BOS Journal - January 1988

The Journal of Bangladesh Orthopaedic Society

January 1988	Volume 3
CONTENTS
EDITORIAL
1. Watson Jones Philosophy On Fractures Dr J. N. Wilson. Ch-M., FRCS, Consultant Orthopaedic Surgeon, Royal National Orthopaedic Hospital, London; Former President of the World Orthopaedic Concern;Visiting Professor in RIHD, Dhaka.
2. Treatment Of Old Unreduced Posterior Dislocation Of Elbow DR. A. F. M. RUHAL HUQUE, FRCS, Associate Professor of Orthopaedic Surgery, RIHD, Dhaka. DR. RAMDEW RAM KAIRY, M. S. (Ortho), Assistant Professor of Ortho. Surgery, RIHD, Dhaka.
3. To Produce Bony Union By Surgery: Some Comments Arthur L. Eyre-Brook, M. S. (London), F. R. C. S. (Eng), Past President, British Orthopaedic Association; Visiting Professor in RIHD, Dhaka.
4. Evaluation Of The Results Of Operative Treatment Of Giant Cell Tumour Of Bone Dr. Shamsuddin Ahmed, FCPS, FAO (Germany), Assoc. Prof. of Orthopaedic Surgery. Dr. Sk. Nurul Alam, D. Orth., M. S. Orth., Lecturer of Orthopaedic Surgery ,R.I.H.D. Dhaka.
5. Orthopaedic Implants in Developing Countries R. J. Garst. M.D, F.A.C.S., A.B.O.S.
6. False Aneurysm Of Femoral Artery- A Case Report Col Syed Fazie Rahim, M.B.B.S, (Dhaka), MS (Ortho) Orthopaedic Surgeon, Combined Military Hospital, Dhaka.
7. Review Of “Putti-Platt'' Procedure For Recurrent Anterior Dislocation Shoulder Dr. Md. Ferdous Hossain Serajee, MBBS, D. Ortho, M S. (Ortho), Student RIHD, Dhaka.
8. Case Report: Fibrodysplasia Ossificans Progressive Dr. Ashok Bajracharya, MBBS, Student of M. S. (Orth ) Course, RIHD, Dhaka,
9. Case Report: Multiple Pseudo Cystic Tuberculosis Bone DR, SIRAJ-UL-ISLAM. M.S (Orth) Student, RIHD. Dhaka
10. Case report: Fracture of the upper third of the shaft of radius with superior radio-ulnar dislocation Dr. M. A. H, M, Jafar, Asstt. Prof. of Orthopaedic Surgery, R. I. H. D., Dhaka,

WATSON JONES PHILOSOPHY ON FRACTURES
J. N. Wilson
Ch-M., FRCS.
Consultant Orthopaedic Surgeon, Royal National Orthopaedic Hospital, London.
Former President of the World Orthopaedic Concern,
Visiting Professor in RIHD, Dhaka.

Sir Reginald Watson Jones, who died in 1972 at the age of 70, was probably the most colourful & dynamic of all the fracture surgeons of his time. His attitude towards fracture treatment is perhaps best summed up in the following quotation made in a speech in his honour New York – “To Sir Reginald Watson Jones, always positive, the ever in doubt & by the grace of God usually right”! His views on the union of fractures were much influenced by his predecessors at Liver Pool, Sir Robert Jones & Hugh Owen Thomas. These views may be summarised in the statements made in his book that “The cause of non-union of fractures is inadequate immobilisation” and that “non-union of fractures due to failure of Surgeons much more than to the failure of Osteoblasts”. This has led to the unfair criticism that Sir Reginald would immobilise a fracture indefinitely in plaster to the detriment of limb function, a criticism which also led the of opposite school of fracture treatment at St. Thomas' Hospital to deride prolonged immobilisation with the comment “Plaster means is Disaster.” Sir Reginald who essentially a conservative surgeon as far as fracture treatment was concerned and once describe himself as a 'Physician destined to the role of a Surgeon'. He would never have agreed with the philosophy of the Swiss school of Surgeons who have advocated primary internal fixation of fractures to avoid ‘the fracture disease’ of prolonged immobilisation. The only fracture disease that Sir Reginald recognised was that brought about by iatrogenic diasters and on many occasions showed conclusively that prolonged immobilisation of normal joints did not produce stiffness.

> His philosophy on fracture healing de-pended largely upon a study of nature and the sequence of events which lead to union. Fracture do not unite by end to end union & the primary bone healing of the A. O. philosophy is a myth. A bone at the time of fracture must suffer some degree of vas-cular insult at the time of the injury, the amount depending upon the severity of the trauma & the comminution. Fractures will therefore take some considerable time to revascularise, and in the meantime repair is ‘brought about by the formation of external callus. That external callus is natures way of fracture healing is shown dramati-cally in the repair of the stress fracture of a metatarsal, when commonly the first radiographic sign of the fracture is exter-nal callus. The stimulation to form this callus is almost certainly a small amount of movement possible within a plaster or a fracture splint. Without there being excessive movement likely to disrupt the fragile gra-nulations forming in the early stages. Should operater interference upset this dedicate balance, as for example by the insertion of a plate with rigid fixation, union may in fact be delayed. It would be wrong however to leave the impression, that Sir Reginald was against operator intervension in fracture treatment. Far from it, provided there was good reason for surgery, open reduction internal fixation would certainly be advised, but it would be regarded as incident in conservative treatment not as an alternative. The disadvantages of operative treatment must be emphasised in particular the words of Ellis, “operation shall entails the conversion of a closed fracture into open one." & Sir Reginald would certainly agree with E. A. Nicoll when he said “the most dangerous aspects of the present vogue for internal fixation is its tendency to produce enthusiasts who would fix everything principle”.

There is a saying in Britain that “there are many ways of killing a cat.” So it is with fracture treatment. We must be capable of applying the right treatment to the right case. For example if there is a segmented fracture of the Tibia, intramedullary fixation is probably the best treatment, but this does not mean that every tibial fracture must be treated in this way.

> Plaster of Paris immobilisation is still the valuable & most versatile method for the treatment of fractures & therefore the conservative bias outlined by Sir Reginald has much to commend it. It was E. A. Nicoll who said – “A totalitarian approach is fundamentally misconceived - every fracture is an individual problem & the decision to treat by internal fixation or indeed conservatively should be based upon a realistic assessment of the advantages & hazards of each method.” If Sir Reginald were alive today it is certain that he would reiterate these words as the basis of his own philosophy.

DR. A. F. M. RUHAL HUQUE
FRCS., Associate Professor of Orthopaedic Surgery. RIHD. Dhaka.
DR. RAMDEW RAM KAIRY
M. S. (Ortho), Assistant Professor of Ortho. Surgery, RIHD, Dhaka.

Key Word: - Old dislocation elbow

57 patients aged from 8-64 years underwent open reduction for untreated posterior dislocation of elbow. The dislocations were 2 months to 2 years old. The operation was done by posterior approach (standard speed technique). About 73.6% gained a useful movement of elbow. Complication after operation included five cases of post operative infection, three cases of tourniquet palsy and three cases of ulnar nerve palsy which recovered later on. Neither the age nor the duration of dislocation influenced the result.

Arthur L. Eyre-Brook,
M. S. (London), F. R. C. S. (Eng).
Past President. British Orthopaedic Association.
Visiting Professor in RIHD, Dhaka.

Key Word: - Bony Union

Bony union may be required between two fragments of one bone. Sound bony union takes 12 weeks whether the interphalangeal or the knee arthrodesis are considered; or the bony contact is much more extensive in the knee but the disruptive forces are so much greater. The realm of primary cortical union is not the province of this article and we will not enter into this continuing debate.
Factors involved in body union are:-

The quality of the bone - Fusion in Charcot joints. Union in infantile pseudoarthrosis of tibia.
The extent of bony contact - absent after excision of a major portion of bone.
The stability/instability at the contact between the bones.
Bone grafting - cortical, cancelleous, free or vascularised.
Fixation between bones, bone fragments and bone graft. Good fixation encourages the early active phase of union and discourages the formation of the fibrous layer consequent on movement of bone on bone.

All of the factors will be referred to both in arthodesis and in bone grafting techniques.

Dr. Shamsuddin Ahmed
FCPS, FAO (Germany), Assoc. Prof. of Orthopaedic Surgery.
Dr. Sk. Nurul Alam
D. Orth., M. S. Orth, Lecturer of Orthopaedic Surgery R. I. H. D, Dhaka.
Key Word: - Giant cell Tumour

In a developing country like Bangladesh because of the lack of facilities for diagnosis and treatment in remote areas and also for mild nature of the initial symptoms, the patie-nts often present for treatment in referral hospitals only when the tumour have grown to an enormous size and well advanced for which the surgeon is to face a great problem.
In the two and half years period from June/83 to November/85, we treated 27 cases of Giant Cell Tumour of bone. The incidence of Giant Cell Tumour is about 11% of all primary tumours of bone as per study conducted in R. I. H D. Dhaka

R. J. Garst
M.D. F.A.C.S., A.B.O.S.

In ths western countries Orthopaedic Surgeons are used to the most sophisticated implants, instruments and equipment. Expense is no bar and consequently the approach to management of orthopaedic problems is often considerably different to that in the developing countries. Hospitalisation in U.S.A. costs several hundred dollars per day. But in Bangladesh 2-3 US dollars per day. It is obvious that in the west the approach of the Orthopaedist must be to get the patient out of the hospital in the shortest possible time. This may not necessarily be the best line of treatment however. Another difference, the Orthopaedist with everything available aims to get patient immobilized so well with internal fixation that he will not require a cast of additional protection. This way the patient may be able to be weight bearing immediately. With the “C” arm x-ray machine and a sophisticated fractur table, closed intramedullary nailing is very commonly used. How many institutions in the developing countries have a " C" arm available? In addition to the closed nailing it is becoming more popular to lock the nail at either one or both ends.

> It should be remembered that fractures have been treated for years without these sophisticated appliances and the patients have had normal healing and complete recovery. We should impress on the surgeon of the third world that they should be famil-iar with all of the standard principles. It is not a sign of failure to combine limited internal fixation with plaster casts, traction and longer periods of hospitalization and bed rest. This paper will deal with inexpensive implants that I have used over the years.

Col Syed Fazie Rahim
M.B.B.S, (Dhaka), MS (Ortho), Orthopaedic Surgeon, Combined Military Hospital, Dhaka.

Key Word: - False Aneurysm

ABSTRACT:
A case of False Aneurysm of femoral artery is presented here. False Aneurysm is caused by injury to an artery by pene-trating wound from without or from a fracture. The arterial wall may be partially lacerated or the entire thickness of the wall is divided resulting in ballooning out of the arterial wall or formation of a large haematoma. Clinically it presents as a pulsating tumour mass and may sometime be confused with Aneurysimal bone cyst or Angioma. Radiology of the part is unlikely to show any bone change. Treatment is surgery and prognosis of the aneurysm of extremity has a good result.

Dr. Md. Ferdous Hossain Serajee
MBBS. D. Ortho: M S. (Ortho) Student. RIHD. Dhaka.

Key Word: - Recurrent Anteior discolatin of Shoulder

ABSTRACT:
30 recalled patients were evaluated in detail, revealing one recurrence, some end up with occasional pain, and some have changed their occupation but inspite of 8° external rotation limitation all have good results. At the Singapore General Hospital** the putti-platt procedure is the most frequently performed procedure. In 24 patients out of 30, important aetiological factor were youth, strenous, athletic activity and ina-dequate immobilization. Follow up ranged from 3 months to 8½ years With an average 3 years and 4 months.

** This review was done at Singapore General Hospital during his stay at Singapore for post graduate training in Orthopaedic Surgery (Editor)

CASE REPORT: FIBRODYSPLASIA OSSIFICANS PROGRESSIVE
Dr. Ashok Bajracharya
MBBS, Student of M. S. (Orth) Course, RIHD, Dhaka.

Key Word: - Myositis Ossificans

Fibrodysplasia Ossification Progressiva, also known as Myositis Ossifcans Pro-gressiva, is a progressive ossification, pri-marily of fibrous structures related to muscles as well as the muscle itself being secondarily affected. First case was described by Mr. John Freke in 1740, in a young boy whose erector spine muscles were ossified. Since then some cases have been sporadically reported in western literature only.

Dr. Siraj–Ul-Islam
M.S (ORTHO) Student, RIHD. Dhaka

Key Word: - A typical Tuberculosis

Multiple pseudo-cystic tuberculosis of bone is a rare manifestation of skeletal tube-rculosis in children in which cystic lesion occur in the different bones. This and the other cystic bone lesions in tuberculosis (The solitary focus of diaphysial tuberculosis osteitis, tuberculosis dactylitis) have been the subject of confused nomenclature. Con-fusion in terminology dates from l920 when Jugling used the term "Osteitis. Tuberculosa multiplex cystoids" to describe such lesion in adults. It was nothing but sarcoidesis. After a great deal of work by various persons. Komin proposed the following terminology to avoid further confusion:

The characteristic multiple cystlike bone lesion of tuberculosis in child-ren be called "Multiple pseudo cystic tuberculosis of bone".
The adult multiple tuberculosis lesion in bones that appear roen-tgenographically to be cystic is called "disseminated bone tuberculosis" as suggested by Alexender and Mansuy.

Additional cases have since been repor-ted by Dr. Pape (1954) and by Murry first described the characteristic features of multiple pseudo cystic tuberculosis of bone in children of which the most important were: - common in childhood, affects the long bones symmetrically and to progress and regress in harmony, the lack of early bone reaction with later cortical expansion and fusiform enlargement without sequestrum formation. The case to be illustrated here fulfils most of the criteria described.

Dr. M. A. H, M, Jafar
Asstt. Prof. of Orthopaedic Surgery, R. I. H. D. Dhaka

Key Word: - A typical Tuberculosis

INTRODUCTION:
Fractures of the upper third of shaft of Radius with superior radio-ulnar dislocation is a rare injuiry. Four such cases has been encountered by the author and it is worth while to report these cases and its management.