BOS Journal - July 1993 - Volume 8, Number 2

The Journal of Bangladesh Orthopaedic Society

July 1993	Volume 8, Number 2
CONTENTS
EDITORIAL 1. Regional Anaesthesia – an overview M.S. ALAM D.A. (Lond), Consultant Anaesthesiologist A.F.M. RUHUL HAQUE FRCS (Ed), Editor, Journal of Bangladesh Orthopaedic Society
2. Pes Anserinus Transposition for Chronic Anteromedial Rotatory Instability of the knee Joint: Study and Evaluation of Results of Twenty one Case MAJOR CHOWDHURY ISHRAQ UZ ZAMAN, MBBS (Dhaka), M.S. (Orth) (Dhaka University), Orthopaedic Surgeon, Combined Military Hospital, Chittagong Cantonment. A. F. M. RUHAL HAQUE, FRCS, Associate Professor of Orthopaedic Surgery, DMCH.
3. Incidence and Management of Side Swipe Injury MD. AMJAD HOSSAIN, MS.(Orth), Asstt. Prof., Orthopaedic Surgery, R.I.H.D., Dhaka. A.F.M. RUHAL HOQUE, Associate Professor, Dept. of Orthopaedic Surgery, DMCH. RAFIQUL ISLAM, Jr. Consultant (cc), Sadar Hospital, Hobiganj. MD. ZIAUDDIN, Medical Officer, RIHD, Dhaka. SHAHJAHAN, Medical Officer, RIHD, Dhaka.
4. Factures in Neonates QAZI SHAHIDUL ALAM, Associate Professor Orthopaedics, Head of the Department of Causualty, Dhaka Medical College & Hospital, Dhaka. MD. SERAJUDDIN AHMED, Assistant Professor, Department of Orthopaedics, Dhaka Medical College & Hospital, Dhaka.
5. Brachial Plexus Block Anaesthesia Through Axillary Route BIPUL KUMAR DAM Asstt. Professor, Orthopaedic Surgery, Rajshahi Medical College & Hospital, Rajshahi. AYJAZ AHMED KHAN Asstt. Professor, Orthopaedic Surgery, Rajshahi Medical College & Hospital, Rajshahi. MD. TAIBUR RAHMAN Registrar, Orthopaedic Surgery, Rajshahi Medical College and Hospital, Rajshahi. MD. MONIRUL ISLAM House Staff, Orthopaedic Surgery, Rajshahi Medical College & Hospital, Rajshahi.
6. Management of pressure sore over sacrum by myocutaneous flap K. M. ESHAQUE, Former Associate Professor of Orthopaedic Surgery, Rangpur Medical College Hospital. Now Associate Professor of Orthopaedic Surgery RIHD, Dhaka. NURUN NAHAR, Lecturer, Anatomy Department, Dhaka Medical College, Dhaka.
7. Case Report: Unusual presentation of Ewing’s Sarcoma – 3 Case Reports M. A. SAMAD, Orthopaedic Consultant, Institute of post Graduate Medicine and Research, Dhaka. SK. N. ALAM, Assist. Professor, Rehabilitation Institute and Hospital, for Disabled (RIHD), Dhaka. M. A. HANNAN, Associate Professor, Rehabilitation Institute and Hospital for Disabled (RIHD), Dhaka.
8. Case Report: Reconstruction of Neglected Severed Patellar Tendon by Keli – Kian Procedure MD. AMJAD HOSSAIN, MBBS, Student of M. S. (Orth ) Course, RIHD, Dhaka, M.A. HANNAN, Associate Prof. Orthopaedic, RIHD. SYED ANWARUZZAMAN, MS(Orth) Student, RIHD.

Regional Anaesthesia – an overview
M.S. Alam
D.A. (Lond), Consultant Anaesthesiologist
A.F.M. Ruhul Haque
FRCS (Ed), Editor, Journal of Bangladesh Orthopaedic Society

Regional analgesia is the abolition of painful impulse from any region/regions of the body by temporary interrupting the sensory nerve conductivity (Daniel C. More).

Koller with Sigmoid Freud introduced cocaine in 1884 as topical anaesthesia in anesthesiology. This was the first era in the history of local anaesthesia2. Then in 1904 Einhorn introduced procaine which was followed by lignocaine, tetracaine, mepivacaine, bupivacaine, and etidocaine2. All these drugs are either esters or amides having different toxicity, metabolism, onset and duration of action. All these local anaesthetic drugs block the propagated action potential of nerve impulses and produce the regional block.

Use of regional blocks or local anaesthetic techniques varies from hospital to hospital, and country to country. In Bangladesh the advances of regional blocks are very recent and due to this, the few techniques that are used vary from person to person. Infiltration and spinal anaesthesia were most widely used but generally major nerves plexus are blocked with success and are generally gaining in popularity. Among the major nerve plexus blocks, epidural, brachial plexus and Bier’s blocks are more popular than any others.

These regional blocks are being used in other clinical situations like – pain relief in labour, post operative pain relief and mangement of intractable pain in cancer.

A groups of doctors, including anesthesiologist in any specialty are users of local anaesthetics. No local anaesthetics are free from undesirable side effects. So the search is still on for a suitable drug3. With proper training and adequate preparation side effect can be minimized. The misuse has long a bad name for an otherwise a good procedure. Such an example is Rowe & Rowe. It was a famous case in England which brought a bad name to spinal anaesthesia in England and virtually for many years the English anesthesiologists were reluctant to use this procedure. Author (MSA) met two cases of fatal over dose and two cases of sloughing of skin over penis at the penile block with local anaesthesia mixed with adrenaline by young surgeons. Recently one patient stated that she was administrated spinal anaesthesia for laparotomy for ectopic pregnancy which is absolutely contraindicated. The local anaesthetic drug has some actions on C.V.S. and C.N.S.5. So users should be ready to resuscitate a patient if any undesirable side effects on these vital systems of the body are effected.

As stated by McKenzi and Louch5 regional anaesthesia has lot to offer in orthopaedic surgery than in any other surgical specialty. They compared the spinal and epidural block with G.A in respect to blood loss, arterial oxygenation, D.V.T., mental functions and outcome of the surgery and opined that if properly administrated, regional anaesthesia is better than G.A. In orthopaedic surgery. Brachial plexus blocks are being used which has got three different approaches axillary, suprascapular, interscalene. Each approach has got its own merits and demerits but if properly applied axillary block a catheter technique are being used for long duration of hand surgery and post – operative analgesia which is of advantage in early movement of hand post operatively. This catheter technique has got another advantage during micro – vascular surgery of hand as the L.A. cause vaso – dilation and outcome of the surgery is better. Recently there is an increasing interest in intrapleural block which can be used instead of stelate ganglion blocks. Other regional blocks in orthopaedic surgery can be used are femoral, sciatic, and common peroneal block.

In G.A. theater enviornment air is being polluted by expired fluothane and other anaesthetic gases of patient which are being again inhaled by all surgeons, anaesthesiologists and other thetre users. So by using regional block this pollution is completely avoided.

In conclusion authors want to impress that regional anaesthesia is a good technique if properly used, keeping in mind those undesirable side effects on C.V.S. and C.N.S.

Local anaesthetics are readily available all around the country. It is cost effective. Surgeons should take advantage of this technique in their practice.

Reference:
Danial c. Moore: Regional block. 4th Ed. 4th Pr. Chales c. Thomas. Page – 5.
Andres Goth : Medical pharmacology: 8th Ed. : The C.V. Mosby Company, page – 363.
Louis S. Goodman and Alfred Gilman: The pharmacological Basis of Therapeutics. 5th Ed. Mcmillan publication Co. INC. 1975, page – 380.
S. Reiz & S. Nath: Cardio – toxicity of Local Anaesthetic Agents. br. J. Anaesth. 1986, 58, 736 – 740.
C. B. Scott: Toxic Effects of Local Anaesthetic Agents on The Central Nervous System. Br. J. Anaesth. 1986, 58, 732 – 735.
P. J. McKenzie & A.B. loach : Local Anaesthesia for Orthopaedic Surgery : Br. J. Anaesth. 1986, 58, 779 – 789.

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PES ANSERINUS TRANSPOSITION FOR CHRONIC ANTEROMEDIAL ROTATORY INSTABILITY OF THE KNEE JOINT: STUDY AND EVALUATION OF RESULTS OF TWENTY ONE CASE

MAJOR CHOWDHURY ISHRAQ UZ ZAMAN
MBBS (Dhaka), M.S. (Orth) (Dhaka University), Orthopaedic Surgeon,
Combined Military Hospital, Chittagong Cantonment.
A. F. M. RUHAL HAQUE
FRCS, Associate Professor of Orthopaedic Surgery, DMCH.

Between July 1989 and August 1991 the pesanserinus transposition was performed on 21 patients presenting with chronic anteromedial rotatory instability of the knee at the Rehabilitation Institute and Hospital for the Diabled (R.I.H.D.), Dhaka. The mean age of such patients was 23.67 years – corresponding to an age with a high level of physical activity. Contact sports accounted as the cause in 80.95% of the cases, of which 76.19% was due to football. The mean follow – up period was 8.49 months (longest 12.21 months, shortest 6.32 months). The overall mean of the follow – up period of other workers to which this work was compared was 52.49 months. The short follow – up interval of this study was found to have a direct bearing on its outcome. 72.22% of cases showed improvement at last follow – up (on the basis of the “Thirty point Scoring System”) as compared with 84.99% in case of all the other series combined (p<0.05). Freeing of the semitendinosus tendon for a distance more proximal than that described in the original operation by Slocum and Larson, and reconstruction with the leg in slight internal rotation in some of the patients in this study gave a better result. This, however, remains to be conclusively confirmed through studies involving a larger number of patients and with longer follow – up intervals.

MD. AMJAD HOSSAIN, MS.(Orth), Asstt. Prof., Orthopaedic Surgery, R.I.H.D., Dhaka.
A.F.M. RUHAL HOQUE, Associate Professor, Dept. of Orthopaedic Surgery, DMCH.
RAFIQUL ISLAM, MS (Orth), Jr. Consultant (cc), Sadar Hospital, Hobiganj.
MD. ZIAUDDIN, D.(Orth), Medical Officer, RIHD, Dhaka.
SHAHJAHAN, D.(Orth), Medical Officer, RIHD, Dhaka.

SUMMAY:

The term “Side Swipe Injury” which is self – explanatory for the particular type of injury in the automobile accident causing mutilating and devastating trauma in and around the elbow. Thirty five cases of side swipe injury reported to Rehabilitation institute and Hospital for disabled (RIHD) from January 1991 to July – 1993. All the victims were in young age group ranging from 10 to 40 years. Male patients were predominant 31 (88.58%) & female only 4 (11.42%). Varying degrees of skin and soft tissue involvement were present in all cases. Considering bone involvement, 80% were found to have type three open injury (Gustilo). Among them, comminuted fracture of lower end of humerus along with fracture of upper end of ulna and radius were 9 (25.73%), comminuted fracture of olecranon 4(11.45%), inter condylar fracture of humerus 4(11.43%), segmental loss of shaft of humerus 2(5.71%) cases. 3(8.57%) patients were received in emergency with their arm amputated at the site of occurance. There were 11(31.43%) case having major nerve injury. Regarding management, after a quick initial assessment, resuscitation measure were taken. Then under general anesthesia surgical toileting and debridement were done in all cases. Some sort of internal fixation was done in 18(51.42%) cases. Vascular repair was performed in two (5.91%) cases but failed, above elbow amputation done in 9(25.72%) case. Subsequent debridement were needed in 19(54.29%)cases. Split thickness skin graft was done in 26(75.29%) patients. In all these cases physiotherapy were given. All the patients left the hospital with moderate to severe form of deformity and disability.

QAZI SHAHIDUL ALAM
Associate Professor Orthopaedics, Head of the Department of Causualty,
Dhaka Medical College & Hospital, Dhaka.
MD. SERAJUDDIN AHMED
Assistant Professor, Department of Orthopaedics, Dhaka Medical College & Hospital, Dhaka.

Fractures during difficult delivery are not rare. We received 33 such cases from the Obstetric Department of Dhaka Medical College during August 1992 and February 1994 within ten days of birth. Anoxia to the baby in the prolonged second stage of labour may necessitate rapid extraction in most of the cases. No random screening were performed for all the deliveries. The fractures were diagnosed clinically and afterwards confirmed radiologically. Some of the cases were quite obvious being noticed by the mother or relatives of the new born.

One such case of fracture of the humerus was first discovered on the 10th day of delivery. Four cases were complicated by neurovascular problems presenting with big swelling at the fracture site when the bone was superfically placed.

BIPUL KUMAR DAM
Asstt. Professor, Orthopaedic Surgery, Rajshahi Medical College & Hospital, Rajshahi.
AYJAZ AHMED KHAN
Asstt. Professor, Orthopaedic Surgery, Rajshahi Medical College & Hospital, Rajshahi.
MD. TAIBUR RAHMAN
Registrar, Orthopaedic Surgery, Rajshahi Medical College and Hospital, Rajshahi.
MD. MONIRUL ISLAM
House Staff, Orthopaedic Surgery, Rajshahi Medical College & Hospital, Rajshahi.

SUMMARY:

A prospective study of 190 patietns with upper limb orthopaedic problem underwent surgery in the Orthopeadic department, Rajshahi Medical College Hospital from July 1991 to January 1993. The age limit was from 10 years to 65 years. The average onset of anaesthesia was 15 minutes and average duration of anaesthesia was one and half hours. No major complictions were observed except 3% failure of anaesthesia.

A.K.M. ESHAQUE
Former Associate Professor of Orthopaedic Surgery, Rangpur Medical College Hospital. Now Associate Professor of Orthopaedic Surgery RIHD, Dhaka.
NURUN NAHAR
Lecturer, Anatomy Department, Dhaka Medical College, Dhaka.

SUMMARY:

Ulcer produced over the sacrum involving various layers extending from skin to bone mainly due to pressure followed by some pathological changes in a paraplegic or unconscious patient is known as sacral pressure sore. 25 cases had been studied at orthopaedic department in Rangpur Medical College Hospital and private clinics from September 1990 to September 1991, male and female ratio 24:1, mean age 43:56 years and age range from 25 yrs. to 60 years. All cases were treated initially by conservative method that is excision of ulcer and daily dressing. Results were satisfactory in 10 cases. Conservative treatment failed in 15 cases. They were treated by operative method i.e. excision of ulcer and primary closer 4, Myocutaneous flap 10, skin grafting 1 and transcutaneous skin flap 1. Poor Nutrition and low general condition were the problem in all cases. Nutritional status were improved by high calorie, high protein and vitamin supplement diet. In 6 out of 10 cases of myocutaneous flap wound healed in first intention and 4 cases after control of infection. One needs skin grafting. Average results of myocutaneous flap were satisfactory. Follow up result were also good.

M. A. SAMAD
Orthopaedic Consultant, Institute of post Graduate Medicine and Research, Dhaka.
SK. N. ALAM
Assist. Professor, Rehabilitation Institute and Hospital, for Disabled (RIHD), Dhaka.
M. A. HANNAN
Assist. Professor, Rehabilitation Institute and Hospital, for Disabled (RIHD), Dhaka.

SUMMARY:

Ewing’s sarcoma is the 2nd common primary bone tumour. Diaphyseal involvement of long bones is the usual presentation. Extraskeletal occurence is also reported though not common. Blood borne metastasis usually occurs in lung. The mode of presentation from iliac bone as abdominogluteal lump has not been reported in Bangladesh. So this cases of E. Sarcoma are considered worth reporting. We have three cases of Ewing’s Sarcoma recently which presented with Abdominogluteal lump. This presentation is unusual. Outcome of Ewing’s Sarcoma is favourable if diagnosed and treated earlier. So identification in earlier stages is important. We have presented three such cases which presented unusually, diagnosed late with unfavourable outcome. The main idea of presentation is to inform the specialists about these abnormal presentation to keep the mind wide for early diagnosis of this problem.

Three cases of adult male admitted with complains of pain, swelling in Abdominogluteal region followed by high rise of temperature. Investigation shows Leucocytosis with elevated ESR. Radiology shows typical Osteolysis and Osteogenesis. Finally the biopsy confirmed the diagnosis. Excisional treatment was not possible due to excessive adhesion and involvement of vital structures. Presentation as Abdominogluteal lump arising from iliac bone is a rare occurrence. Rarity of such presentation led to report the cases.

MD. AMJAD HOSSAIN Asst. Prof. Orthopaedic, RIHD.
M.A. HANNAN Associate Prof. Orthopaedic, RIHD.
SYED ANWARUZZAMAN MS(Orth) Student, RIHD.

SUMMARY:

After the complete severence of the patellar tendon, if it is not repaired the patella migrates proximally due to the contraction of quadricaps tendon. Only the skeletal traction can bring the patella down by stretching the quadriceps muscles. In Rehabilitation Institute and Hospital for the Disabled (RIHD), Dhaka an eight months old patellar tendon injury of a youngman was treated by applying Kelikian et al1 technique & followed for more than a year. The result was found to be satisfactory.