marker is often used to claim superiority. The British did this in Ireland where there was a racial conflict between Protestants and Catholics.

Even to present day there is Islamophobia in Europe and in the United States. In North America and Europe, muslim religious identity constitutes one of the most prominent markers of human superiority and inferiority. In these regions of the world islamophobia has led the white supremacist to label muslims with many unsavoury labels with reference to civility, violence, abuse of rights of children, women and gay/lesbians [2]. In these two regions of the world color racism and religious racism continues to be of great importance and entangles itself in complex ways.

In other parts of the world ethnic, linguistic, religious and or cultural identity is used to define racial dominance. Malaysia is a shining example of such racism.

Concept of race in Malaysia

In social sciences the concept of race to analyze and classify groups of people has no scientific foundation and analytical concept of race has been rejected [3]. The main concern of race studies has been the construction of race as a social reality and the survival of race as a concept.

In Malaysia, the term race is widely used as an accepted scientific concept to discuss ethnic relations.
Syed Husin Ali [4], a Malaysian anthropologist, argues that population groups such as Malays, ethnic Chinese, ethnic Indian and so on should be referred to as ethnic groups rather than racial groups. The reason being, all these so called racial groups in Malaysia belong to the same racial stock, namely Mongoloid.

Johann Friedrich Blumenbach’s classification of human race in the 18th century divided the various population groups into three races, namely the Mongoloid, Caucasoid and Negroid [5].
Others have used race for class relationship in Malaysia. Sundram [6] used the term race to discuss social stratification of the three major ethnic groups in Malaysia. He believed that race is a social construction and racial categorization has taken a particular configuration within Malaysian society
on an everyday level and it has become a reality.

The concept of race was introduced into Malaya by the British who popularized it among the people of British Malaya through the education system, mass media and law. They categorised the local population into three major races, namely the malays, ethnic chinese and ethnic indians. The indigenous people of Sabah and Sarawak, and non malay indigenous people the orang asli were labeled as others.

The race concept inherited from the British was retained to give legitimacy to Malay dominated government to sustain and protect the malay power and privileges provided for by the Malaysian Federal Constitution.  Ethnic bargaining and accommodation among the three major ethnic groups resulted in the special privileges for the malays in the Malaysian federal constitution. The bargaining resulted in Non-Malays obtaining citizenship and protection of their culture and language while Malays were guaranteed their special position [7]. Article 153 of the Federal Constitution makes the  monarch responsible for safeguarding the special position of Malays and other indigenous groups [8]. Article 153 provides for the special treatment of Malays and natives of Sabah and Sarawak in federal public service, education, scholarships, training privileges, permits, licenses for trade and business [7].

Article 160 of Malaysian Constitution defines Malay as a person who professes Islam, habitually speaks the Malay language and practices Malay customs. Malays and other indigenous people are known as bumiputras or the son of the soil. Their special position has been achieved through a series of policies know as bumiputera policies which were introduced after the May 13 riots in 1969 [8]. The New Economic Policies (NEP) was introduced to eradicate poverty from Malaysia to improve the economic standing of the bumiputera. In education and employment malays were given priority.

Racism in Malaysia

The Malaysian Federal Constitution has provisions which prohibit racial discrimination in the country, and this is spelt out in Article 8 (1, 2) and Article 12.

Article 8 (1 & 2) states that:
(1) All persons are equal before the law and entitled to the equal protection of the law.
(2) Except as expressly authorized by this Constitution, there shall be no discrimination against citizens on the ground only of religion, race, descent or place of birth or gender in any law or in the appointment to any office or employment under a public authority or in the administration of any law relating to the acquisition, holding or disposition of properly or the establishing on carrying on of any trade, business, profession, vocation or employment.

Article 12 (1) state that:
Without prejudice to the generality of Article 8, there shall be no discrimination against any citizen on the grounds only of religion, race, descent or place of birth.
Although the principles of equality in the protection of rights of every Malaysian exits, exceptions have been made by Article 153 on the Malaysian Constitution.

Article 153 (1) states that:
It shall be the responsibility of the Yang di-Pertuan Agong to safeguard the special position of the Malays and natives of any of the States of Sabah and Sarawak and the legitimate interests of other communities in accordance with the provisions of this Article.

Reservations of quotas for public service positions, scholarships, educational or training privileges, business permits and licenses are also spelled out in this Article. Points (7) and (8) of Article 153 has provisions to ensure the protection of legitimate interests of other communities.

Article 153 (7):
Nothing in this Article shall operate to deprive or authorize the deprivation of any person of any right, privilege, permit or license accrued to or enjoyed or held by him or to authorize a refusal to renew to any person any such permit or license or refusal to grant to the heirs, successors or assigns of a person any permit or license when the renewal or grant might reasonably be expected in the ordinary course of events.

The pro-bumiputera Malays claim that The Federation of Malaya Agreement signed on 21 January 1948 at King House by the Malay rulers, and by the British government representative Sir Edward Gent granted the malays leadership among the three races. This claim however, is apparently not accurate. Upon independence from the British all 3 races were supposed to be given equal rights. Dato' Onn Jaafar - then heading UMNO, agreed to abide by the above original terms of The Federation of Malaya Agreement. After 1951, UMNO, however, gradually  meandered a different course, enshrining the rights of Malays over all other races in law. Today, the Malays dominate in politics at both national and state levels, the civil service, military and security forces [9,10].

The malay dominated government ensures that Bumiputras of Malay origin are given preferential treatment when it comes to admission to public universities and colleges [11]. Many of the Chinese and Indians chose private universities to pursue their studies because of a lack of places for them in public institutions [12]. The private housing developers are forced to give discounts for new houses to the Malays. They also receive cheaper burial plots in most urban areas. All key government positions are held by the malays including the top posts of most sporting associations. Listed companies are expected to have a minimum of a 30% Malay Bumiputera.  Full funding for mosques and Islamic places of worship is provided by the government. Special trust funds which provide high interest rates are set up for the Bumiputera Malays. Special share allocations for new share applications are provided to the Bumiputera Malays. The Malay language has been made a compulsory examination paper to pass in national schools [13,14,15,16,17].

After the 1969 riots the National Economy Policy (NEP) was introduced with two major objectives: “to eradicate poverty irrespective of race” and “to restructure society to abolish the identification of race with economic function” [18]. Prior to 1969 the colonial capitalism had created an ethnic division of labour which emerged from uneven development and socioeconomic disparities. Crudely the three major ethnic groups were labelled as  the Malay farmers, the Chinese traders and the Indian estate labourers.

The NEP aimed to reduce poverty by reducing the incidence of poverty from 49 per cent of all households in 1970 to 16 per cent in 1990 and to restructure society, the NEP planned to raise the bumiputera share of corporate equity from 2.5 per cent in 1970 to 30 per cent in 1990. The NEP also planned to create a Bumiputera Commercial and Industrial Community (BCIC).

Though the aim of the NEP was to eradicate poverty irrespective of race, in reality the poverty eradication programmes rarely reached the non-Malay poor, including the urban poor and the Chinese New Villagers [18].

The NEP allowed and justified the public sector taking on multiple new roles. The public sector emerged as the main provider of opportunities for the Malays. It enlarged the existing numbers of Malay entrepreneurs, graduates and professionals. The aspiring Malay entrepreneurs were given financial assistance, credit facilities, contracts, preferential share allocations, subsidies as well as training. New public universities and all-Malay residential schools and colleges were established. Tens of thousands of young malay students and mid-career officers were sent to universities abroad. The social engineering resulted in an increase numbers of Malay entrepreneurs and capitalists [19] and a sizeable Malay middle-class [20]. The bumiputera participation rate in all professions increased [21].

The public sector became a stringent regulator of both local and foreign businesses. The Industrial Coordination Act (ICA) was introduced in 1975 which enforced compliance with the NEP’s restructuring. A Foreign Investment Committee was set up to introduce bureaucratic procedures, which met the needs of the NEP. A 30% bumiputera (malay) equity participation and employment in companies was introduced and this was enforced through the ICA. The ICA gave the minister of trade and industry power over licensing, ownership structure and employment targets. Product distribution quotas, local content and product pricing were controlled by the ministry of trade and industry [22]. Strict bureaucratic regulations were introduced even at state and local government level which regulated non Malay businesses. NEP requirements were imposed by land offices, town and country planning departments, municipal councils and state economic development corporations for real estate development. NEP requirements were imposed on land-use conversions and on various planning guidelines.

The public sector also became a major investor so that malay ownership of corporate equity could be increased. State resources were used to expand malay ownership of assets via “restructuring” exercises. Public sector started setting up its own companies as well as buying local and foreign companies. This foray into corporate sector allowed the public sector to control large portions of the Malaysian economy in areas such as plantations, mining, banking and finance, property and real estate [23].

With the introduction of NEP the public sector became the trustee of malay economic interests. State-owned agencies such as Bank Bumiputera, Urban Development Authority, Perbadanan Nasional (National Corporation), Permodalan Nasional Berhad (National Equity Corporation), Amanah Saham Nasional (National Unit Trust Scheme) and the state economic development corporations, held equity “in trust” for the bumiputera (malays) [24,25]. 

After 1970, many new public enterprises proliferated and their numbers grew rapidly to perform their new and expanded roles to fulfil the requirements of the NEP [25]. Federal Off-Budget Agencies and companies formed by state economic development corporations came into existence and grew significantly in all sectors of the economy. Their financial allocations steadily rose after 1971. Though the aim of these increase in allocations at federal and state levels was for development, with the aim of eradicating poverty among all ethnic groups, the direction in which public sectors concerns took became  increasingly ethnicized [18].

The expansion of the public sector under the NEP’s restructuring objective served two purposes. The first was to increase employment of the malays in the civil service via a massive civil service recruitment drive. The proportion of malay Division 1 officers in the civil service in 1968 was 37.4% and in 1987 the proportion became 65%. In year 2000 the number of civil servants were 979,464 and in 2013 the sized was 1.42 million. The proportion of malays in the civil service before implementation of the NEP in 1969-70 was 64.5% and in 2009 it was 76.2%. In 1969-70 the proportion of chinese and indians was 18.8% and 15.7%, respectively, and in 2009 it was in 6.0% and 4.3% [27]. Probably the numbers of non malay civil servants is much less now in 2018.

The second objective of the NEP was elimination of identification of race with economic function and malay domination of the civil service clearly contradicts this 2nd objective of the NEP.
The Malay special rights were to be applied only to recruitment, and not to promotion in civil service. In practice, however, malays have been getting promoted because of their race. The highest policy-making positions are  filled by Malays without regard to objective performance standards and these promotion are carried out at rapid rate [28].

As early as 1975, ethnic discrimination in tertiary education which favoured the malays was obvious at all levels of tertiary education in local public universities. Affirmative action favouring malays involved student enrolment in public institutions of tertiary education, disbursement of scholarships, as well as the recruitment of academic staff. Many qualified non-Malay students were denied admission to local public institutions [29].

The Bumiputera ownership of share capital of public listed companies rose from 2.4 per cent in 1970 to 20.6 per cent in 1995.

Quotas and targets were set and were modified as and when necessary in all areas of economic and social life to provide preferences and discrimination favouring the bumiputeras. Price subsidies and discounts were given by the public sector to overcome the bumiputera’s lack of competitiveness.
The NEP had set a 20-year target to achieve a 30% share of corporate assets for bumiputeras. This was interpreted as a minimum of 30 per cent bumiputera participation, in employment in private companies, in allocation of new shares in public listed companies; in sale or transfer of corporate or other assets in selected sectors; in award of government contracts and projects; in admission of students in tertiary education, in awarding of scholarships and financial assistance; and in the development and sale of urban housing and commercial space [18].

With the interpretation of a minimum of 30% bumiputera participation, the bumiputera quotas frequently exceeded 30 percent of whatever was believed to fall within the ambit of restructuring and redistribution. This restructuring and redistribution exercise led to malay versus non-Malay polarity and public-private dichotomy. The public services, public enterprises and statutory bodies became increasingly Malay domains while the private sector remained as a Chinese domain [30].

The borders between Malay social enterprise and Malay private business became blurred as NEP’s multidimensional state economic interventions took the form of statist capitalism. There was a continuous support by the state for malays to accumulate private wealth. Joint ventures between the malays and non-malay partners (socalled “Ali Baba” arrangements) became common.

Expansion of malay private enterprise continued with appointment of malays to company directorships and the politically well connected malays  could obtain government contracts. State capitalism allowed too much power to be put in the hands of a few leaders which in turn led to the corrosion of democratic culture and institutions.

UMNO being the party of the Malays, it made the NEP as its national agenda, which allowed it to enter into business on a large scale and in the process built itself a corporate empire [31]. The technocrats and administrators of this rapidly enlarged Malay-dominated bureaucracy ended up controling vast economic resources in the name of Malay trusteeship via the state-owned enterprises [32].

Lack of business experience and capability among the public bureaucrates  prevented many public enterprises from meeting the criteria of efficiency and profitability. This weaknesses in public sector governance led to large-scale deficits and losses. The public sector deficit rose from RM400 million to RM15.2 billion between 1970 and 1982. In 1982, the statutory bodies, public enterprises and the state governments, collectively owed the federal government as much as RM8.743 billion [32].

Some state managers became entrepreneurs themselves by acquiring the very enterprises they were managing earlier. The malay entrepreneurs complained of unfair state competition and pushed the states to transfer the assets to them directly. UMNO’s entry into business to generate funds for the party saw the establishment of Fleet Holding. In the 1980s and 1990s, Umno’s assets were mostly held through privately held Hatibudi Sdn Bhd and Fleet Group Sdn Bhd. Tan Sri Halim Saad, a businessman and one of Umno’s well-known proxies controlled Hatibudi Sdn Bhd. Hatibudi held substantial stakes in United Engineers (M) Bhd (UEM) and Hume Industries (M) Bhd as well as a 60% stake in Seri Pacific Corp. UEM, which was awarded contracts to build two mega infrastructure projects namely the North-South Expressway and the Malaysia-Singapore Second Link, became one of the biggest conglomerates in Southeast Asia.

Through the Fleet Group, Umno held substantial stakes in several Bursa Malaysia-listed companies, including the New Straits Times Press (M) Bhd, Time Engineering Bhd, Bank of Commerce Bhd, Commerce International Merchant Bankers Bhd (both banks later subsumed into CIMB Group) and Faber Group Bhd. UMNO thus built up an economic empire that penetrated most economic sectors in the name of protecting the rights of the malays and fulfilling the aims of the NEP [19,31]. UMNO managers themselves became big capitatlist themselves by securing enormous lucrative state projects, contracts and assets [19]. Gradually intramalay competition  became more obvious within the party bureaucracy and class axis.  Standard expectations of public sector governance such as transparency, accountability and impartial oversight gradually became diminished due to lack of executive discretion, intervention by the party, corporate rent-seeking, cronyism as well as outright corruption [18].

Conclusion

Racism and racial discrimination has become entrenched in Malaysia. There is not and there will not be a full stop to this issue of racism in Malaysia in the future. It is present in every aspect of our lives. It is seen in business, education and even sports. The politics of hate and instigation of racial tension is a norm in our everyday life. Politicians in Malaysia spew racial hatred on a regular basis to garner support from their majority races.

Malicious and racially provocative statements that are meant to offend a certain ethnic group are a norm on social media nowadays.

No policies and practices to address the issue of racism and racial discrimination exist in Malaysia. There is no engagement by the government with civil society organisations, academicians, media and other sectors of Malaysian society to address this phenomenon. A collective effort by multi-stakeholders is desperately needed to combat the rising incidences of religious and racial discrimination in Malaysia.

References

1. The Cambridge English Dicitionary at https://dictionary.cambridge.org/dictionary/english/racism.
2. Grosfoguel R. What is Racism? Journal of World-System Research. 2016; Vol. 22 (1) : 9-15.
3. Farish A.Noor. What your teacher didn’t tell you; the Annexe Lectures (Vol.1). Petaling Jaya: Matahari Books, 2009.
4. Syed Husin Ali. Ethnic relations in malaysia: Harmony & Conflict, Petaling Jaya: Strategic Information and Research Development Centre, 2009.
5. Barkan E. The retreat of scientific racism: Changing concepts of race in Britain and the United States between the world wars. New York and Melbourne: Cambridge University Press, 1992.
6. Sundram, Jeyaratnam M. A.. “Race, class and uneven development in Malaysia”. MA thesis. Department of Sociology at Michigan State University, 1983.
7. Shad Saleem Faruqi. 2005. “Affirmative action policies and the constitution”. In The 'Bumiputera policy': dynamics and dilemmas Kajian Malaysia Journal of Malaysian Studies special issue, edited by Richard Mason and Ariffin Omar, 21( 1 & 2), 2005.
8. Mason R and Omar A. “The Bumiputera policy:Dynamics and dilemmas”. In The Bumiputera policy: Dynamics and dilemmas Kajian Malaysia Journal of Malaysian Studies special issue, edited by Richard Mason and Ariffin Omar, 21( 1 & 2), 2005.
9. Hong-Hai Lim (2007). "Ethnic Representation in the Malaysian Bureaucracy: The Development and Effects of Malay Domination". International Journal of Public Administration. 30 (12-14: Comparative Asian Public Administration): 1503–1524. doi:10.1080/01900690701229731.
10. Muthiah Alagappa (1 September 2002). Coercion and Governance: The Declining Political Role of the Military in Asia. Stanford University Press. p. 259. ISBN 978-0804742276.
11. Jennifer Pak (2 September 2013). "Is Malaysia university entry a level playing field?". BBC.
12. "Malaysia's system of racial preferences should be scrapped". The Economist. 18 May 2017.
13. Dimitrina Petrova (22 November 2012). "Affirmative Action versus Equality in Malaysia". Oxford Human Rights Hub.
14. Boo Su-Lyn (11 April 2014). "Even in death, no escape from rising prices". The Malay Mail. http://iphira.tripod.com/smih/spm.htm
15.  "Race-based affirmative action is failing poor Malaysians". The Economist. 18 May 2017.
16. "The Malay Language and its role in nation building"- Summary of Saturday Night Lecture 14th September 2013". UTM. 24 September 2013.
17. Khoo Boo Teik. Ethnic Structure, Inequality and Governance in the Public Sector Malaysian Experiences. Democracy, Governance and Human Rights Programme Paper Number 20 December 2005. United Nations Research Institute for Social Development.
18. Searle, Peter. 1999. The Riddle of Malaysian Capitalism: Rent-Seekers or Real Capitalists? Allen and Unwin, St. Leonards, New South Wales.
19. Abdul Rahman Embong. 1995. State-Led Modernization and the New Middle Class in Malaysia. Palgrave Macmillan, Houndmills.
20. Jomo, K.S. 1999. “A Malaysian middle class?” In K.S. Jomo (ed.), Rethinking Malaysia: Malaysian Studies I. Malaysian Social Science Association, Kuala Lumpur.
21. Jesudason, James V. 1989. Ethnicity and the Economy: The State, Chinese Business and Multinationals in Malaysia. Oxford University Press, Singapore.
22. Heng Pek Koon and Sieh Lee Mei Ling. 2000. “The Chinese business community in Peninsular Malaysia, 1957–1999.” In Lee Kam Hing and Tan Chee Beng (eds.), The Chinese in Malaysia. Oxford University Press, Kuala Lumpur.
23. Searle, Peter. 1999. The Riddle of Malaysian Capitalism: Rent-Seekers or Real Capitalists? Allen and Unwin, St. Leonards, New South Wales.
24. Gomez, Terence Edmund and K.S. Jomo. 1997. Malaysia’s Political Economy: Politics, Patronage and Profits. Cambridge University Press, Cambridge.
25. Lim Hong Hai. 2003. The Representativeness of the Bureaucracy in Malaysia: The Problems of Public Administration in a Plural Society. Paper presented at the International Conference on Reform in Public Administration and Social Services in Asia, Macao Polytechnic Institute, Macao, China, 8–9 November 2003.
26. Lim, H. H. (2013). The public service ethnic restructuring under the New Economic Policy: The new challenge of correcting selectivity and excess. In .T. Gomez & J. Saravanamuttu (Eds.), The New
27. Economic Policy in Malaysia: Affirmative action, ethnic inequalities and social justice. Singapore: NUS Press.
28. Means. 1972. “‘Special rights’ as a strategy for development.” Comparative Politics, Vol. V, October, pp. 46–48.
29. Lee, Molly N.N. 2004. Restructuring Higher Education in Malaysia. School of Educational Studies, Monograph Series No. 4/2004. Universiti Sains Malaysia, Penang.
30. Jomo KS. 1990. Growth and Structural Change in the Malaysian Economy. Palgrave Macmillan, London.
31. Gomez TE. 1990. Politics in Business: UMNO’s Corporate Investments. Forum, Kuala Lumpur.
32. Mehmet, Ozay. 1986. Development in Malaysia. Poverty, Wealth and Trusteeship. Croom Helm, London.

Coccydynia-Treatment

                           Coccydynia-Treatment

                                                      Dr KS Dhillon

Anatomy of the coccyx

The coccyx, also known as the tailbone is the terminal end of the spine, just distal to the sacrum. It is about one inch in length and is curved like a hawk’s beak.The human coccyx is considered as a vestigial remnant of a tail. It is composed of 3-5 coccygeal vertebrae. In 80% of individuals, the coccyx is made up of 4 coccygeal vertebrae. The individual bones fuse together to form a single coccygeal bone throughout adulthood. In some individuals, however, the bones only partially fuse, resulting in two separate coccygeal bones.

Anteriorly the coccyx is concave and posteriorly it is convex in shape. The coccyx has an apex, base, anterior surface, posterior surface and two lateral surfaces. The base located proximally contains a facet for articulation with the sacrum. The apex is situated distally at the inferior tip of the coccyx. The lateral surfaces of the coccyx are marked by a small transverse processes, which project from 1st coccygeal vertebra.

The 1st coccygeal vertebra has two small articular processes called coccygeal cornua which articulates with the sacral cornua to form the  sacrococcygeal symphysis. It is a fibrocartilaginous joint which allows limited flexion and extension movements. The intercoccygeal joints also
contain fibrocartilaginous discs.

There are four configurations of the coccyx which were described by Postacchini and Massobrio [1]

Type I: Coccyx is slightly curved forward, with the apex directed downward and caudally.
Type II: Forward curvature is more marked, and the apex extends straight forward.
Type III: Coccyx angulates more sharply forward.
 Type IV: Coccyx is subluxated at sacrococcygeal joint or at intercoccygeal joint.


The sacrococcygeal symphysis is supported by five ligaments:

• Anterior sacrococcygeal ligament which is a continuation of the anterior longitudinal ligament of the spine, and it connects the anterior aspects of the vertebral bodies.
• Deep posterior sacrococcygeal ligament which connects the posterior surface of the 5th sacral body to the posterior surface of the coccyx.
• Superficial posterior sacrococcygeal ligament which attaches the median sacral crest to the dorsal surface of the coccyx.
• Lateral sacrococcygeal ligaments which run from the lateral aspect of the sacrum to the transverse processes of 1st coccygeal vertebra.
• Intra articular ligaments which stretch from the cornua of the sacrum to the cornua of the coccyx. 

The coccyx has an attachment for the gluteus maximus muscle which is a major extensor of the thigh at the hip. The levator ani muscle which consists of the coccygeus, iliococcygeus, and pubococcygeus, also arise from the coccyx. This muscle group supports the pelvic floor (preventing inferior sagging of the intrapelvic contents) and also plays a role in maintaining fecal continence. A midline component of the muscle is the anococcygeal raphe which supports the position of the anus. The coccyx via the anococcygeal ligament helps to support the anus by holding the external anal sphincter in place.

Function of the coccyx

The coccyx and the ischial tuberosities forms a tripod on which an individual sits.The coccyx bears more weight when the seated person is leaning backward and less weight when a person leans forward.

Besides the weight bearing function it also provides support for the pelvic floor and the anus as well as plays a role maintaining fecal continence. 

Coccydynia

Coccydynia (also referred to as coccygodynia, coccalgia, coccygalgia, or coccygeal pain) is a painful syndrome affecting the coccygeal region. It is a rare condition. The patient presents with pain in the coccygeal region which occurs while sitting on hard surfaces and sometimes on getting up from sitting position.

Epidemiology

Frequency

Coccydynia is the cause of back pain in less than 1% of all back pain conditions [2, 3, 4]. It is five times more common in women as compared to men [5]. The mean age of onset is usually around 40 years of age [5].

Etiology of Coccydynia

The most common cause of coccydynia is external or internal trauma. External trauma usually results from a fall on the buttocks or a fall backwards which leads to a bruised, dislocated, or broken coccyx [6]. The  coccyx may also be injured during childbirth especially with instrumented and difficult deliveries. Prolonged sitting on hard narrow and uncomfortable surfaces can lead to minor trauma to the coccyx leading to coccydynia [2]. Non-traumatic coccydynia can result from degenerative joint or disc disease, hypermobility of the coccyx, hypomobility of the sacrococcygeal joint, infections,and malignancies. The pain in the coccygeal region can also be referred pain from other sites. Less commonly coccydynia can be associated with non-organic causes, such as somatization disorder and other psychological disorders [7].

The configuration of the coccyx can predispose a patient to coccydynia and influence the type of pain the patient has. Types II, III, and IV are usually  more painful than type I [1]. Obesity can also a predisposing factor for coccydynia.

Clinical presentation and diagnosis

Most patients present with a history of a fall or an antecedent childbirth. The incidence of posttraumatic coccydynia is about 69.2% [8]. Some patients will present with no preceding incidence of trauma and the onset of pain can be insidious.

Patients usually present with tailbone pain which is worse on prolonged sitting, leaning back while sitting, on getting up from sitting and sometimes on prolonged standing. Sexual intercourse and defecation may also be associated with tailbone pain in some patients.

Physical examination usually reveals tenderness over the coccyx. A rectal examination allows manipulation of the coccyx and it will elicit pain and may reveal hypermobility or hypomobility of the sacrococcygeal joint.

X rays of the coccyx can reveal fractures, subluxations and dislocations of the coccyx. A comparison of lateral radiographs which are taken in the standing and in the most painful sitting position can reveal posterior subluxation of the coccyx and hypermobility of the coccyx [8]. Further evaluations can be carried out using CT scan images. When infection, tumours or other sources of pain are sought, an MRI can be useful.

Treatment of coccydynia

Non-surgical treatment

Non-surgical management remains the gold standard treatment for coccydynia. In many patients the pain resolves without treatment and conservative treatment is usually successful in 90% of cases [3,9,10]. Wedge-shaped cushions (coccygeal cushions) can be used to relieve pressure on the coccyx when  the patient is seated and these are usually available over the counter. Circular cushions (donut cushions) can increase pressure on the coccyx and are not suitable for treatment of coccydynia. Sitting bent forward helps to take pressure off the coccyx and its helps reduce the pain. Application of heat and cold sometimes helps too. Nonsteroidal antiinflammatory drugs (NSAIDs) are most commonly given for pain relief. Opioids are generally not prescribed for pain relief.

Maigne and Chattelier [11] studied the usefulness of levator ani massage, levator ani stretching, and sacrococcygeal joint mobilization in the treatment of coccydynia. They found that at 6-month the success rates for message were 29.2%, for stretching 32% and for joint mobilization 16%. The overall success rate with these conservative approaches was 25.7%.

Local injections of steroids with long acting anesthetics have been used for treatment of coccydynia where conservative treatment has failed. Wray et al [12] recommended a mixture of 40 mg methylprednisolone and 10 ml 0.25% bupivacaine. In some patients where symptoms persisted a third injection was performed in conjunction with coccygeal manipulation under general anesthetic. They reported a success rates of 59% with injections alone and 85% for the injections with manipulation. Twenty one percent patients receiving injections and 28% of those undergoing injections with concurrent manipulation developed recurrence of symptoms.

Although injections into the pericoccygeal tissues have been used in the treatment of coccydynia, there appears to be no clear consensus in the literature regarding the exact site of injection.
Plancarte et al [13] were the first to describe the use of radiofrequency to block the ganglion impar for pericoccygeal pain due to carcinoma. Others have used the same technique to relieve pain in patients with severe coccydynia [14]. Evidence-based literature supporting the effectiveness of these interventional procedures remains lacking.

The published literature on the use of various modes of treatment for coccydynia described above consists of case series which is especially vulnerable to selection bias. Unfortunately there are no cohort studies comparing different interventions and their outcomes.

Surgical treatment

Surgery for the treatment of coccydynia is used only as a last resort when all other treatment options have not been successful. The commonly used surgical procedure used for the treatment of chronic coccydynia not responding to other forms of treatment is coccygectomy. It involves surgical removal of the coccyx just proximal to the sacrococcygeal junction. There is scarcity of literature to support the use of this surgical procedure. As with other modes of treatment of coccydynia most of the available literature consists of case reports and retrospective case series with no cohort studies. The available literature suggests that a coccygectomy may provide relief in some subset of patients who have failed all other forms of treatment [8,10,12,15].

Infection is the most serious complication of coccygectomy because of  proximity of the coccyx to the rectum and anal canal. Rates as high as 16.6% [16] and 14.75% [17] have been reported in literature. Partial skin necrosis and superficial wound infection causing delay in wound healing has been reported in about 50% of the patients [1]. Besides the high complication rates, the procedure can be associated with failure to achieve pain relief. Therefore, ‘based on current available information, this procedure generally is not recommended’[18].

Conclusion

The etiology of the coccydynia can be complex and may often be multifactorial. It is a relatively rare condition with no universally accepted treatment protocol. The symptoms are often mild and the condition can sometimes be self limiting. Though most patients respond to conservative treatment, some may require more aggressive treatment.
A multidisciplinary approach using physical therapy, workplace adaptations, medications (NSAIDs), injections and psychotherapy where necessary, will provide the best opportunity for success in the treatment of these patients. Surgical coccygectomy is generally not recommended for the treatment of patients with coccydynia. More research is needed to establish which is the best mode of treatment of patients with coccydynia. Randomized control trials to study the outcome of treatment of patients with coccydynia are needed.

References

1. Postacchini F, Massobrio M. Idiopathic coccygodynia. Analysis of fifty-one operative cases and a radiographic study of the normal coccyx. J Bone Joint Surg Am. 1983 Oct. 65(8):1116-24.
2. Pennekamp PH, Kraft CN, Stütz A, Wallny T, Schmitt O, Diedrich O. Coccygectomy for coccygodynia: does pathogenesis matter?. J Trauma. 2005 Dec. 59(6):1414­9. 
3.  Thiele GH. Coccygodynia: Cause and treatment. Dis Colon Rectum. 1963 Nov­Dec. 6:422­-36.
4. Peyton FW. Coccygodynia in women. Indiana Med. 1988 Aug. 81(8):697­8. 
5. Fogel GR, Cunningham PY 3rd, Esses SI. Coccygodynia: evaluation and management. J Am Acad Orthop Surg. 2004 Jan­-Feb. 12(1):49­54.
6. Schapiro S. Low back and rectal pain from an orthopedic and proctologic viewpoint; with a review of 180 cases. Am J Surg. 1950 Jan;79(1):117-128.
7. Nathan ST, Fisher BE, Roberts CS. Coccydynia: a review of pathoanatomy, aetiology, treatment and outcome. J Bone Joint Surg Br. 2010 Dec;92(12):1622-1627.
8. Maigne JY, Doursounian L, Chatellier G. Causes and mechanisms of common coccydynia: role of body mass index and coccygeal trauma. Spine (Phila Pa 1976). 2000 Dec 1. 25(23):3072­9.
9. Capar B, Akpinar N, Kutluay E, Müjde S, Turan A. Coccygectomy in patients with coccydynia [in Turkish] Acta Orthop Traumatol Turc. 2007 Aug-Oct;41(4):277–280. 
10. Trollegaard AM, Aarby NS, Hellberg S. Coccygectomy: an effective treatment option for chronic coccydynia: retrospective results in 41 consecutive patients. J Bone Joint Surg Br. 2010 Feb;92(2):242–245. 
11. Maigne J, Chattelier G. Comparison of three manual coccydynia treatments: a pilot study. Spine. 2001;26:E479–84.
12. Wray C, Easom S, Hoskinson J. Coccydynia: aetiology and treatment. J Bone Joint Surg. 1991;73:335–8.
13. Plancarte R, Amescua C, Patt RB, Allende S. Presacral blockade of the ganglion of Walther (ganglion impar) Anesthesiology. 1990; 73(3A):A751.
14. Toshniwal GR, Dureja GP, Prashanth SM. Transsacroccygeal approach to ganglion impar block for management of chronic perineal pain: a prospective observational study. Pain Physician 2007;10:661–6.
15. Perkins R, Schofferman J, Reynolds J. Coccygectomy for severe refractory sacrococcygeal joint pain. J Spinal Disord Tech. 2003 Feb;16(1):100–103.
16. Bayne O, Bateman JE, Cameron HU. The influence of etiology on the results of coccygectomy. Clin Orthop 1984;190:266–72.
17. Doursounian L, Maigne JY, Faure F, Chatellier G. Coccygectomy for instability of the coccyx. Int Orthop 2004;28:176–9.
18. Lirette LS, Chaiban G, Tolba R, Eissa H. Coccydynia: an overview of the anatomy, etiology, and treatment of coccyx pain. Ochsner J. 2014;14(1):84-7.