BOS Journal - July 1999 - Volume 14, No 2

The Journal of Bangladesh Orthopaedic Society

July 1999	Volume 14, No 2
CONTENTS
EDITORIAL
1. CLINICAL RESEARCH IN ORTHOPAEDICS Geoffrey Walker FRCS, Honorary Member World Orthopaedic Concern
ORIGINAL ARTICLE
2. COMPARATIVE STUDY OF SUPRACLAVICULAR BRACHEAL BLOCK WITH OR WITHOUT ADUVANT M. C. Paul, Associte Pro&ssor of Anaesthesiology M. Rahman, Professor of Anaesthesiology. Akhtar Murshed, Assistant Professor, Orthopaedic Surgery, Bangladesh Medical College. A. K. M. Azizul Hoque, Junior consultant of Anaesthesiology. A. Sammader Peter, Anaesthesiologist. Asgari Begum, Junior consultant of Anaesthesiology, Department of Anaesthesiology, RIHD, Dhaka.
3. LIMB LEG LENGTHENING OF FEMORAL SEGMENT USING UNIAXIAL EXTERNAL FIXATOR Iqbal Qavi, Asstt. Prof. Dept. of Orthopaedic Surgery, DMCH. Rafiqul Islam, Asstt. Prof. Dept. of Orthopaedic Surgery, DMCH. A. B. M. Fazlur Rahman, Asstt. Prof. Dept. of Orthopaedic Surgery, RIHD. A. F. M.Ruhal Haque, Prof. & Chairman of Dept. of Othopaedic Surgery, BSMMU.
4. COMPARISON OF FUNCTIONAL STATUS OF KNEE JOINT BETWEEN POST-OPERATIVE MANAGEMENT WITH OR WITHOUT CAST AFTER STABLE FIXATION OF FRACTURE PATELLA Md. Faruque Quasem, MS Student (Thesis Part) Md. Reja-ul-Karim, MS Student (Part II) Ayjaz Ahmed Khan, Assoc. Professor, Ortho. Surgery, RIHD. A. H. M. S. Kamruzzaman, MS Student ( Thesis Part)
5. SURGICAL RECONTRUCTION OF CLAW TOES IN LEPROSY. M. M. Bari. Reconstructive & Orthopaedic Surgery Unit. A. Hadi. Leprosy Control Institute & Hospital, Mohakhali, Dhaka.
6. THE ILIZAROV METHOD OF TREATMENT IN NON-UNIONS, MAL-UNION FRACTURES AND DEFORMED LIMBS IN RIHD, DHAKA. Md. Mofazzel Hoque, Asst. Professor of Orthopaedic Surgery, RIHD, Dhaka. R. R. Kairy, Assoc. Professor of Orthopaedic Surgery, RIHD, Dhaka. Abdus Samad Sheikh, Director & Professor of Orthopaedic Surgery, RIHD, Dhaka.
CASE REPORT
7. FIVE YEARS FOLLOW UP STUDY OF A CASE OF UNIFOCAL EOSINOPHILIC GRANULOMA OF CLAVICLE. Partho Sarothi Shome, Associate Professor of Orthopaedic Surgery, Rangpur Medical College Hospital

Geoffrey Walker FRCS
Honorary Member World Orthopaedic Concern

This is an account of nearly 40 years involvement with clinical research in orthopaedics, which started during my general surgical training, and continued when I was learning orthopaedics. It then developed into a teaching activity within a U.K. rotating orthopaedic training scheme. During these 40 years I have also spent a considerable amount of time in the developing world, and have always been involved in promulgating to orthopaedic trainees and others the value of being involved in clinical research.

It is a result of discussing ‘why and how to do this’ with teachers and trainees that I have been asked to prepare this article, which expresses some of my personal thoughts and experiences.

What is Research?
In Orthopaedics, and in most other subjects, research can be considered as either Basic, (also known as pure or fundamental) or Clinical, although obviously there can be considerable overlap. For me Basic Orthopaedic Research is usually performed by workers who have received special training and are likely to spend the majority of their time in a laboratory or office. I have virtually no practical experience of this type of investigation, and therefore will concentrate on clinical research which usually involves spending a considerable amount of time with patients and their orthopaedic problems. Be that as it may, clinical orthopaedic research can involve co-operating with, and involvement in the work of other disciplines, and this cross fertilisation can also be very valuable for all those with shared interests but different training.

Why do Research?
While it is true that few of us are likely to make major discoveries there are several reasons why involvement in research, which for most of us is more likely to be ‘clinical’, is important:

It demands personal involvement. It is necessary to learn how ‘to think’ and to put one’s thoughts in order. It is hard work, and encourages the development of self-discipline as well as an ability or organise oneself and to learn how to co-operate with, and to encourage colleagues.

It involves learning how to read critically, and to think and to write clearly. It thus produces a critical approach to the study of publications of other authors. Preliminary searches of the literature, followed by the necessary reading is an integral part during the early and preparatory stages of any research project, and this too will broaden the mind. Of course I am aware of the difficulties of doing this really adequately in situations which lack good ‘medical libraries’, but these days there are various ‘electronic’ methods available, and it is often very surprising what can be located with persistence and an enquiring mind.

Then there is always the possibility that something of practical value may result from the study. In some ways this can be regarded as a bonus, although in fact there are few of us who have not changed our beliefs and habits as a result of reading or hearing somewhere of the result of the work of someone else!

Finally, there is the need to publish. A few interesting articles published in reputable journals, or presented at important orthopaedic meetings, does look good on a C.V., although this has probably resulted in the publication of a good deal of material which has little real value. It is always pleasant to read a C.V. which contains more than one article on the same subject, as this indicates that the author has found a project ‘to sink his or her teeth into’, and which probably has generated real interest.

Beware also of ‘multi-authored articles’. These days most publications seem to stem from several researchers, and in some countries it is customary always to include the name of the Head of the department. Personally I do not like this, and did not allow inclusion of my name unless I had actually done some of the work. It is always possible to give thanks to those who merit mention in a paragraph at the end of the article, and I believe that this should cover secretaries, librarians, and any others who have been closely involved.

How to do Research.
Finding a project. For most trainees this is one of the most difficult parts of doing clinical research, and it is only after having been actively involved with a project that one begins to ask the questions ‘WHY’, or ‘How’? Most orthopaedic departments are busy places, and young surgeons (and those more senior) are usually heavily committed to service work, and also in many parts of the world to the need to earn enough money to support themselves and their family. However, it is surprising that after having successfully completed one or more clinical research projects, others then seem to present. On ward rounds, or in clinics and operating theaters, one begins to ask oneself (and others), why does ‘such and such’ seem to happen, or ‘wouldn’t be better to try some other method of treatment’, or even ‘what will happen if I do nothing’? It is thus that new ‘projects’ often appear, and it can be helpful if teachers and others maintain a list of possible and practical subjects which might be suitable for a relatively simple ‘clinical research’, (or even do it themselves).

Case Reports. Many of us start with the publication of a solitary case report’, although this is unlikely to be accepted by a major journal unless it is something of either great rarity, or of really significant importance. However, the preparation of the article, with the necessary preliminary literature survey (one nearly always discovers previous accounts of the same condition!) is good training and the actual writing, probably at this stage with at least six drafts is also very educative. The advice and help of a senior experienced colleague is always invaluable and there is a good deal to be said for the Director of a Training Programme assigning each trainee (with their project) to a specific teacher, reviewing personally from time to time the actual progress being made. Thus everyone learns.

‘Multiple Case Reports’ are obviously more acceptable than solitary examples, and it is surprising how many ‘cases’ can be found. Colleagues often have notes and X-rays of interesting conditions filed away somewhere, so it is important to have a means of advertising what one is doing, and what one is looking for. Perhaps a notice board should be available on which are listed all the projects currently in hand, together with the names of the trainee and teacher responsible. However, it is most important that all ‘offered help’ is rapidly followed up as otherwise it is unlikely to be repeated. It is always important to demonstrate enthusiasm to one’s colleagues. During my active career I followed the idea of the late Mr. George Lloyd Roberts and kept a small note-book in which I entered the names and relevant details of all ‘interesting cases’. These little books provided the material for several relatively simple clinical research projects.

New Techniques and New Instruments. Reports of inventions and descriptions of new techniques can perhaps be included as forms of clinical research, but they usually involve work over a considerable length of time. However one does occasionally encounter a trainee who has had a novel idea, and then followed this up with relatively extensive study and development. With new operative techniques there is always the problem of ‘follow-up’ which alas in the developing world poses almost insurmountable problems. The development of external fixators is a good example of what can be done, and I have come across several interesting developments during my travels.

Studies of the Natural History of Orthopaedic Problems. This is a subject dear to my heart, as my interest in the orthopaedics of children, particularly those fortunate to live in more developed societies resulted in considerable concern, as many seemed to be being treated unnecessarily. If a virtually asymptomatic condition, such as idiopathic knock-knees of young children has an excellent natural history, with spontaneous correction occurring during growth, then surely there is no need for any specific treatment? In the past these unfortunate individuals were subjected to various forms of splintage, some quite horrific in their extent, to the devoted labours of physiotherapists, or to the use of heel wedges (and I could never remember whether these should be applied medially or laterally), when all that is required is an explanation to the family of the natural history together with firm re-assurance that all will be well with nature and the passage of time. It is however most important to have gained the confidence of the parents by listening to them attentively, and examining carefully the whole of the naked child.

The natural history of many benign conditions affecting children during growth have now been established, but there are others both in children and in adults which remain worthy of study.

The Results of Treatment. This remains a great potential source for clinical research, but BEWARE. The area resembles a mine-field. Only too often one meets a trainee who has been asked by his or her chief ‘while you are with me, I would like you to look at all the upper tibial osteotomies that I have performed, that will make a nice little research for you, and should lead to a publication which can be noted on your C.V.’ Alas this only too often leads to great disappointment after much hard work WHY?

Primarily because it will be a retrospective study, and alas the notes recorded during the treatment of the patient will prove totally inadequate for any sort of reasonable study. Some major orthopaedic journals will only consider publishing retrospect studies if they are of very special value or interest. The poor unfortunate trainee will devote much time and effort to searching for, and then studying inadequate records and will be unable to trace either the relevant x-rays or the patients. So my advice is ‘Don’t even start’? But you may have trouble with a Chief from time to time.

This leads naturally to Prospective Studies which are of much greater value, although even her the difficulties of ensuring adequate follow-up an pose very great problems. How to do these is described below.

Setting up a Clinical Research Project.
After having decided (or been instructed) to undertake a specific project, a great deal of thought and effort has to be spent in the preparatory work. If this is not done then much time is almost certain to be wasted.

It is vital to have a really clear idea of what exactly is being sought, i.e. there must be a relatively definite end point, and in fact with most clinical research projects one has a pretty good idea at a very early stage of what the final conclusion will be. It is then very important to decide what to do, and how to do it. Very often either during this preparatory stage, or during the actual work, colleagues, and sometimes oneself suggest modifications to the original plan. These should usually be avoided, and every effort concentrated on remaining on a ‘straight and narrow’ path.

Having decided what to do, and the likely result, it is vital to make as comprehensive a literature search as possible. One good way to start is by examining the references and bibliographies often given at the end of relevant chapters in standard orthopaedic text-books. These will in turn lead to other books, and to specific articles. These will have references, some of which will probably be relevant and useful. At the same time one should attack the ‘Index Medicus’, a series of large volumes containing details of the contents of virtually all articles published in the recognised journals. It is important to examine all the references which may be a all relevant, and this means searching under all the titles which might contain something of interest. When details of an appropriate and potentially useful reference are found, they should be noted in full, as if this is not done it may well become necessary to refer yet again either to the article, or to the Index, and this is very time consuming. From all this a reasonably complete list of references should have been complied. Of course these days literature searches can be made by electronic means, but in my limited experience of these, vast quantities of irrelevant information is produced, and I find it easier to follow the simpler, although more demanding route that has already been described.

Then of course it is necessary to examine, and where indicated to read the original articles and at this time to note in some detail the relevant contents, as well as noting in full the title and authors. It is at this stage that a certain degree of depression is likely to occur, as it is very likely that you will find that your project has already been done, sometimes more than once, and that really there is little reason for continuing. However it is better to become aware of this ‘bad news’ at this relatively early stage rather than after completing the clinical part of the work. If and when this does arise, it is sometimes possible to modify slightly to original project, and still end up with something worth doing. This can be a very good time to seek advice and help from senior and experienced colleagues.

Statistical advice. This is absolutely essential if numbers are going to be involved, and should be sought at an early stage. In practice it is often difficult to persuade a Statistician to recommend the inclusion of a specific number of patients in prospective clinical trials, but they can usually be very helpful if approached in a reasonable fashion. It is sometimes necessary and often wise to talk regularly with the statistical adviser during the course of the project, and it may be necessary to modify the original numbers suggested if the results begin to lean heavily in one direction or another.

Proforma. Careful production of the proforma to be used is often the Key to the whole research and the importance of this can not be over stressed. Again advice should be sought, and time spent at this task is never wasted. Thought should be given to the means to be used to correlate the final results as this too may modify the design of the proforma. For instance if punch cards are to be used, then the entries on the form should be designed as far as possible with this in mind. Much will depend on the likely number of patients or acts to be investigated. If there will only be a relative few, then details can be collected from individual proformas which are load out on an appropriate table. If there will be more, then punch cards are a very useful aid. Of course these days we all fly to computers, and their apparent magical ability to do everything for us. But again I advise caution, as in practice a computer can only produce results in relation to the value of the data which is introduced, and they certainly can not do a good deal of the hard work involved in a clinical research project.

It can be important to decide how to record even seemingly simple date such as age. Should this be noted as ‘date of birth’ or the actual age (if the patient knows this) at the time of the procedure, or at the time of the first review, or the last review, and so on? In fact it is probably best to note the date of birth, as the other details can then be calculated from this at a later stage if necessary.

Having produced the ‘Final Draft’ of your proforma it is then absolutely vital to make a trial PILOT STUDY. The result of this will almost certainly be that there will be a mass of facts noted on the bottom of the form for which no definite sections had been prepared. If the research continues in this way, it will be impossible to correlate the final results, and any idea of using the very convenient punch card system will have to be abandoned. A perfect (or nearly perfect) proforma will have only a very small section for ‘Comments’. All the other relevant information will have been noted in specific sections, or boxes, or where possible as Yes/No.

So at last you will be ready to start the actual research project, armed with all the knowledge gained from your extensive literature survey, from discussion with colleagues (a good form of advertising for relevant patients), and from your pilot proforma study. There is insufficient space here to detail all the difficulties with which you may be faced. From time to time they may seem to be insurmountable, and it is then that real determination has to be demonstrated. Good luck, and ‘keep bottom on chair’, are good axioms to follow. Your clinical research project can only be done by YOU.

Then happily one day you will have seen the last patient, or performed the final experiment, and will be faced with correlating your results. It is here that you should reap the benefit of all your preliminary hard work and preparation. If you have been using a proforma linked to a punch card system, then this stage can be relatively easy. All the relevant date needs to be collected, and if possible noted on one page. It is from this that the definitive article can be prepared, and this will need to be produced in a form suitable either for a specific journal, or for an oral presentation. This will be dealt with in a further article.

Conclusion. Clinical Research is never easy. It requires a major effort, with much ‘Thinking’ and a great deal of hard work. The rewards may not be immediately apparent, but I believe that it is a very worthwhile exercise, if only in self-discipline and self-formation.

M. C. Paul,
Associte Pro&ssor of Anaesthesiology
M. Rahman,
Professor of Anaesthesiology.
Akhtar Murshed,
Assistant Professor, Orthopaedic Surgery, Bangladesh Medical College.
A. K. M. Azizul Hoque,
Junior consultant of Anaesthesiology.
A. Sammader Peter,
Anaesthesiologist.
Asgari Begum,
Junior consultant of Anaesthesiology, Department of Anaesthesiology, RIHD,Dhaka.

ABSTRACT:
Supraclavicular 1st rib guided technique of brachial plexus block’ is very effective for upper limb surgery. Our observations were to watch effective anaesthesia for upper extremity.

Fifty male and female patients of ASA grade I and II , age ranging from 11 to 60 years were randomly selected in this study arranging in two groups. The drugs 0.5% bupivacaine and 2% lignocaine, volume not greater than 30 c.c. and exceeding the maximum safe dose were injected to the 1st rib just lateral to the subclavian artery in both groups for brachial block.

In one group (n-30) where no adjuvant used - success rate is 66.66% but in other group (n-20)where premdication peroperative sedation analgesic used -the succes rate is 100% without apprehension.

In concusion from our study, it appears that Spraclavicular Brachial block is more effective and accurate with premedication, Sedation, and analgesia.

Iqbal Qavi,
Asstt. Prof. Dept. of Orthopaedic Surgery, DMCH.
Rafiqul Islam,
Asstt. Prof. Dept. of Orthopaedic Surgery, DMCH.
A. B. M. Fazlur Rahman,
Asstt. Prof. Dept. of Orthopaedic Surgery, RIHD.
A. F. M.Ruhal Haque,
Prof. & Chairman of Dept. of Othopaedic Surgery, BSMMU.

ABSTRACT:
Callostasis following open subperiosteal, submetaphyseal corticotomy using Hofmann's external fixator was used to perform 5 femoral lengthening in five paediatric and adolescent patients (aged 8-14 years). Average gain in length was 4 cm per segment (14% of original bone length). All lengthened segments healed without bone grafting or internal fixation Healing index was 34 days per centimetre gained. Complications included pin-tract inflammation, transient knee flexion contracture, transient hip flexion-abduction contracture, varus angulation, and premature consolidation. Despite the complications, the outcome of lengthening was satisfactory.

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COMPARISON OF FUNCTIONAL STATUS OF KNEE JOINT BETWEEN POST-OPERATIVE MANAGEMENT WITH OR WITHOUT CAST AFTER STABLE FIXATION OF FRACTURE PATELLA

Md. Faruque Quasem,
MS Student (Thesis Part)
Md. Reja-ul-Karim,
MS Student (Part II)
Ayjaz Ahmed Khan,
Assoc. Professor, Ortho. Surgery, RIHD.
A. H. M. S. Kamruzzaman,
MS Student ( Thesis Part)

SUMMARY:
Total 24 cases of fracture patella after stable fixation were compared post-operatively by giving early movement of the knee without using any cast to one group and delayed movement of the knee with use of long leg posterior cast for three weeks to other group. The cause of fracture was mostly due to the road traffic accident and simple fall. Age of the patient varied from 19 to 60 years, with peak incidence at 4th and 5th decades. Mean age was 38.08 years. Both sexes were affected but males were predominent (86.11%). The average delay from time of injury to the definitive treatment was 8 days. Most of the cases were fixed by modified tension band wiring and 04 cases with additional cerclage wiring. Movement of the knee was started as soon as possible in one group as pain permitted. The other group was kept in a long posterior slab for 3 weeks.

The satisfactory (excellent and good) results in cases without cast were 75.00 and 83.33 percent in subjective and objective evaluation of the knee function, respectively. Satisfactory results using postoperative cast were 25.00 and 50.00 percent in subjective and objective evaluations of knee function, respectively.

It appeared that early movement of the knee joint prevents both intraarticular and periarticular fibrosis and also “fracture disease” as postoperative cast was not used.

So, Conclusion is that early movement at the knee joint without cast after stable fixation of the fracture patella give better functional result than those with posterior cast.

M. M. Bari.
Reconstructive & Orthopaedic Surgery Unit.
A. Hadi. Leprosy Control Institute & Hospital, Mohakhali, Dhaka.

SUMMARY:
We have operated 76 patients for correction of claw toes due to Leprosy from March 1992 to August 1999. The method used was flexor longus is cut from it insertion & attached to the tendon there.

The result were satisfactory in 66 of these cases as judged by adequate normal gait & toe positions. The follow up period ranged from 5 months to 7 years. Inadequate post- operative plaster immobilization was the reason for the result to be unsatisfactory in 10 cases.

Md. Mofazzel Hoque,
Asst. Professor of Orthopaedic Surgery, RIHD, Dhaka.
R. R. Kairy,
Assoc. Professor of Orthopaedic Surgery, RIHD, Dhaka.
Abdus Samad Sheikh,
Director & Professor of Orthopaedic Surgery, RIHD, Dhaka.

ABSTRACT:
We have reviewed a series of 20 patients treated at RIHD from Feb. 1992 to Oct. 1998 by Ilizarov circular fixator for various combination of non-union, mal-union & deformed limbs, which is caused by congenital pseudoarthrosis and poliomyelitis. We used segmental excision, corticotomy, distraction, compression, osteogenesis & gradual correction of the deformities followed by plaster and crutch walking.

There were two (02) cases of refracture & two (02) cases of delayed union some months after removal of the frame both of which healed securely in a second frame, correction of the deformity was good, occurring in the regenerated bone rather than at the original fracture site, after removal of the frame. This was associated with very slow maturation of regenerated bone in some patients. The Ilizarov method is valuable but research is needed to overcome the problems of delayed maturation of regenerated bone, living tissue exposed to the stress of gradual traction becomes metabolically active & undergoes regeneration due to active growth. Ilizarov calls this new principle the law of tension.-stress & successfully applied this method to correct a wide variety of orthopaedic problems including fracture mal-union & non-union of bones and deformed limbs.

Failure of union or deformity may be due to an inappropriate mechanical environment or to infection, whatever the cause, complicated non-union, mal-union & deformed limbs are a disaster for the patient& may give severe clinical symptoms.

Partho Sarothi Shome,
Associate Professor of Orthopaedic Surgery Rangpur Medical College Hospital

INTRODUCTION:
Histiocytosis X or Langerhan's cell histiocytosis describes a triad of disease. (1) Letterer siwe disease, (2) Hand Schuller Christian disease (3) Eosinophilic Granuloma that differ in clinical features but share the common features of focal accumulation of Langerhans cells. The cell contains the characteristic black granules which are tubular structures with dilated terminal ends gives them a tennis racquet appearance.

In Eosinophilic Granuloma the bony lesion is solitary. It consists of brownish granulation tissue containing abundant histocyte and Eosinophil with leucocytes and giant cells. Often there may be no symptom but there may be local pain with occasionally pathological fracture.Xray shows well demarcated area of radiolucency within the bone sometimes associated with marked reactive sclerosis.

Area of predilections are mainly skull bone, Rib, femur. Besides this the bone involves are the pelvis, maxilla, vertebral body (vertebra plana), clavicle & scapula, listed in order of frequency.

Operation is usually done to obtain a biopsy. If the lesion is easily accessible it may be completely excised with or without bone grafting.