BOS Journal - January, 1996 - Volume 11, Number 1

The Journal of Bangladesh Orthopaedic Society

July, 1996	Volume 11, Number 2
CONTENTS
EDITORIAL 1. Management of open Fracture in the Emergency Operation Theatre at RIHD, Dhaka Dr. Ayjaz Ahmed Khan, Associate professor of Orthopaedics, RIHD, Dhaka.
2. Evaluation and Comparison of The Results of old Tendoachilles Reconstruction by Bosworth and V – Y plasty Technique A. F. M. Ruhal Haque, Prof. of Orthopaedic Surgery & Project Director, RIHD., Dhaka. Anwarul Azim, Medical Officer, Orthopaedic Surgery Deptt. C.M.C.H. Golam Kibria, Medical Officer, R. I. H. D., Dhaka.
3. Outcome of Vascularized Fibular Graft for the Management of Upper Tibial Nonunion M. A. Samad, Asstt. Prof. of Orthopaedic Surgery, RIHD, Dhaka. M. Habibur Rahman, Consultant, Physical Medicine Dept. IPGMR, Dhaka. M. A. Hannan, Prof. of Orthopaedic Surgery, RIHD, Dhaka. Kh. A. Awal Rizvi, Assoc. Prof. RIHD, Dhaka.. A. Md. Shamimul Haque, Registrar (Orthopaedic, Surgery), SSMC, Mitford Hospital, Dhaka.
4. A Comparative Study Between Conservative and Operative management of Supracondylar Fractures of Femur in Adults Md. Iqbal Qavi, Jr. Consultant (cc), RIHD, Dhaka. Rafuqul Islam, Jr. Consultant (cc), Dhaka Medical College Hospital. A. Md. Shamimul Haque, Registrar (Ortho) Sir Salimullaha Medical College Mitford Hospital, Dhaka.
5. Results of intrathecal infiltration of steroid (Methylprednisolone) in de Quervains diaease M. A. H. M. Jafar. Associate Professor & Head, Department of Orfthopaedic Surgery. M.A.G. Osmani Medical College, Sylhet.. S. M. Idris Ali. Junior Consultant, Department of Orfthopaedic Surgery. M.A.G. Osmani Medical College, Sylhet. Md. Aftabuddin. Department of Cardio Thoracic Surgery, ICVD, Dhaka.
6. Reconstruction of Neglected Patellar Tendon Injury by Doublle Breasting of Tendon, Augmented with Quadricep Apponeurosis Abul Khair Mohammad Eshaque, Professor. Orthopaedic Surgery, IPGMR, Dhaka. Abu Md. Shamimul Haque, Registrar (Ortho – Surgery), SSMC & Mitford Hospital, Dhaka.
7. Clean Routine Orthopaedic Operations in Diabetic Patients – our Experience in BIRDEM Hospital M. K. I. Quayyum Choudhury, Consultant, Department of Orthopaedic and Traumatology, BIRDEM, Hospital, Shahbagh, Dhaka. Anwar Ahmed, Registrar, Department of Orthopaedic and Traumatology, BIRDEM, Hospital, Shahbagh, Dhaka.
8. Effect of Ultrasound Therapy on Tennis Elbow – A Study on 44 Cases Md. Hilalul Islam, Dept. of Physical Medicine, IPGMR, Dhaka. M. Habibur Rahman, Dept. of Physical Medicine, IPGMR, Dhaka. M. M. Zaman, Dept. of Physical Medicine, IPGMR, Dhaka. M. A. Samad, Dept. of Orthopaedic Surgery, IPGMR, Dhaka.. Ahsan Ullah, Dept. of Physical Medicine, IPGMR, Dhaka. M. Q. Islam, Dept. of Physical Medicine, IPGMR, Dhaka.
9. History of Self – Stabilizing Bone Graft Implants For Arthrodesis of the Spine George Bagby. M. D. ABSS, Spokane, WA – USA.
10. Chondromyxoid Fibroma – A case Study S. M. Idris Ali, Consultant Orthopaedic Surgery, MAG Osmani Medical College Hospital, Sylhet. Assoc. Prof. & Head of the Department of Orthopaedic Surgery, MAG Osmani Medical M. A. H. M. Jafar, College Hospital, Sylhet. Kazi Md. Selim, Consultant Orthopaedic Surgery, MAG Osmani Medical College Hospital, Sylhet.

MANAGEMENT OF OPEN FRACTURE IN THE EMERGENCY OPERATION THEATRE AT RIHD, DHAKA
Dr. Ayjaz Ahmed Khan
Associate professor of Orthopaedics, RIHD, Dhaka.

There is no denying the fact that the emergency department of R.I.H.D.Dhaka is facing the major bulk of the traumatic orthopaedic patients of the country. From the practical point of view, daily 20-35 patients crowded in this hospital for emergency operation. Maximum bulk of them are from roadtraffic accident, gunshot bomb blast injury, fall from height and social chaos. Few percentages are associated with or without spinal injury.

> Male supremes than that of female. Most of the working class of people are the victims of these unfortunate catastrophes. Polytrauma patients are about one third of the bulk (International study shows 30%) Pelvic frectures are abut 10% (which is about 20% in henopy country centre USA).

Deaths are mostly due to pelvic and head injury following shock due to haemorrhage as patient come late from distant jurisdiction.

According to Gastillo types multidirfection polyirame patients are as follows

Type I accounts 25%

Type 11 – 42%

Type 111
A – 20%
B – 10%
C – 3%

Most eciting factors for death after admission are haemorrhage and crush injury. In the emergency department, patients are received by E.M.O., most of them are having post graduate degree in orthopaedics and few having post graduate training in trauma management. Management of the patients includes reception at the emergency department, examination, pereneral infusion as per need, pain killer, splintage, bandaging and skiagram of the patients tetanus toxoid, TIG & antibiotics are given accordingly to the patients.

> After assessment, resuscitation and radiological survey they are being sent to emergency operation theatre situated at the same floor.

One or two students (doing post graduation) students are engaged in emergency operation round the clock and they are for 24 hrs in O.T shift duty for 6 units in the hospital, namely – yellow, blue, white, brown, red and green. The students are being helped by clinical assistant, registrar, assistant & associate professor and professor in head. For managing of clame open fracture dislocation and major surgery general anaesthesia is being given.

> Adequate irrigation done by boiled water & then normal water and normal saline repeatedly in addition of antiseptic solution like choorohexidine and prvidone iodine. When required, stabilisation of the fracture done mostly by nailing and ‘K’ wire or steinman pin.

Thorough excision of the devitalised tissues done if needed including skin fascia, muscle, tendon, ligament, periosteum and bony tissues. Long or short plaster of paris slab, and frequently full plaster with window done for subsequent wound dressing. External fixators are also being used. The patient who need prolong treatment are kept admitted in hospital and others are discharged for home with advice to come in the out patient department for subsequent follow up.

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EVALUATION AND COMPARISON OF THE RESULTS OF OLD TENDOACHILLES RECONSTRUCTION BY BOSWORTH AND V – Y PLASTY TECHNIQUE

A. F. M. Ruhal Haque
Prof. of Orthopaedic Surgery & Project Director, RIHD., Dhaka.
Anwarul Azim
Medical Officer, Orthopaedic Surgery Deptt. C.M.C.H.
Golam Kibria
Medical Officer, R.I.H.D., Dhaka.

SUMMARY:

A prospective study was done at RIHD to evaluate and compare the results of old tendoachilles reconstruction by Bosworth and V – Y plasty technique from February 1994 to December, 1995. Out of 12 cases reconstruction by Bosworth technique was done in 6 cases and reconstruction by V – Y plasty technique was done in 6 cases. Young patients between 16 to 48 years of age minimum of 3 weeks and maximum 32 weeks old tendon Achilles ruptures were included in the series. Fresh cases, partial urptures, age above fifty were not included. All were male patients. 7 patients had a history of assault by sharp weapon, 3 patients had spontaneous rupture. Out of 3 spontaneous rupture cases 2 had history of local steroid infiltration for other purposes. After operation above knee immobilisation was done for 6 weeks and below knee immobilisation was done for another 6 weeks. After 12 weeks plaster was removed and patients were evaluated clinically the patients were given 3 to 5 cm heel lift for 1 to 3 months. In the follow up, patients were evaluated by the power of planter flexion, wasting of the calf thickness of the tendon & ability to stand on tip toe on the affected side. Regarding complications wound infection was found in 2 cases (33.33%) in Bosworth technique & 1 case (16.66%) in V – Y plasty technique, Rupture did not occur in the series.

M. A. Samad
Asstt. Prof. of Orthopaedic Surgery, RIHD, Dhaka.
M. Habibur Rahman
Consultant, Physical Medicine Dept. IPGMR, Dhaka.
M. A. Hannan
Prof. of Orthopaedic Surgery, RIHD, Dhaka.
Kh. A. Awal Rizvi
Assoc. Prof. RIHD, Dhaka.
A. Md. Shamimul Haque
Registrar (Orthopaedic, Surgery), SSMC, Mitford Hospital, Dhaka.

SUMMARY:

For the management of upper tibial nonunion of post – traumatic origin, six patients were treated with Vascularized fibular graft (VFG) operation at IPGMR & Samarita Hospital, Dhaka between the period of January 1994 to June 1996. After 3 months of operation, clinical and radiograph showed satisfactory bony union among all the cases. From the result it can be concluded that in the management of upper tibial nonunion VFG operation plays an important role for promoting the bony union.

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A COMPARATIVE STUDY BETWEEN CONSERVATIVE AND OPERATIVE MANAGEMENT OF SUPRACONDYLAR FRACTURES OF FEMUR IN ADULTS

Md. Iqbal Qavi
Jr. Consultant (cc), RIHD, Dhaka.
Rafuqul Islam
Jr. Consultant (cc), Dhaka Medical College Hospital.
A. Md. Shamimul Haque
Registrar (Ortho) Sir Salimullaha Medical College Mitford Hospital, Dhaka.

SUMMARY:

A prospective study was carried out at the Rehabilitation Institute and Hospital for the Disabled (R. I. H. D.), Dhaka, during the period September 1992 to 1994 to evaluate and compare the results of conservative and operative management of closed supracondylar fracture of the femur in the adults. During this period, a total of 20 patients were randomly allocated into two groups. Ten patients were treated by upper tibial traction in Braun – Bohler splint followed by plaster cast (Group – 1) and 10 were treated by open reduction and internal fixation by blade plate followed by plaster cast (Group – II). The mean age of such patients was 40.75 years. Road traffic accidents accounted as the cause in 75% of the cases. The mean follow up period was 11.7 months. In the undisplaced and displaced supracondylar fractures, open reduction and internal fixation was preferable and affords a superior result, provided a good anatomical reduction and rigid internal fixation is achieved. The communited supracondylar fractures are technically very difficulty in fractures. Accurate concluded anatomical reduction and rigid internal fixation in most instances is not possible. Because of these difficulties in operative procedures and poor functional end result, it is concluded that communited fracture should be treated by conservative method.

M. A. H. M. Jafar
Associate Professor & Head, Department of Orfthopaedic Surgery. M.A.G. Osmani Medical College, Sylhet.
S. M. Idris Ali
Junior Consultant, Department of Orfthopaedic Surgery. M.A.G. Osmani Medical College, Sylhet.
Md. Aftabuddin
Department of Cardio Thoracic Surgery, ICVD, Dhaka.

SUMMARY:

One hundred seventy five patients of de – Quervains disease (Tenosynovitis of abductor pollicis longus and extensor pollicis brevis) were studied in this series with corticosteroid (methyl predinisolone) injection infiltrated locally into the synovial sheath, not in tendon or bony tissue. These patients were followed 6 months to 4 years (mean average 2 years). Age ranged of the patients were 30 years to 52 years (mean average 38 years). Sex incidence; Men 17(9.71%) women 158(90.28%). Patients with osteoarthritic changes and irregularities in the radial styloid were excluded from this series. All patients were assessed clinically based mainly on Finklesteins test. X – ray was done to exclude any bony changes in the styloid or wrist joint. 164(93.71%) patients cured after three injections. 11(6.29%), patients not responded fully, only 25% of complaints were not mixed with corticosteriod with the apprehension of incompatibility and infection. Mostly middle aged female of lower or middle class family are affected 7,9. The patients with articular or bony changes were advised to be treated with nonsteriodal anti inflammatory drugs (NSAID) and surgical splitting of the stenosed tendon sheath.

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RECONSTRUCTION OF NEGLECTED PATELLAR TENDON INJURY BY DOUBLLE BREASTING OF TENDON, AUGMENTED WITH QUADRICEP APPONEUROSIS

Abul Khair Mohammad Eshaque,
Professor. Orthopaedic Surgery, IPGMR, Dhaka.
Abu Md. Shamimul Haque,
Registrar (Ortho – Surgery), SSMC & Mitford Hospital, Dhaka.

SUMMARY:

10 cases of neglected cut injury of patellar tendon have been treated by doublle breasting of patellar tendon without disturbing its fibrous union. It is then re – strengthened by Quadricep Apponeurosis. Tension – wire have been given in 4 cases to give early mobilization of knee joint. All cases are adult and have history of assault. Initial treatment they have received at local hospital. Where soft tissues have been sutured without touching the tendon. Age of injury varies from 2 to 3 months. Mean age is 2.19 months. 3 cases have developed post – operative infection. Staphy Lococcus aureus is the causative organism. Infection has been controlled within 7 to 10 days except one, which took 5wks to control.

> Two years is the minimum follow up and 5 years is the maximum follow up. All cases have good knee movement with normal muscle power.

M. K. I. Quayyum Choudhury,
Consultant, Department of Orthopaedic and Traumatology, BIRDEM, Hospital, Shahbagh, Dhaka.
Anwar Ahmed,
Registrar, Department of Orthopaedic and Traumatology, BIRDEM, Hospital, Shahbagh, Dhaka.
Md. Saidur Rahman,
Asstt. Registrar, Department of Orthopaedic and Traumatology, BIRDEM, Hospital, Shahbagh, Dhaka.
Md. Osman Goni,
Syed Musharof Hussain,
Medical Officer, Department of Orthopaedic and Traumatology, BIRDEM, Hospital, Shahbagh, Dhaka.
Md. Kamrul Ahsan,
Medical Officer, Department of Orthopaedic and Traumatology, BIRDEM, Hospital, Shahbagh, Dhaka.

SUMMARY:

The first 100 clean routine operations performed in a newly established Orthopaedic Department of BIRDEM Hospital have been reviewed to determine the rate of post – operative infections and problems of wound healing in the diabetics (group – I) and the non – diabetics (group – II).

> No significant difference was found between the two groups(P>0.1). This finding should not be confused with operations for diabetic infections and gangrenes where infection pre – exists. The purpose of this study is not to encourage operations in diabetics but to stress on the fact that if there is an indication, a clean routine orthopaedic operation in a diabetic person in a tertiary care hospital probably does not bear much more risk than a non – diabetic person. Of course more study is still necessary.

Md. Hilalul Islam
Dept. of Physical Medicine, IPGMR, Dhaka.
M. Habibur Rahman
Dept. of Physical Medicine, IPGMR, Dhaka.
M. M. Zaman
Dept. of Physical Medicine, IPGMR, Dhaka.
M. A. Samad
Dept. of Orthopaedic Surgery, IPGMR, Dhaka.
Ahsan Ullah
Dept. of Physical Medicine, IPGMR, Dhaka.
M. Q. Islam
Dept. of Physical Medicine, IPGMR, Dhaka.

SUMMARY:

To see the effect of therapeutic ultrasound on tennis elbow, a prospective study was done in Dept. of physical Medicine, IPGMR, Dhaka between the period from January 1995 to December 1995. Out of 44 patients with tennis elbow or lateral epicondylitis 22 were randomly allocated to receive ultrasound treatment and 22 given placebo. All 44 cases were given 12 doses of treatments at a rate of two doses per week. The conditions of 13 patients (59.09%) treated with ultrasound and 6 (27.27%) given placebo recovered completely. Improvement in the particular clinical variables (pain score, weight lifting, grip strength) also showed an advantage for the patients given ultrasound treatment.

> Ultrasound enhanced recovery in most patients with lateral epicondylitis or tennis elbow & results were statistically sighificant.(P<0.01).

HISTORY OF SELF – STABILIZING BONE GRAFT IMPLANTS FOR ARTHRODESIS OF THE SPINE
George Bagby,
M. D. ABSS, Spokane, WA – USA.

There is gross historic material on bone grafting for bone healing covering the areas of fracture healing and peripheral joints of the body as well as the spine. They involved such as rods, plates screws, pins, wires and cages. There is a gross difference categorically in that all of the early implants were for stabilization only and separate surgery is needed to carry out preparation of the bone surfaces for anatomic reasons and for encouraging bone growth. For clarity the latter consists of creating iatrogenic surface fractures (except in acute traumatic fractures) and may or may not include bone graft material from elsewhere. A second incision is usually needed for this “bone graft material” and in some cases may equate to significant trauma such as dowels from the ilium and rectangular strips from the tibia. Fragments taken from the ilium through a trocar is less traumatic.

CHONDROMYXOID FIBROMA – A CASE STUDY
S. M. Idris Ali
Consultant Orthopaedic Surgery, MAG Osmani Medical College Hospital, Sylhet. Assoc. Prof. & Head of the Department of Orthopaedic Surgery, MAG Osmani Medical
M. A. H. M. Jafar
College Hospital, Sylhet.
Kazi Md. Selim
Consultant Orthopaedic Surgery, MAG Osmani Medical College Hospital, Sylhet.

INTRODUCTION:

A rare variety of bone tumour in uncommon site is presented here. A Forty year old man presented with a huge swelling of right forearm which was clinically diagnosed as case a of fibrosarcome but biopsy revealed chondromyxoid fibroma.

> Before taking biopsy the tumour was painless but after biopsy the patient started complaining of severe pain with clinical agressiveness of the mass. Though it is one of the benign bone tumour but by consideration the agressiveness of the tumour and to avoid the hazards of limb salvage operation, above elbow amputation was performed. The recurrence is more that 50% which ultimately required amputation latter on.