The Journal of Bangladesh Orthopaedic Society

January, 1999 Volume 14, Number 1
CONTENTS


EDITORIAL
1. Surgical Treatment Of Fracture Olecranon By Tension Band Wiring
      F. H. Serajee, Assistant Prof. of Ortho Surg RIHD.
     Qazi Shahidul Alam, Prof. of Ortho. Surg. RIHD.
     Amjad Hossain, Associate Prof. of Ortho. Surg. RIHD.
2. Evaluation Of Ankle Fractures: Rigid Internal Fixation And Early Joint Movement
     Ayjaz A. Khan, Associate Professor, Orthopaedic Surgery, RIHD, Dhaka.
     Md. Faruque Quasem, Registrar, Orthopaedic Surgery, RIHD, Dhaka.
     Akhtar Murshed, Assistant Professor, Orthopaedic Surgery, Bangladesh Medical College.
     Mohammad Osman, D. Ortho.
3. Comparative Study Between Various Forms Of Allograft Bone Used In Orthopaedic Disorder
     A. K. M. Eshaque, Prof. Orthopaedic Surgery, RIHD, Dhaka.
     Qamrul Saleh, Asstt. Prof. Orthopaedic Surgery, RIHD, Dhaka.
     Md. A. Awal, Asstt. Prof. Orthopaedic Surgery, RIHD, Dhaka.
4. Comparative Study Of The Treatment Result Of Open Fractures Of The Limb Bones
     By Ilizarow Method And Traditional Methods
      Golam Kabir, Consultant, Faridpur Sadar Hospital.

5. The Management of Bone Loss of Diaphyseal Tibial Long Bones by the g.a. Ilizarov Technique
      Md. Mofakhkhaiul Bari. Assistant Professor (Ortho.) MMCH.
     A. K. M. Sayeedul Islam. Assistant Professor (Ortho.) MMCH.
     Mesbahuddin Ahmed. Assistant Professor (Ortho.) MMCH.
     Mohsinul Hossain Mazumdar. Assistant Professor (Ortho.) MMCH.
6. Results Of The Intralesional Injection Of Methyl Prednisolone With Local Anaesthetic In Tennis Elbow
     Dipankar Narth Talukder, M.S.(Orth) Junior Consultant, Orthopaedic Surgery,
     Sadar Hospital, Brahmanbaria.
     Naresh Kumar Ray, D. Orth.,M.S.(Orth) Junior Consultant, orthopaedic surgery,
     Sadar Hospital, Joypurhat.
     Gouranga Bairagi, M. S.(Orth) Junior Consultant, orthopaedic surgery,
     Dhaka Medical College Hospital.
7. Operative & Non-Oprative Management Of Theintercondylar Fracture Of Humerus Of Adult
     And Comparison Of The Evaluated Results
     Hosain Ahamed, M.B.B.S, M.S(Ortho), M. Asst. Prof. ortho, OSMC.
8. Pattern Of Trauma Patients Admitted At Rajshahi Medical College Hospital
     B. K. Dam, Assistant Professor, Orthopaedic Surgery, Rajshahi Medical College.
CASE REPORT
9. Late Recurrence Of Giant Cell Tumour Of Bone, A Report Of Three Cases
      F. H. Serajee. Asstt Prof of orth surg. R.I.H.D.
     SK. Nurul Alam. Prof of orth. surg, D.M.C.H.
     Qazi Shahidul Alam. Prof of orth. surg, R.I.H.D.



Back to Top

EDITORIAL
CHALLENG THE SILENT KILLER

F. H. Serajee
Assistant Prof. of Ortho Surg RIHD.
Qazi Shahidul Alam
Prof. of Ortho. Surg. RIHD.
Amjad Hossain
Associate Prof. of Ortho. Surg. RIHD.


Thrombo- embolic complications are a well recognized cause of morbidity & mortality in hip fracture patients ( Saizman et al 1976; Haake et al 1989, Todd et al 1995). The common belief that the thrombo-embolic events & its complications are rate in Asia, especially in our country is gradually loosing ground. This is partly because of the increased awareness among the medical profession and the public at large and also because of the availability of the diagnostic facilities. But it is worth mentioning that these facilities are not available in most parts of Bangladesh.

> It is now known that the fracture patients undergo a coagulative response at the time of the injury. So, these patients constitute a different group from patients undergoing routine surgery. Various studies have shown those patients undergoing surgery are at risk for development of venous thrombo-embolic complications, and general medical patients are also at risk. But it is beyond doubt that the orthopaedic patients carry higher risk of developing deep venous thrombosis (DVT) and its fatal complication pulmonary embolism (PE).

Some student have shown that DVT and its fatal pulmonary embolism remains that the most common cause of hospital deaths in surgical patients. PE account for 5% death of general surgical procedure and 23.7% after orthopaedic surgery. Sajzman et al in 1976, claimed that DVT may be seen in one third to half of the patients after hip fracture and without prophylaxis fatal pulmonary embolism have seen in up to 10% of the patients (Sevitt et al 1959; Todd et al 1995). Unfortunately DVT may be silent in up to 80% of cases and thus has gained the disrepute of “Silent Killer”.

> The means of diagnosis of DVT are ultrasonography & venography & still remains as the gold standard. Typically PE is unrecognized in majority of cases, revealed only by pulmonary ventilation and perfusion scintigraphic scan or by a pulmonary angiography (Andre planes et al, 1996). Tectnically these procedure are not difficult but unfortunately are not widely practiced.

A number of risk factors have been identified in regards to DVT. Surgical or non surgical trauma, immobilization, heart failure, previous venous thrombosis, myocardial infraction, paralysis of lower limb, varicose veins, obesity and peripheral thrombophebitis are some from the extended list. The patients undergoing surgery may be graded into high, moderate and low risk group according to the likelihood of suffering from DVT.

> We all agree that DVT occurs when certain changes take place in the vein like injury to the vessel wall, stasis in the flow or activation of the coagulation cascade. There have been large number of the studies looking at the various prophylactic measures against thrombo-embolic complications. These measures have been deduced from patho-physiologic considerations. These include agents such as aspirin, warfarrin, low dose low molecular weight heparin, dextran and pneumatic leg compression device.

Alterations of the venous wall, which can not be changed in trauma patients, may be attenuated during the operative procedures on the hip. Applying special elastic stockings may decrease stasis. This mode of prophylaxis is relatively effective in the group of moderate risk patients. In the high group drug therapy is also required, Drugs commonly used include un-fractionated heparin (UH) and low molecular weight heparin (LMWH). Among these two LMWH has better bio-availability in prophylactic use, it also has a longer plasma half life after sub cutaneous.



Back to Top

SURGICAL TREATMENT OF FRACTURE OLECRANON BY TENSION BAND WIRING

Dr. Kh. Abdul Awal (Rizvi)
Associate Professorof Orthopaedic surgery, RIHD, Dhaka


ABSTRACT:

We reviewed 25 patients who underwent surgical treatment for fracture olecranon by tension band writing during the year 1998.With the exception of two cases all regained almost full regained almost full range of motion, stable elbow and good extension power. Follow up ranged from 12 month to 18 months with an average of 16 months. It is our purpose to emphasise that this procedure is still a good method provided we do it carefully. RESULTS:

In over all series of 25 cases results were generally good. In 30% cases there were no loss of injection and a more stable antiocoagulant response. Therefore LMWH is clearly emerging as the drug of choice for prophylaxis in high-risk orthopaedic patients.

> As previously mentioned, in Bangladesh DVT and its complication of pulmonary embolism is often undetected in many post operative patients. This is due to the lack of awareness in many surgeons as well as a lack of facilities and resources for the diagnosing DVT. However, this condition with its fatal complications can easily be prevented by the prophylactic use of LMWH or UH. Therefore for high risk orthopaedic patients prophylactic use of these drugs should become routine practice to prevent the prophylactic use of LMWH or UH. Therefore for high risk orthopaedic patients prophylactic use of these drugs should become routine practice to prevent unnecessary mortality. Some authors have suggested that the failure to use thrombo-prophylaxis in major orthopaedic surgery could indicate medical negligence (Parker Williams et al 1991). It is also high time to conduct broad based studies of our own population and to devise guide lines for the prevention of DVT.


REFERENCES:





 Back to Top

EVALUATION OF ANKLE FRACTURES: RIGID INTERNAL FIXATION AND EARLY JOINT MOVEMENT

Ayjaz A. Khan
Associate Professor, Orthopaedic Surgery, RIHD, Dhaka.
Md. Faruque Quasem
Registrar, Orthopaedic Surgery, RIHD, Dhaka.
Akhtar Murshed
Assistant Professor, Orthopaedic Surgery, Bangladesh Medical College.
Mohammad Osman
D. Ortho.


A series of 33 ankle fractures which has been operated with small DCP for fibula and tension band wiring for medical malleolus is being presented. NO plaster was given and joints mobilized early.

> Ankle injuries are common and the goal of treatment of these fracture acitivity. Ankle fracture are now widely treated by elective internal fixation based on the philosophy that accurate restoration of anatomy must result in perfect return of function. Burwell and charnley (1965) felt that the quality of clinical outcome varied in relation to the accuracy of reduction. Hughes et al (1979) reviewed the results of three series and found that operative treatment was superior to conservative treatment.

Accepting this correlation a randomized trial of open reduction and internal fixation of the ankle fractures is being reviewed.

We had no difficulty in the fixation of the fracture of the ankle and decided to review our cases.



Back to Top

COMPARATIVE STUDY BETWEEN VARIOUS FORMS OF ALLOGRAFT BONE USED IN ORTHOPAEDIC DISORDER

A. K. M. Eshaque
Prof. Orthopaedic Surgery, RIHD, Dhaka.
Qamrul Saleh
Asstt. Prof. Orthopaedic Surgery, RIHD, Dhaka.
Md. A. Awal
Asstt. Prof. Orthopaedic Surgery, RIHD, Dhaka.


SUMMARY:

Various forms allograft bone have been used in 117 Orthopaedic cases. Comparative studies have been done to find out suitable form for grafting with minimum antigen-antibody. 32 cases of Giant cell tumour, 24 cases of anurysmal bone cyst. 20 cases of simple bone cyst. 39 cases of nonunion and 2 cases of chr.-osteomyelities have been treated with various forms allograft bone. Followup studied have been done for 4 yrs. till graft has been rejected in 25 cases. Infection seen in 20 cases. Streptococcus aurius and pseudomonas are the causative organism. 6 cases needed translocation of ulna. 5 cases needed turngraft either tibia or femur. 7 cases required amputation due to recurrence of tumour or servere infection. Maximum number of cases treated by irradiated bone showed incorporation of bone. Long follow-up showed incorporation of graft with new bone formation with good function.



Back to Top

COMPARATIVE STUDY OF THE TREATMENT RESULT OF OPEN FRACTURES OF THE LIMB BONES BY ILIZAROW METHOD AND TRADITIONAL METHODS

Golam Kabir
Consultant, Faridpur Sadar Hospital.


INTRODUCTION:

Open fractures have experienced an unsatisfactory progress healing and various complications. This problems more pressing if we bear in mind that patients suffering from open fractures of bones sustain long period of disability and often become invalid. The most serious complications are deep infections, post traumatic osteomyelities, pseudoarthrosis and contracture of joins.

> Reduction of cases can realized through solving the following most important aspects of the problem a) Characterisation and systematization of soft tissue damage, b) Problem of infection and the means to control it c) Peculiarities of skin grafting , d) Surgical tractics in treating wounds and bone fragment, means of stabilization of the bone until they become united.

A scientifically sound tactic for fragment immobilization appears to be extremely important for a successful treatment of open fractures of bones. In the treatment of open fracture of bones that the advantages of extra focal osteosynthesis become more apparent. The devices provide an immobilization of the bone fragment for the whole period of fixation which facilitates a more rapid union in condition when no massive parts of the fixation apparatus are present in the wound, thus making its healing smooth and uncoiled by microbial contamination. More over the devices improve the quality of observation over the course of healing and provide for earlier functional mobility, including rated loading of the injured limb.

> This approach allows one not only to compact the serious development of wound infection, but also to circumvent in many cases the otherwise unavoidable removal of the metal used for fixation, in this way the fracture union becomes possible. With the function of the diseased joint being retained, not only for open fracture the method of extra focal compression distraction osteosynthesis is used to treat pseudoarthrosis of the tibia, through, it is recommended for use in other localization too, in the treatment of patients with orthopaedic diseases and deformities and in the rehabilitation of post traumatic false joint and bone defects.



Back to Top

THE MANAGEMENT OF BONE LOSS OF DIAPHYSEAL TIBIAL LONG BONES BY THE G.A. ILIZAROV TECHNIQUE

Md. Mofakhkhaiul Bari
Assistant Professor (Ortho.) MMCH.
A. K. M. Sayeedul Islam
Assistant Professor (Ortho.) MMCH.
Mesbahuddin Ahmed
Assistant Professor (Ortho.) MMCH.
Mohsinul Hossain Mazumdar
Assistant Professor (Ortho.) MMCH.


ABSTRACT:

The management of segmental defects within the diaphysis of long bones is one of the most diaphysis problems that the surgeon confronts in his practice. The procedures traditionally used to bridge bone gaps include autogenous bone grafting, posterolateral bone grafting, transplantation of allograft bone & tibialisation of fibula procedures. All the above traditional method of management of bone defects somethings require surgical intervention. The treatment period is long & weight bearing may not be possible while the functional results are often less than satisfactory. Recent studies showed that the G.A. llizarov technique is a more popular than vascularised bone grafts especially for big bone defects.



Back to Top

RESULTS OF THE INTRALESIONAL INJECTION OF METHYL PREDNISOLONE WITH LOCAL ANAESTHETIC IN TENNIS ELBOW

Dipankar Narth Talukder,
M.S.(Orth) Junior Consultant, Orthopaedic Surgery, Sadar Hospital, Brahmanbaria..
Naresh Kumar Ray,
D,Orth.,M.S.(Orth) Junior Consultant, orthopaedic surgery, Sadar Hospital, Joypurhat.
Gouranga Bairagi,
M.S.(Orth) Junior Consultant, orthopaedic surgery, Dhaka Medical College Hospital.


SUMMARY:

106 patients of tennis elbow were treated with 1 c.c. Methyl Prednisolone with 1.5 cc of 2% Lignocine in RIHD, Dhaka and Sadar Hospital. Brahmanbaria in private practice between the periods of July 1996 to June 1998 who were followed up, included in this series. 6 Patients lost from the follow up and total 100 patients were included in the study. Out of the 100 patients 75 patients (75%) cured by single dose of mixture of Ic.c Inj. Methy1 Prednisolone and 1.5 c,c 2% Inj. Lignocaine locally under the origin of the wrist extensors especially under extensor carpi radialis brevis. 20 patients (20%) cured after two injections with six weeks interval. 4 patients (4%) required three injections. 1 Patient (1%) responded satisfactorily with 3 injections but experienced mild to moderate pain in griping.

> The Patients were followed up 6 months to 2 years (average mean 8 months). Age range of patients were 30 to 60 years (average mean 45 years). Sex incidence was female 53% and male 47%. Prevalence of the disease was found to be more common among the house wives (42%) and manual workers (38%). Patients with uncontrolled diabetes and calcification over the lateral epicondyle from this series.

All patients were assessed clinically and improvements in the particular clinical variables e.g. pain score, weight lifting and grip strength. No remarkable side effects were found in any of the cases except all patients experienced moderate to severe pain inspite of taking analgesic in the first day of injection. All patients were treated with NSAIDS for 2 weeks and advised for wrist stretching exercise. The patients with hyperuricemia were treated with allopurinol 100 mg (Tab. Esluric) for at least 6 weeks and dietary restreiction advised of purine containing diets followed by injections of Methy1 Prednisolon mixed with local anaesthetic responded well.



Back to Top

OPERATIVE & NON-OPRATIVE MANAGEMENT OF THEINTERCONDYLAR FRACTURE OF HUMERUS OF ADULT AND COMPARISON OF THE EVALUATED RESULTS

Hosain Ahamed,
M.B.B.S, M.S(Ortho), M. Asst.Prof. ortho, OSMC.


ABSTRACT:

In this paper we describe a series of twenty nine intercondylar fracture of humerus which were treated by open reduction and internal fixation in group –I & II treated by olection traction over period of 2 years. The fracture patterns were classified according to system of Resiborugh & Radine and strike rating scale incorporating, subjective data, objective motion and functional motion of the involved elbow was used for the result. At a mean follow up 14 months, Five (35.7%) cases result were rated excellen, four (28.57%) as good three (21.42%) as fair and two as poor in group-I. In group –II no case was rated excellent four (33,4%) cases were rated as good. five (41.6%) cases as fair & remaining three cases as poor. Complication included post operative ulnar nerve palsy one (16-6) case, two (13.3) myositis ossificance and superficial stitches infection in two (13.3%) cases and three (21) cases showed pin tract infection. The results of two group were evaluated and compared.



Back to Top

PATTERN OF TRAUMA PATIENTS ADMITTED AT RAJSHAHI MEDICAL COLLEGE HOSPITAL

B. K. Dam
Assistant Professor, Orthopaedic Surgery, Rajshahi Medical College.


ABSTRACT:

A retrospective study of 956 patients admitted in Orthopaedic Department of Rajshahi Medical College Hospital are treated by various methods. Among these trauma victims 68.20% were the victim of Road traffic accidents, 16.31% were that of home injury, 10.04% are trauma by human violence and 5.43% are the victim if fall from height.



Back to Top

CASE REPORT
LATE RECURRENCE OF GIANT CELL TUMOUR OF BONE, A REPORT OF THREE CASES


F. H. Serajee
Asstt Prof of orth surg. R.I.H.D.
SK. Nurul Alam
Prof of orth. surg, D.M.C.H.
Qazi Shahidul Alam
Prof of orth. surg, R.I.H.D.


ABSTRACT:

We report 3 Cases who had a local recurrence eight to twelve years after curettage and bone grafting of Giant Cell tumber of bone. It is our purpose to point out that although most of Giant Cell tumour of bone are expected to recur within the first two years some patients remain at risk for a much longer period.