31 (2) 2016 - bosbd.org

Ortho-Make (January 2016 Vol 31 No. 2) 1

Published by

BANGLADESH ORTHOPAEDIC SOCIETY

The Journal of

Bangladesh Orthopaedic Society (JBOS)

The Journal of


JOURNAL COMMITTEE 2016 - 2018

Chairman Prof. Ramdew Ram Kairy

Editor : Dr. Md. Golam Sarwar

Associate Editor : Dr. Mohammad Mahfuzur Rahman

Assistant Editor : Dr. Mohammad Moazzam Hossain

Dr. Maftun Ahmed

Members : Dr, Monaim Hossen

Dr. Md. Wahidur Rahman

Dr. Md. Jahangir Alam

Dr. Kazi Shamim Uzzaman

Dr. Mohammad Khurshed Alam

The Journal of Bangladesh Orthopaedic Society is

published twice in a year in the month of January and July.

Articles are received throughout the year in the office of

BOS, NITOR, Dhaka. Acknowledgement receipt may be

taken from the office. Letter of acceptance will be given on

demand after initial scrutiny of the paper by the Journal

committee. If any paper is found to be copied, pirated or

not a genuine works as claimed by the author, will be

discarded automatically without information. Authors are

requested to follow the instructions outlined below:

Preparation of manuscript:

Manuscript should be typed on white A4 size paper with

liberal margins and double spacing and on one side of the

paper only. Pages are to be numbered consecutively

beginning with the title page & not exceeding six (6) pages.

Title page:

The title page should contain the title of the study of

investigation and abstract, mentioning basic procedures,

main findings, principal conclusions and keywords.

Text:

The text of the article should be divided into introduction,

materials & methods, results, discussion and conclusion.

Tables & Illustrations:

Each table or illustration is to be typed on a separate sheet

& numbered in roman numbers & attached at the end of

the text.

Photographs should be clear, glossy and in black & white

preferably. Top of the picture should be indicated by arrow

sign (T). Diagrams & graphs are to be drawn by jet black

ink or printed by laser printer in white sheet.

References:

References are to be numbered consecutively in the order

in which they appear in the text. The form of references

should be as per examples below:

a) References for journal:- References should be written

according to the following sequenceauthors name,

topic, name of the journal with year of publication,

INFORMATION TO CONTRIBUTORS

volume number, page numbers e.g: Ratliff ABC.

Truamatic Separation of the upper femoral epiphysis

in Children. J.B.J.S. (Br.) 1968. 5013:57507-70.

When there are seven authors or more the first three

names will be listed & then the word ‘et. al’ to be

added.

b) References for Complete books:

Sequence for references are - authors name, name of

book, number of edition, Publishers name, Year of

Publication, Page e.g: Adams J.C. Outline of

Orthopaedic. 9th edition Churchill Livingstone

1981. 347.

c) Reference of articles of Magazines

Sequence of reference are - authors name, name of subject,

name of magazine, year & date, Pages e.g: Zachary R.B.

Result of nerve suture M. Seddon H.S. Ed. Peripheral Nerve

injuries. MRC Special Report Series No. 282. London. 1954

3 5c4-88.

Authors may submit the article composed in Microsoft

Word as in the journal format in two columns with pictures

and diagrams. 3 copies of printed article to be submitted at

Bangladesh Orthopaedic Society office along with soft

copy composed in Microsoft Word in a CD or data can be

transferred by pendrive or by e-mail. Original copies &

digital photos in JPEG format to be attached in a separate

folder.

Articles are accepted for Publication on the condition that

they are contributed solely to this journal.

Address of Bangladesh Orthopaedic Society Office:

National Institute of Traumatology & Orthopaedic

Rehabilitation (NITOR)

Sher-e-Bangla Nagar, Dhaka-1207, Bangladesh.

Tele-Fax: +88 - 02 - 9135734

PABX: +88 - 02 - 9144190-4, Ext-280

Mobile: +88 - 01917-665140

web: www.bosbd.org

e-mail: [email protected],

FORWARDING LETTER FOR SUBMISSION TO JBOS

Date.................................................................................

To

The Editor

Dr. .....................................................................................................................

The Journal of Bangladesh Orthopaedic Society (JBOS)

Sub: Submission of manuscript

Dear Sir,

We are submitting our manuscript entitled, ........................................... by, ........................................... 1, ..........................................

2, ......................................... 3, ......................................... 4, .......................................... 5. for publication in your journal. This

article has not been published or submitted for publication elsewhere.

We believe that this article may be of value to medical professionals engaged in Orthopaedic Surgery & related

subjects/................................... We are submitting 3 copies of manuscript along with an electronic version (CD).

We therefore, hope that you would be kind enough to consider our manuscript for publication in your journal as

original / Review article / Case Report.

Thanks and best regards

(2)

Associate Professor,

Department of ......................................... BSMMU/NITOR/

Medical College. .............................

(1)

Professor,


Medical College. .............................

(3)

Assistant Professor


Medical College. .............................

(4)

Consultant /.........................................../..................................

.....................................................................................................

....................................................................................................

Date : .................................................

To

...........................................................................................

...........................................................................................

...........................................................................................

...........................................................................................

Subject : Acceptance of the Article for publication

Dear Author

Your article Titled “...................................................................................................................................”

has been accepted for publication by the Editorial Board of the The Journal of Bangladesh Orthopaedic

Society (JBOS)

Your article will be published in any of the coming issues.

Thanking you.

...........................................................

Editor

The Journal of Bangladesh Orthopaedic Society (JBOS)

The Journal of


CONTENTS

ORIGINAL ARTICLES

l Evaluation of Vitamin D Status among Doctors of a Specialized Hospital in Bangladesh 80

Syed Shahidul Islam, Md. Abdul Gani Mollah, Mohammad Mahfuzur Rahman, Md. Alimur Reza,

Monaim Hossen, Md. Wahidur Rahman, Md. Jahangir Alam, Susmita Islam

l Evaluation of Closed Reduction of Shoulder Dislocation with or without Avulsion Fracture of 85

Greater Tuberosity of Humerus in Adult

Md. Nazrul Islam, MAK Shamsuddin, Md. Rezaul Alom, Nazmul Huda

l Percutaneous Plate Fixation in the Management of Distal Diametaphyseal Tibia Fracture 88

Md. Sofikul Islam, Ahmed Asif Iqbal, Zahidur Raman, Kazi Mainur Rahman

l Proximal Femoral Locking plate in Unstable Extracapsular Proximal Femoral Fractures: 93

A Retrospective Analysis

Md. Kamruzzaman, Shakawat Hossai, Tanvir Hossain, MA Sabur

l Total Knee Arthroplasty In Patients With Fixed Flexion Deformity 97

Abdus Salam, Golam Sarwar, Tanvir Hasan, Mohammad Moazzem Hossain, Riad Majid

l Evaluation of Result of Treatment of Epidural Steroid Injection in Lumbar Radiculopathy 103

Apel Chandra Saha, Muhammad Awlad Hossain

l Evaluation of the results of decompression and stabilization of traumatic lower cervical incomplete 107

spinal injury by cervical plate and screw

Abdur Rob, AKM Zahiruddin, Shakawat Hossain, Riad Majid, Abdul Khaleque,

Mohammad Mahbubur Rahman Khan, Ripon Kumar Roy

l Outcome of Surgical Management of Cauda Equina Syndrome in Combined Military 111

Hospital (CMH), Dhaka

Md. Salim-Ur-Rahman, S.M. Iqbal Hossain, Saihan Arefin Rony, Mohd. Reza-ul-Karim,

Md. Al Amin Salek, Md. Aminul Islam, RU Chowdhury

l Experience in the Management of Cases of Neglected Ruptured Achilles Tendon Repair in 114

Community Based Medical College Hospital

Md. Saiful Islam, Md. Tufael Hossain, Md. Nasir Uddin, Md. Anwarul Hoque,

Mamunur Rashid Chowdhury, Md. Sabbir Hasan

l Study of Serum Cholesterol and Serum Creatinine Level In Polytraumatic Patient 122

Farzana Khondoker, Md. Anisur Rahman, Major Tohmina Aktar, Afreen Ferdous

l Bacteriological Study of Surgical Site Infection Following Emergency Abdominal Surgery 126

Shahidul Huq, Prabir Chowdhury, Farhana Mahmood, Mohammad Sanaullah, Md. Jalal Uddin

THE JOURNAL OF BANGLADESH ORTHOPAEDIC SOCIETY

VOLUME 31 NUMBER 2 JULY 2016

l Audit of Anaesthetic Management for Total Hip Replacement with Ankylosing Spondylitis in NITOR 131

Nasir Uddin Ahmed, Suhel Ahmed, Nuzhat Nadia, Golam Sarwar, Abdus Salam, M A Gani Mollah

l Evaluation of the Treatment of Closed Tibial Diaphyseal Fracture by SIGN Interlocking 134

Intramedullary Nail in Adults

Md. Ferdous Rayhan, Manjurul Haque Akanda Chowdhury, Md. Abdus Sabur, Jibananda Halder,

Mir Shahidul Hasan, Md. Mohoshin Sarker

l Intertrochanteric Fracture Fixation in a Patient with Below-knee Amputation Presents 138

A Surgical Dilemma: A Case Report

Md. Kamruzzaman, Shamol Chandra Debonath, Syed Golam Samdani, Hamidul Islam,

S.M. Shakawat Hossain

l Innovating Minimally Invasive Retrograde Tibiotalocalcaneal Arthrodesis using SIGN Nail 141

S. Anwaruzzaman, M. Asraf Ul Matin, M. M. R. Bhuiyan

l Glomus Tumour Excision by Nail Sparing 146

Jahangir Alam, Md Mohiuddin, Mohammad Mahfuzur Rahman, Manosh C, Raqiub Monjoor,

Sajedur Reza Faruquee, Malay Kumar Saha

Original Article

1. Professor of Ortho Surgery & Academic Director, NITOR

2. Professor of Ortho Surgery & Director of NITOR

3. Medical Officer, Department of Ortho Surgery, BSMMU, Dhaka

4. Deputy Manager, DMA, Beximco Pharmaceuticals Limited

5. Associate Professor, Ortho Surgery, NITOR, Dhaka.

6. Lecturer, Physical Medicine, NITOR, Dhaka

Correspondence: Dr. Syed Shahidul Islam, Professor of Ortho Surgery & Academic Director, NITOR, Dhaka

Syed Shahidul Islam1, Md. Abdul Gani Mollah2, Mohammad Mahfuzur Rahman3, Md. Alimur Reza4,

Monaim Hossen5, Md. Wahidur Rahman5, Md. Jahangir Alam5, Susmita Islam6

ABSTRACT

Vitamin D deficiency is now recognized as a widespread phenomenon, even in a sunny country likeBangladesh.

Physicians may be vulnerable to low vitamin D levels due to long work hours and lack of sun exposure.This study

sought to determine the prevalence of vitamin D deficiency and its relationship with sociodemographic

characteristics among doctors of a specialized hospital in Bangladesh. This cross-sectional study involved 157

doctors who were present in the hospital at the day of examination and were willing to take part in the study.

Levels of 25-hydroxyvitamin D [25(OH) D] were measured and other sociodemographic characteristics were

recorded according to detailed study criteria. Vitamin D deficiency was defined as serum 25(OH) D levels below

20 ng/mL.The prevalence of vitamin D deficiency was present in 89.8% of the entire study population. The prevalence

of vitamin D deficiency was significantly lower in those aged more than 45 years than those aged less than 30

years (77.3% & 94.3% respectively; p-value 0.003). Participants who had history of vitamin D supplementation had

significantly lower percentage of vitamin D deficiency than those who had no such history (80% and 95.1%

respectively; p-value 0.005). Vitamin D deficiency is prevalent among the doctors of tertiary care hospital and is

largely attributed to obesity, female sex, smoking, hypertension and CHD. History of Vitamin D supplementation is

a strong protective factor for vitamin D Deficiency.Considering that vitamin D deficiency is very common in all age

groups and that only few foods contain vitamin D, supplementation might be considered at suggested daily intake

and tolerable upper limit levels, depending on age and clinical circumstances.

Keywords: Vit-D Status, Doctors, Specialized Hospital

Evaluation of Vitamin D Status among

Doctors of a Specialized Hospital in

Bangladesh

INTRODUCTION

Vitamin D deficiency is pandemic, yet it is the most under-

diagnosed and under-treated nutritional deficiency in the

world 1–3. It is widespread in individuals irrespective of

their age, gender, race and geography. It has been estimated

that 20% to 80% of US, Canadian, and European men and

women are vitamin D deficient.4,5In a study on the vitamin

D status of Australian adults, vitamin D deficiency

(25[OH]D <20 ng/mL) was 31% (22% in men and 39% in

women); 73% had 25(OH)D levels less than 30 ng/mL.6 In

the Middle East and Asia, vitamin D deficiency in children

and adults is highly prevalent.7 In South Asia, 80% of the

apparently healthy population is deficient in vitamin D

(<20 ng/mL) and up to 40% of the population is severely

deficient (<9 ng/mL)8. In Bangladesh, a prevalence study

was done on women and found that hypovitaminosis D is

common in women regardless of age, lifestyle and

clothing9.

The classical functions of vitamin D include the regulation

of mineral ion homeostasis and bone metabolism.

Therefore, vitamin D has been associated primarily with

bone health, and it is well known that vitamin D can reduce

bone resorption and subsequent bone loss. Recently,

nonclassical functions of vitamin D have been recognized,

e.g. control of cell growth and differentiation; regulation

of immune function and endocrine effects, such as insulin

resistance; inflammation, renal and muscle function10.

Vitamin D receptor (VDR), which triggers most of vitamin

VOL. 31, NO. 2, JULY 2016 80

81 Syed Shahidul Islam, Md. Abdul Gani Mollah, Md. Alimur Reza, Monaim Hossen, Md. Wahidur Rahman, Md. Jahangir Alam et al

The Journal of Bangladesh Orthopaedic Society

D actions, is widely distributed across almost all the major

human organs including heart, brain, livers, bone, kidney,

and urinary system, as well as a number of tissues such as

immune cells, pancreatic ² cells, cardiomyocytes,

endothelial cells, and vascular smooth cells. Through the

widely distributed VDR, vitamin D controls vital genes

related to bone metabolism, oxidative damage,

inflammation, and chronic diseases11. Therefore, vitamin

D deficiency has been linked to a wide spectrum of diseases

including osteoporosis, cancer, diabetes, cardiovascular

and immune disorders11.Physicians may be vulnerable to

low vitamin D levels due to long work hours and lack of

sun exposure. This study sought to determine the

prevalence of vitamin D deficiency and its relationship

with sociodemographic characteristics among doctors of

a specialized hospital in Bangladesh.

MATERIALS AND METHODS:

This study was conducted using a cross-sectional study

design which was carried out at National Institute of

Traumatology and Orthopedic Rehabilitation which is a

specialized hospital in Dhaka, Bangladesh. A total of 168

doctors (153 men and 4 women) of NITOR hospital took

part in the study who were available at the day of data

collection. To be eligible, participants were required to be

the doctor of NITOR, healthy males and females aged

between 18 to 65 years. Participants were excluded if they

were pregnant or diagnosed with any hepatic or renal

disease, metabolic bone disease, malabsorption, type 1

diabetes, hypercortisolism, malignancy etc and who were

immobile for more than one week. Subjects using

medications affecting either vitamin D absorption or bone

health were also excluded. This study was conducted

according to the guidelines laid down in the Declaration

of Helsinki.

Data collectionwas conducted in examination centers at

NITOR by trained staff according to a standard protocol.

All subjects were medically examined and interviewed

using a standardized questionnaire to collect informationon

age, gender, physicalactivity level during leisure time, use

of vitamins and medications,sunlight exposure time, coffee

drinking (yes/no), smoking, self-reported diabetes, self-

reported coronary heart disease(CHD), and self-reported

stroke. The smoking habit was classified as never, current

(smoking regularly in the past 6 months), or ever

(cessationof smoking for more than 6 months),Subjects

were divided into four groups based on tea

consumption:group I, 0 to 4 cups of tea weekly; group II,

5–8 cups of tea weekly;group III, 9–12 cups of tea weekly;

and group IV, N12 cups of teaweekly. Daily sunlight

exposure was quantified based on the interviewquestions

on frequency and length of outdoor activities,

sunscreenuse, and usual outdoor attire. Body weightand

height were measured according to a standard protocol.

Blood pressure was measured in the non-dominant arm

while the participants were in a seated position after 5 min

of rest using asphygmomanometer device.

A blood sample was collected from the subjects by

disposable syringe through venepuncture and protected

from sunlight. After clotting, serum was separated by

complete centrifuge of blood sample. The serum was

collected in tubes and preserved at -200C. Finally, the serum

sample was transported to the laboratory on dry ice in a

special type of container and preserved in the freezing

room of the International Centre for Diarrhoeal Disease

Research, Bangladesh for further analysis. Serum 25-OHD

was used to evaluate the vitamin D status. According to

US Endocrine society guideline12 Vitamin D deficiency

was defined as a serum circulating 25-hydroxyvitamin D

[25(OH)D] level below 20 ng/ml (50 nmol/liter), and vitamin

D insufficiency as a 25(OH)D of 21–29 ng/ml (52.5–72.5

nmol/liter).

Descriptive analysis was carried out on the study variables

and the frequency table of determinants and socio-

demographic characteristics was created. Data was shown

as mean ± SD and prevalence rates was reported as

percentages and 95% confidence intervals. The differences

was considered significant at p values of less than 0.05.

With respect to the participants’ vitamin D statuses and

characteristics, t-test for independent samples and one-

way ANOVA were used for continuous data, and the Chi-

square test was used to compare frequencies.All analyses

were performed using SPSS for Windows, version 24.0

(SPSS Inc., Chicago, IL, USA).

OBSERVATION AND RESULTS

Among the 157 subjects 97.4% (153 Subjects) were male

and 2.6% (4 subjects) were female. Mean age of the

participants were 39.18±9.447. Among all the participants

13.6% were obese and 47.8% were overweight; around

30% were current or ever (cessation of smoking for more

than 6 months) smoker and 14% had a history of

dyslipidemia, 7.6% had Diabetes and 3.8% had other

diseases mainly hypertension. The overall mean (±SD)

serum 25(OH)D level was 13.71 ± 5.364 ng/mL. The

prevalence of vitamin D deficiency was 89.8% among the


doctors of National Institute of Traumatology and

Orthopedic Rehabilitation (Figure-1). The vitamin D status

of all participants according to different characteristics is

summarized in Table-1. The studiedpopulation aged more

than 45 years exhibited a mean serum 25(OH)D levelthat

was higher than the studied population who wereaged 30-

45 years and less than 30 years of age. Indeed, there was

a significant differencein the prevalence of vitamin D

deficiency among the total populationof different age

groups: the prevalence of vitamin D deficiency was

significantly lower in those aged more than 45 years (P

=0.003).Fig.-1: Vitamin D Status of the participants (n=157)

Table-I

Vitamin D status of all participants according to different characteristics(n=157).

Variables Frequency Serum D3 concentration (ng/dl) Vitamion D Defficiency

N(%) Mean ± SD P-value % P-value

Age (Years)

<30 years 35(22.3%) 12.17±3.86 .087 94.3% 0.03

31-45 years 78(49.7%) 13.77±4.18 94.9%

>45 years 44(28.0%) 14.84±7.62 77.3%

Gender

Male 153(97.4%) 13.80±5.39 0.79 89.5% 0.197

Female 4(2.6%) 10.15±2.90 100.0%

BMI

Normal 59(37.6%) 13.86±5.83 0.068 88.0% 0.05

Overweight 75(47.8%) 13.74±4.85 89.8%

Obesity 21(13.4%) 13.15±5.38 95.2%

Smoking

Never 103(65.6%) 14.84±6.85 0.988 86.5% 0.061

Current 37(23.6%) 13.39±5.02 100.0%

Ever 12(7.6%) 13.50±3.13 89.3%

Tea/Coffee Drinking

0-4 Cups/Week 38(24.2%) 14.27±5.33 0.489 91.7% 0.995

5-8 Cups/Week 43(27.4%) 13.94±6.74 90.0%

9-12 Cups/Week 24(15.3%) 13.73±4.77 89.5%

>12 Cups/Week 50(31.8%) 12.20±4.22 88.4%

Daily sunlight exposure

Sufficient 87(55.4%) 13.27±4.48 0.318 92.0% 0.455

Not Sufficient 64(40.8%) 14.17±6.50 85.9%

Medical History

Hyperlipidemia 22(14.0%) 13.62±4.60 - 90.90% -

Diabetes 12(7.6%) 15.39±10.10 83.30%

Chronic Heart Disease 2(1.3%) 10.90±5.09 100%

Others 6(3.8%) 10.03±2.34 100%

Evaluation of Vitamin D Status among Doctors of a Specialized Hospital in Bangladesh 82

VOL. 31, NO. 2, JULY 2016


Moreover, men exhibited significantly higher serum

25(OH)D levels compared with women (13.80±5.39 vs.

10.15±2.90 ng/mL, respectively). Vitamin D deficiency was

more prevalent in women (100%) than in men (89.5%).

Mean serum concentration of 25(OH) D was lower in the

group of obese participants than normat weight

participants. Subjects with increased tea consumption were

more likely to have higher 25(OH)D concentrations and

lower percentages of vitamin D deficiency. Participants

with history of chronic heart disease and hypertension

had lower mean 25(OH)D concentrations, and 100% had

vitamin D deficiency.

Table-II

Vitamin D Defficiency status of the participants in

respect to H/O Vitamin D Supplementation

H/O Vitamin D Vitamin D Status P-

Supplementation Deficiency Insufficiency Sufficiency value

Last 3 months 33.30% 66.70% 0.00% 0.000*

3-6 months 100.00% 0.00% 0.00%

> 6 Months 85.10% 8.50% 6.40%

Never 95.10% 4.90% 0.00%

*Pearson Chi-Square-35.885

Mean serum concentration of 25(OH) D was significantly

higherin the group of individuals who had a history of

vitamin D supplementation than those who had no such

history. Similarly, participants who had history of vitamin

D supplementation had significantly lower percentage of

vitamin D deficiency (Table-2). All the participants (100%)

had vitamin D deficiency who were current smoker whereas

86.5% had vitamin D deficiency who have never smoked.

DISCUSSION

The results of the study inNational Institute of

Traumatology and Orthopedic Rehabilitation which is a

specialized hospital in Dhaka, Bangladesh, confirms

thehigh prevalence of vitamin D deficiency (89.8%)and

insufficiency (8.3%) among the adult populationand an

even higher prevalence amongwomen.Although Dhaka is

asunny city, direct exposure to sun is, however,limited.

Traditionally, all women are requiredto wear traditional

clothes. On the other hand, most men wear long-

sleeveshirts, especially as all our participants work in

governmentaladministrations. Indeed, poor vitamin D

status has also been reported previously in Bangladesh

that were conducted with premenopausal Bangladeshi

women9. The prevalence of vitamin D deficiency in this

study was higher than the findings in North-Western

China13 (89.8% vs. 75.2%), US4, Canada5 and Europe6.

Conversely,the prevalence was almost similar than what

has been reported for SaudiArabianmen (where 87.8%

ofmiddle-aged and elderly men had vitaminD levels lower

than 20 ng/mL)14, Iran15 and Pakistan16.

The present study demonstrated that obesity, smoking,

hypertension and CHDwere independent predictors of

vitamin D deficiency. Previous study have demonstrated

that obesity17is associatedwith lower serum25(OH)D

levels. The inverse relationshipbetween 25(OH)D levels

and obesity may be because of a largerbody pool of vitamin

D and 25(OH)D, or to a slower saturation andmobilizationof

thesemetabolites fromadipose tissues, or both. Thus,

obeseindividuals have lower vitamin D bioavailability

fromcutaneous and dietarysources because of a tendency

for vitamin D to deposit in adipose tissue18. Furthermore,

in diseases thatcause disability such as CHD, reduced

outdoor activity mightinduce low vitamin D levels, which

has been linked to calcium malabsorptionand may cause

secondary hyperparathyroidism. In this study as there

was misperception about the level of sun exposure, hence

found conflicting result between sun exposure and vitamin

D level. According to clinical practice guideline of American

endocrine society12 a variety of factors reduce the skin’s

production of vitamin D3, including increased skin

pigmentation, aging, and the topical application of a

sunscreen, change in latitude, season of the year, or time

of day etc. For sufficient vitamin D we need 15 to 20 minutes

of daily sun exposure without sunscreen in lower

Midwestern and southern latitudes between 10:00 am

and 3:00 pm in bare chest & back is usually sufficient to

ensure adequate synthesis of vitamin-D metabolites. So,

It will be very difficult to achieve the necessary amount of

vitamin D by safe sun exposure.Furthermore,the present

study demonstrated that tea intake and H/O vitamin

Dsupplementation were protective factors against

vitaminD deficiency. Such an observation suggests that

subjectswith theserisk factors will particularly benefit from

vitamin D supplementationand/or food fortification and

increased sunshine exposure andtea consumption.

CONCLUSION

Vitamin D deficiency is very common (89.8% with 25(OH)D

<20 ng/ml) among doctors of tertiary care institute and

hospital in Bangladesh and and is largely attributed to

obesity, female sex, smoking, hypertension and CHD.It is

very difficult to achieve the necessary amount of vitamin

D by safe sun exposure and fortified food. History of

83 Syed Shahidul Islam, Md. Abdul Gani Mollah, Md. Alimur Reza, Monaim Hossen, Md. Wahidur Rahman, Md. Jahangir Alam et al



Vitamin D supplementation has a statistically significant

association with vitamin D Deficiency. Considering that

vitamin D deficiency is very common in all age groups and

that few foods contain vitamin D, supplementation might

be considered at suggested daily intake and tolerable

upper limit levels, depending on age and clinical

circumstances.

REFERENCES

1. Van Schoor, N.M.; Lips, P. Worldwide Vitamin D Status.

Best Pract. Res. Clin. Endocrinol. Metab. 2011, 25, 671–

680.

2. Mithal, A.; Wahl, D.A.; Bonjour, J.P.; Burckhardt, P.;

Dawson-Hughes, B.; Eisman, J.A.; El-Hajj Fuleihan, G.;

Josse, R.G.; Lips, P.; Morales-Torres, J.; et al. Global

vitamin D status and determinants of hypovitaminosis D.

Osteoporos Int. 2009, 20, 1807–1820.

3. Van der Meer, I.M.; Middelkoop, B.J.; Boeke, A.J.; Lips,

P. Prevalence of vitamin D deficiency among Turkish,

Moroccan, Indian and sub-Sahara African populations in

Europe and their countries of origin: An overview.

Osteoporos. Int. 2011, 22, 1009–1021.

4. Ganji V, Zhang X, Tangpricha V. Serum 25-hydroxyvitamin

D concentrations and prevalence estimates of

hypovitaminosis D in the U.S. population based on assay-

adjusted data. J Nutr. 2012; 142(3):498–507. [PubMed:

22323766]

5. Greene-Finestone LS, Berger C, de Groh M, et al. 25-

Hydroxyvitamin D in Canadian adults: biological,

environmental, and behavioral correlates. Osteoporos Int.

2011; 22(5):1389–1399. [PubMed: 20730415]

6. van Schoor NM, Lips P. Worldwide vitamin D status.

Best Pract Res Clin Endocrinol Metab. 2011; 25(4):671–

680. [PubMed: 21872807]

7. Singh RJ, Taylor RL, Reddy GS, Grebe SK. C-3 epimers

can account for a significant proportion of total circulating

25-hydroxyvitamin D in infants, complicating accurate

measurement and interpretation of vitamin D status. J

Clin Endocrinol Metab. 2006; 91(8):3055–3061. [PubMed:

16720650]

8. Arya V, Bhambri R, Godbole MM, Mithal A.Vitamin D

status and its relationship with bone mineral density in

healthy Asian Indians. Osteoporsis Int 2004; 15(1): 56—

61.

9. Islam MZ, Lamberg-Allardt C, Karkkainen M, et al.

(2002) Vitamin D deficiency: a concern in premenopausal

Bangladeshi women of two socio-economic groups in rural

and urban region. Eur J Clin Nutr 56:51-56.

10. Haussler MR, Haussler CA, Bartik L, Whitfield GK, Hsieh

JC, Slater S, et al. (2008) Vitamin D receptor: molecular

signaling and actions of nutritional ligands in disease

prevention. Nutr Rev 66:S98–S112. doi: 10.1111/j.1753-

4887.2008.00093.x PMID: 18844852

11. Davis CD, Dwyer JT (2007) The “sunshine vitamin”;

benefits beyond bone? J Natl Cancer Inst 99:1563–5.

PMID: 17971523

12. Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon

CM, Hanley DA, Heaney RP, et al. Evaluation, treatment,

and prevention of vitamin D deficiency: an Endocrine

Society clinical practice guideline. J Clin Endocrinol

Metab. 2011;96(7):1911–30.

13. Zhen D,Liu L, Guan C, Zhao N, & Tang X. High prevalence

of vitamin D deficiency among middle-aged and elderly

individuals in northwestern China: its relations hip to

osteoporosis and lifestyle factors. Bone.

2015;71:1±6.https://doi.org/10.1016/j.bone.2014.09.024

PMID:25284157

14. Ardawi MS, Sibiany AM, Bakhsh TM, Qari MH,

Maimani AA. High prevalence of vitamin D deficiency

among healthy Saudi Arabian men: relationship to bone

mineral density, parathyroid hormone, bone turnover

markers, and lifestyle factors. Osteoporos Int

2012;23:675–86.

15. Hovsepian, S.; Amini, M.; Aminorroaya, A.; Amini, P.;

Iraj, B. Prevalence of vitamin D deficiency among adult

population of Isfahan City, Iran. J. Health Popul. Nutr.

2011,29, 49–155.

16. Mehboobali N, Iqbal SP, Iqbal MP. High prevalence of

vitamin D deficiency and insufficiency in a low income

peri-urban community in Karachi. JPMA. 2015;65: 946.

17. Holick MF. Vitamin D, status: measurement,

interpretation, and clinical application. Ann Epidemiol

2009;19:73–8.

18. Need AG, Morris HA, Horowitz M, Nordin C. Effects of

skin thickness, age, body fat,and sunlight on serum 25-

hydroxyvitamin D. Am J Clin Nutr 1993;58:882–5.

Evaluation of Vitamin D Status among Doctors of a Specialized Hospital in Bangladesh 84

VOL. 31, NO. 2, JULY 2016


Evaluation of Closed Reduction of

Shoulder Dislocation with or without

Avulsion Fracture of Greater Tuberosity

of Humerus in Adult

Md. Nazrul Islam1, MAK Shamsuddin2, Md. Rezaul Alom3, Nazmul Huda4

ABSTRACT

Conservative treatment is the first choice to treat simple dislocation of shoulder joint and dislocation of shoulder

with and without avulsion fracture of greater tuberosity of humerus. This is the prospective clinical trial conducted

in the department of orthopedic-surgery, Shaheed Ziaur Rahman Medical College & Hospital, Bogra during the

period from April’2013 to July’2015. In this study A total of 50 adult patients were evaluated with regard to

limitation of movement, pain, instability & recurrent dislocation, All Patients were treated with conservative

method i.e. closed reduction with general anesthesia and immobilization of the limb by leucoplast strapping for 2-

3 weeks with adduction of Shoulder joint and hand placed on the opposite shoulder, The finger, hand and wrist

must be left entirely free, and exercised from the beginning. Static, Iso- metric deltoid muscle contraction should

be practiced at that time. The patients were categorized into two groups. Group-1, which constituted 30 patients

advised for immobilization for 3 weeks and group-2 has 20 patients having immobilization for 2 weeks.

Follow up of the patients ranged from seven to twenty six months with and average of 12.4 months. 34% of the

patients reported some symptoms at follow up. Restriction of movement was in 6 patients, 2 patients had mild

instability of the joint, 3 patients had recurrent dislocation of shoulder, and rasidual pain was in 6 patients, Out of

50 patients 40 were male and 10 were female, Male: female ratio was 4:1. Final outcome was satisfactory in 33

patients (66%) and unsatisfactory in 17 patient (34%) .

Key word: Dislocation of shoulder joint greater tuberosity, avulsion fracture.

1. Associate Professor and Head. Department of Ortho-Surgery Shaheed M Monsur Ali Medical College & Hospital, Sirajgonj

2. Associate Professor and Head, Department of Ortho-Surgery, Rajshahi Medical College, Hospital, Rajshahi.

3. Associate Professor and Head, Department of Ortho-Surgery Shaheed Ziaur Rahman Medical College & Hospital, Bogra.

4. Associate Professor, Dept. of Orthopaeic Surgery, Kustia Medical College

Correspondence: Dr. Md. Nazrul Islam, Associate professor and Head. Department of Ortho-Surgery Shaheed M Monsur Ali Medical

College & Hospital, Sirajgonj

INTRODUCTION:

Simple dislocation of the shoulder and dislocation of

shoulder with avulsion fracture of the greater tuberosity

of the humerus are major injuries of the shoulder joint. in

adult person.

This evaluation is based on longtime results of treatment

of simple dislocation and dislocation with avulsion fracture

of greater tuberosity of the humerus by closed reduction

and immobilization of the affected limb. The techniques of

reduction of the dislocation were kocher’s maneuver and

Hippocrate’s maneuver. In this study 34% of the patients

reported some symptoms. The symptoms were restrictions

of abduction and cirumduction movement of shoulder

joint, mild instability, residual pain and recurrent

dislocation. All the cases were reduced under general

anesthesia & immobilized by adhesive leucoplast.


This was a prospective clinical trial conduced in the

department of orthopedic surgery, Shaheed Ziaur Rahman

Medical College Hospital, Bogra during the period from

April 2013 to July 2015, Eighty patients of adult ages who

had a dislocation of shoulder with or without avulsion of

greater tuberosity of humerus were treated conservatively

by close reduction. 30 patients were excluded from the

study because of insufficient follow up. There were 50

patients for whom the follow up examination was

Original Article

VOL. 31, NO. 2, JULY 2016 85


completed. In this patients the duration of follow up

averaged 12.4 month (the range was from seven to twenty

six months), 40 of this patients were male 80% and 10

patients were female (20%). Male Female ratio was 4:1.

simple dislocation of the shoulder was 30 patients and

dislocation with avulsion fracture of the greater tuberosity

of the humerus was 20 patient.

The patents those are included in this clinical trial satisfied

the following criteria.

(a) simple dislocation of shoulder and dislocation of

shoulder with avulsion fracture of the greater

tuberosity of humerus only.

(b) The patients had been 15 years old or more at the

time of dislocation.

(c) The treatment was closed reduction and the technique

of reduction was either kocher’s or the Hippocrate’s

method.

All the patients had pre-reduction radio graph and

radiographic check up was also done after reduction and.

At the time of follow up range of motion of the affected

shoulder was compared with contra lateral normal shoulder

joint. Any loss of movement of the joint was recorded.

The follow-up radiographs were done for any degenerative

charges in the joint and for the assessment of healing

progress of the fractured grater tuberosity. All the patients

were carefully asked with regard to discomfort, pain and

aching in the shoulder.

This symptoms were graded to discomfort, pain and aching

in the shoulder. The grades were (a) None (b) mild, (c)

moderate and (d) severe. Instability was diagnosed if there

is was a history of recurrent dislocation of shoulder or if at

physical examination demonstrated laxity of the joint.

All patients had immobilized of the shoulder by leucoplast in

the position with adduction arm by caring the elbow across

the body to wards the midline and the arm was rotated medially

so that the hand fells across the opposite shoulder, In this

study an associated avulsion fracture of the greater tuberosity

came back to the position as the dislocated head was reduced

and special treatment was not required.

At the initial stage of the study the patient were advised

for immobilization of shoulder for 3 weeks. Later on

patients were advised for immobilization of shoulder for 2

weeks (till the pain and swelling subsided). It was observed

that those patients having immobilization for 3 weeks had

limitation of movement, pain & discomfort, but instability

with recurrent dislocation was more when immobilization

time was less.

RESULTS:

Most common type of dislocation was anterior dislocation

and this type had 46 patient 26 patients of anterior type of

dislocation of shoulder were associated with avulsion

fracture of grater tuberosity of humerus, 4 patients had

subglenoid dislocation and there was no patient of poster

dislocation of shoulder join. Most common mechanism of

injury was road traffic accident (motor byke accident).

Dislocation following road-traffic accident was 42 patient

(84%), fall were the mechanism of injury in 5 patients (10%),

01 dislocation was due to assault (2%) and 2 had sports

injury (4%). NO major deference was noted between the

prevalence of involvement of dominant and non-dominant

extremities.

Reduction was done under general anesthesia in all

patients. Reduction was performed by kocher’s method in

10 patients and by Hippocrate’s method in 40 patients,

after reduction all patients had leucoplast strapping with

hand placed on the opposite shoulder. Duration of

immobilization ranged from 2 to 3 weeks. After that the

limb was maintained only by collar and cuff bandage for

another 7 to 10 days and active movement of the shoulder

was advised within the bandage.

Fig.-1: Distribution of the patients by sex (n-50)

Fig.-2: Distribution of Simple dislocation and dislocation

with avulsion fracture. (n-50)

Evaluation of Closed Reduction of Shoulder Dislocation with or without Avulsion Fracture 86

VOL. 31, NO. 2, JULY 2016


DISCUSSION

The dislocation of shoulder of is caused most commonly

due to road traffic accident. Then the next cause is due to

fall on ground. Then due to sport injury and assault; the

most popular method of reduction is under general

anesthesia or without general anesthesia is Hippocrate’s

method.

The extremity is immobilized in adduction with the elbow

in midline of the chest and hand on the opposite shoulder

and maintained the position by leucoplast stropping for

2-3 weeks. After that the limb is maintained only by collar

& cuff bandage to further 7-10 days and advised for active

movement of the shoulder at the same time. Prolonged

immobilization leads to shortening and fibrosis of the

injured capsule there by limiting movement of the joint.

Table-I

Distribution of patient by mechanism of injury (n-50)

Mechanism of Injury No of patient Percentage

1. Road traffic audient 42 84%

2. Fall on ground 5 10%

3. sports injury 2 4%

4. Assult 1 2%

Total 50 100%

Table-II

Distribution of patient by dislocation type.

Dislocation type No of case Percentage

Anterior type 46 92%

Subglenoid type 04 8%

Posterior type 00 00

Total 50 100%

In the series painful sequalae were less common when

immobilization was less. But when immobilization time was

less there was a chance of increase risk of recurrent

dislocation of shoulder.

By protection of shoulder joint in a position of medial

rotation by the side of the body for 3 weeks the possibility

of recurrence of the dislocation was diminished.

Table-III

Data for Method of reduction of dislocation

Method of Reduction No of patients Percentage

Kocher’s Method 10 20%

Hippocrates’s Method 40 80%

Total 50 100%

In 26 patients dislocation of shoulder there were also a

fracture of the greater tuberosity from avulsion. This

fracture usually does not add to the difficulty of the

treatment because of the large fragment retains periosteal

attachment. at its base so that it is incompletely separated

from the humerus and after manipulative reduction of the

dislocation the fragment resumes its anatomical position.

Table- IV

Data showing complication after reductions.

Complication No of Patient Percentage

Restrictions of movement 06 12%

Residual pain 06 12%

Mild Instability 02 4%

Recurrent Dislocation 03 6%

Total 17 34%

Final out come this study shows satisfactory result 66%

and unsatisfactory result 34%.

CONCLUSION

Dislocation of shoulder treated by closed reduction and

immobilization for 2-3 weeks show excellent results

associated with or without avulsed fracture of the greater

tuberosity of humerus. If the grater tuberosity has been

avulsed and accurately repositioned by closed

manipulation. There is good chance of healing without

any surgical intervention.

REFERENCES

1. Simonet W.T Melton LJ III, Cofield RH, llstrup DM:

incidence of anterior dislocation of shoulder in olm stead

county. Minn Clin. Orthop - 186:186, 1984.

2. Moneley HF, Athletic injuries to the shoulder region Am

J Surg. 98: 401, 1959.

3. Oni OOA, Acute anterior dislocation of shoulder due to a

loose fragment from an associated fracture of the grater

tuberosity, injury 15:138, 1983.

4. Seradge H, Ormi G: Acute anterior relocation of shoulders,

J trauma, 22:330, 1982

5. Eyre- Brook, recurrent dislocation of the shoulder joint,

journal of Bone and joint surgery 30- B:39, 1948.

6. Neviaser RJ, Neviaser TJ, Neviaser J.S: Concurrent rupture

of rotator cuff and anterior dislocation of shoulder in older

patient. J Bone and joint Surg. 70 A: 1308, 1988.

7. Watson- Jones Recurrent dislocation of shoulder J. Bone

and joint surgery 30.B: 233; 1948.

87 Md. Nazrul Islam, MAK Shamsuddin, Md. Rezaul Alom, Nazmul Huda



Original Article

Percutaneous Plate Fixation in the

Management of Distal Diametaphyseal

Tibia Fracture

Md. Sofikul Islam1, Ahmed Asif Iqbal2, Zahidur Raman3, Kazi Mainur Rahman4

Abstract

Operative treatment of distal diametaphyseal tibia fracture is difficult to manage. Conventional osteosynthesis is

not suitable because distal tibia is subcutaneous bone with poor vascularity and exposure of implant, malunion

and infection are the major problem. Closed reduction and minimally invasive plate osteosynthesis (MIPO) with

distal tibial locking compression plate (LCP) has emerged as an alternative treatment option because it respects

biology of distal tibia and fracture hematoma and also proivides biomechanicaly stable construct. Evaluation of

clinical and radiological outcome of distal diametaphyseal fracture operated by distal tibial locking compression

plate by MIPO technique. 14 Patient with closed distal diametaphyseal tibia fracture with or without intra articular

extension (AO classification 9 type 43.A1, 1 type 43.A2, 2 type 43.A3 and 2 type 43.B1) operated by minimally

invasive plate osteosynthesis technique with distal tibial locking compression plate having 4.5/5 proximal and

3.5/4 screw holes and follow them prospectively. The follow up duration was from January 2014- July 2016.

Average injury-surgery interval was 13.85 days (2to 28 days). Mean time of fracture union was 19.5 weeks.

Average follow up was 19.64 months (range 06- 30 months). One patient had superficial infection which was

managed by appropriate antibiotic and dressing. One patient had delayed union and three patient complained

ankle pain during walking. Another one patient had ankle varus angulation < 5o. Our study shows that MIPO with

LCP is an effective treatment method in terms of union time and complication rate and provides good, stable

fixation with excellent patients compliances for distal diametaphyseal tibia fracture. skin irritation is a common

problem because of prominent hardware . Limitation: Portable –X-rays were used in stead of C-arm and small

number of patients were taken.

Key words: Distal diametaphyseal tibia fracture, MIPO, LCP, Percutaneous, Osteosynthesis

1. Junior Consultant, Ortho-Surgery, Upazilla Health Complex, Durgapur, Rajshahi

2. Assistant Professor, Hand & Micro Ortho-Surgey, Rajshahi Medical College, Rajshahi

3. Assistant Professor, Dhaka Medical College Hospital, Dhaka

4. Senior Consultant, Department of Orthopaedic Surgery, General Hospital, Khulna

Correspondence: Dr. Md. Sofikul Islam, Junior Consultant, Ortho-Surgery, Upazilla Health Complex, Durgapur, Rajshahi, E-mail: [email protected]

INTRODUCTION

Treatment of distal diametaphyseal tibia fracture with or

without articular extension is challenging because of its

unique anatomical characteristics of subcutaneous

location with precarious blood supply and proximity to

Ankle Joint. Most of these fractures are managed with an

operative intervention such as closed reduction and

intramedullary interlocking (IMIL) nailing or open

reduction and internal fixation (ORIF) with platting or

closed reduction and percutaneous platting or external

fixators.1-3 Each of these techniques has their own merits

& demerits. IMIL has been reported with higher rate of

malunion because it is difficult to achieve two distally

locking screws. Wound infection, skin necrosis and

delayed union or non union requiring secondary

Procedures like bone grafting are some of the complications

associated with Conventional osteosynthesis with

plates.4-7 Similarly Pintract infection, Pin loosening,

malunion and non union leading to osteomylitis are

potential complications of external fixators and hence not

preferred as definitive fixation method.8-11

Recently techiniques of closed reduction and minimally

invasive plate osteosynthesis (MIPO) with locking

compression plate (LCP) has emerged as an alternative

surgical option for distal diametaphyseal tibia fracture. When

applied subcutaneously, LCP does not endanger periosteal

blood supply, respect fracture hematoma and provides

biomechanically stable construct .12-13 Minimally invasive

VOL. 31, NO. 2, JULY 2016 88


plating technique decrease the wound complications

associated with traditional open plating techniques, less

invasive methods of plating have been developed 14 .

The purpose of this prospective study was to evaluate

the functional and radiographic results of 14 consecutive

patient treated in our private hospital for fracture of distal

tibia by MIPO techniques.

METHOD

14 patients with closed distal diametaphyseal tibia

fractures with or without intra articular extension treated

in our hospital between January 2014 to July 2016 were

prospectively followed (Table- 1). Demographic variables,

mode of injury, injury-surgery Interval, time required for

union, complications were recorded. Fractures was

classified according to AO/OTA classification system

(Figure- 1). Patients with pathological fractures, ipsilateral

multiple fractures and open fracture were excluded. After

stabilizing the traumatized patient, routine pre-anesthetic

investigations were carried out. Standard antero-posterior

and lateral radiographs of the affected leg with knee and

ankle joint were taken. X-rays were evaluated for fracture

morphology, level and extent of communition. The type

and likely length of the plate was calculated. The leg was

immobilized in a plaster slab till definitive surgery in fresh

fracture. Patients with precarious skin condition were

managed with limb elevation, regular dressing care and

prophylactic intravenous antibiotic; surgery was delayed

till appearance of the wrinkle sign. Surgery was performed

in our hospital under regional anesthesia with a tourniquet

in the supine position. In the distal tibia, the locking

compression plate was applied on the antero-medial

surface. A locking compression plate of adequate length

so that 6-8 cortices are obtained of either side of fracture.

The fracture was reduced by indirect means without

opening the fractured area except two cases where

reduction was not satisfactory. So small opening by

anterior approach was done to reduce the fracture. Gentle

manual traction and external manipulation were done.

portable x-rays were taken to confirm fracture reduction

as c arm was not available in our hospital. After provisional

reduction, a 3-4 cm vertical incision was given at the centre

of the medial malleolus and a subcutaneous tunnel was

opened with a hemostat or kobe. Then the selected locking

compression plate with a locking sleeve screwed into its

distal hole was held with a pen-like grip. The plate was

tunneled proximally subcutaneously across the fracture

site, using the locking sleeve as handle. Smooth and

gentle supination-pronation motions were used while

inserting the plate. The thumb was kept anteriorly on the

tibia crest and was used to guide the proximal part of the

plate onto the antero-medial surface of the tibia. Non

locking screws were inserted first in either the proximal or

distal fragment as required to aid in the reduction of the

fracture so as to pull the bone to the plate. Locking screws

were then passed through holes of the plate. Fibula was

not Routinely fixed unless it was not involved at the level

of syndesmosis. skin was closed with non absorbable

sutures. Wound was inspected on third post operative

day for any sign of wound infection and change of

dressing. Patient was discharged on third or fourth post

operative day if skin condition was satisfactory and wound

was dry. On fourteen post operative days stitches were

removed and X-ray of the leg was taken. Posterior back

slab was removed. Intermittent ankle mobilization was

initiated but weight bearing was not allowed for next four

to six weeks. Patient was subsequently followed up in six

weeks intervals to asses fracture healing. Partial weight

bearing was started once callus was visible in X-ray and

gradually increased accordingly. Fracture was considered

as union when visible bridging callus was seen at least

three cortices in X-rays of leg and absence of pain on

weight bearing. Malunion was defined as varus–valgus

angulation e”5o and antero-posterior angulatione”1o and

shortening of e”15 mm. once fracture united, if patients

wished to remove the implant or implant related complaints

like malleolar skin irritation then plate was removed.

Statistical analysis was done by using SPSS programme.

AO Classification System of type 43 distal tibial fracture

89 Md. Sofikul Islam, Ahmed Asif Iqbal, Zahidur Raman, Kazi Mainur Rahman



Table

Patients and injury data.

Pre operative X-ray Ap & lateral view Post Operative X-ray Ap & lateral

view

Skin Condition of the leg

at fourth Month

Percutaneous Plate Fixation in the Management of Distal Diametaphyseal Tibia Fracture 90

VOL. 31, NO. 2, JULY 2016


RESULTS

Amoung 14 patients 8 were male and six were females

(mean age 42 years, range 27-65 years). According to AO

classification 9(65%) of fracture were 43. A1, 1(07%) 43

A2, 2(14%) 43. A3 and 2( 14%) 43.B1.More than half patients

sustained injury in road traffic accidents (65%) and other

modes of injury- fall injury in 2(14%) patients and physical

assault in 2 (14% ) patients. One patient had controlateral

colle’s fracture which was managed conservatively by

colle’s plaster. Average injury-surgery interval was 13.85

days (range 2-28 days). Mean time of fracture union was

19.5 weeks ( range 16-28 weeks). Average total follow up

19.64 months ( range 06-30 months).Demographic profiles

and out come of each case are tabulated in table -1. One

patient had superficial infection which was managed by

appropriate antibiotics and dressing. One patient had

delayed union and three patient complained ankle pain

during walking. Another one patient had ankle varus

angulation < 50. On request of the three patients Implants

were removed due to skin irritation.

DISCUSSION

Distal diametaphyseal tibia fracture with or without intra

articular extention is one of the difficult fractures to

manage. None of the treatment options available perfectly

fulfill requirements of fracture characteristics of distal

diametaphyseal tibia. Distal tibia has got circular cross

sectional area with thinner cortex as compare to triangular

diaphysis with thicker cortex. So, intramedullary nail which

is disigned for tight interference fit at diaphysis can not

provide same stability at distal fracture.15,16 Other

potential complications of IMIL nailing are malunion (0-

29%) and implant failure(5-39%). 15,17 ORIF with

conventional plate which needs striping of periosteum is

also not an ideal treatment option because tibia is

subcutaneous bone and periosteum provides 2/3 rd of

blood supply. Non union, delayed union and infection are

reported with the range of 8.3-35% 8.3 -25% respectively

with ORIF with plating. 4-7,19 Similarly external fixators as

a difinitive method of treatment for distal diametaphyseal

tibia fracture are also reported with higher rate of infection,

implant failure and malunion or nonunion and hence

recommended only for temporary method of stabilization

in open fracture with severe soft tissue injury.17,20

With the development of technique of MIPO with LCP

which preserve extra osseous blood supply respect

osteogenic fracture haematoma, biologically friendly and

stable fixation method is available for distal diametaphyseal

tibia fracture. Indirect reduction method and sub-

cutaneous tuunneling of the plate and application of

locking screws with small skin incission in MIPO technique

prevents iatrogenic injury to vascular supply of the bone.21 Unlike conventional plates, LCP is a friction

independent self stable construct which provides both

angular and axial stability and minimizes risk of secondary

loss of reduction through a threaded interface between

the screw heads and the plate body12.

In spite of use of MIPO with LCP as internal external

fixators, anatomical reduction of the fracture by using

indirect reduction maneuvers before applying the plate is

important step. Malreduction and suboptimal pre

contouring of the plate can result delayed union, nonunion,

prominent hard ware, malleolar skin irritation and pain.

Percutaneous platting of the distal tibia offers a similar

stability as classic ORIF, however without the need for

extensive dissection. 22-24 Therefore fewer soft tissue

complication can be expected. In the present study pain

and malleolar skin irritation was common problem and so

that implant was removed after fracture union.

CONCLUSION

Distal diametaphyseal tibia fracture is one of the difficult

fractures to mange with available treatment options. MIPO

technique can be used in fractures where locked nailing

cannot be down like distal tibia fracture with small

metaphyseal fragments, vertical split and markedly

comminuted fractures. MIPO with LCP is an effective

treatment method in terms of union time and complication

rate which is comparable to other studies. It provides goods

stable fixation for distal diametaphyseal tibia fracture. Skin

irritation is a common problem because of prominent hard

ware.

Pre-Operative X-ray Post Operative X-ray after

Union

91 Md. Sofikul Islam, Ahmed Asif Iqbal, Zahidur Raman, Kazi Mainur Rahman



REFERENCES:

1. Farouk O, Krettek C, Miclau T, Schandelmaier P, Guy P,

Tscherne H, Minimally invasive plate osteosynthesis and

vascularity: Preliminary results of a cadaver injection study.

Injury. 1997;28 (Suppll): A7-12.

2. Mohammed A, Saravanan R, Zammit J, King R,

Intramedullary tibial nailing in distal third tibial fractures

: distal locking screws and fracture non-union. Int Orthop.

2008;32:547-9.

3. Wrysch B, McFerran MA, McAndrew M. Operative

treatment of fractures of the tibial plafond . A randomised,

prospective study. J Bone Jt Surg Am. 1996;78;1646-67.

4. Redfern DJ, Syed SU, Davies SJM. Fractures of the distal

tibia: minimally invasive plate osteosynthesis. Injury 2004,

35:615-620.

5. Apivatthakakul T, phornphutkul C, patumasutra S. ldea

and innovation: Simple minimally invasive plate

osteosynthesis(MIPO) instruments. Injury Extra 2009,

40:39-44.

6. Vallier HA, Le TT, Bedi A. Radiographic and clinical

comparisons of distal tibial shaffractures (4 to 11 cm

proximal to the plafond): plating versus intramedullary

nailing . J Orthop Trauma 2008, 22:307-11.

7. Yang SW, Tzeng HM, Chou YJ, Teng HP, Liu HH, Wong

CY. Treatment of distal tibia metapyseal fractures: plating

versus shortened intramedullary nailing. Injury 2006,

37:531-535.

8. Guo JJ, Tang N, Yang HL, Tang TS. A prospective,

randomised trial comparing closed intramedullary nailing

with percutaneous plating in the treatment of distal

metaphyseal fractures of the tibia, J Bone Joint Surg Br

2010, 92-B:984-8.

9. Hasenboehler E, Rikli D, Badst R, Locking compression

plate with minimally invassive plate osteosynthesis

diaphyseal and distal tibial fracture: a retrospective study

of 32 patients. Injury 2007, 38:365-70.

10. Gun-11 Im, Suk-kee Ta. Distal metaphyseal fractures of

tibia: A prospective randomized trial of closed reduction

and intramedullary nail versus open reduction and plate

and screws fixation. J Trauma 2005, 59:1219-1223.

11. Watson JT, Moed BR, Karges DE, Cramer KE. Pilon

fractures, Treatment protocol based on severity of soft

tissue injury, Clin Orthop Relat Res 2000, 375:78-90.

12. Wagner M, Frigg FR, Locked plating Biomcchanics and

biology and locked plating: Clinical indications, Techniques

in Orthopaedics 2007,22(4):209-218.

13. Frigg R. Development of the locking compression plate.

Injury Suppl 2003, 2:B6-B10.

14. Whittle A P,2008, Fractures of the lower extremity, In

Canale ST , Beaty JH (editors) Campbells Operative

Orthopaedics,11th ed , Vol III New york, Mosby, year

book, Inc., pp 3108-3109.

15. Knifel T, Buckley R . A comparison of one versus two

distal locking screws in tibial fractures treated with

unreamed tibial nails: a prospective randomized clinical

trial. Injury 1996, 27:271-273.

16. Trafton PG , Tibial Shaft Fracturs. In: Skeletal trauma. 4th

edn. Edited by Browner DB, Jupiter JB, Levine

AN, Trafton PG, Krettek C, Philadelphia; Suaanders

Elsevier; 2009:2319-2452.

17. Ronga M, Longo UG, Maffulli N. Minimally invasive

locked plating of Distal tibia fractures is safe and effective.

Clin Orthop Relat Res 2010, 468:975-82.

18. Mosheiff, Safran O, Segal D, Liebergall M, The unreamed

tibial nail in the treatment of distal metaphyseal fractures.

Injury 1999,30:83-90.

19. Megas P, Zouboulis P, Papadopoulos AX, Kerageorgos A

Lambiris E. Distal tibial fracture and non- unions treated

with shortened intramedullary Nail. Inter Orthop 2003,

27:348-35.

20. Joveniaux P, OhI X, Harisboure A, Berrichi A, Labatut L,

Simon P, Mainard D, Vix N, Dehoux E, Distal tibia

fractures: mangement and complications of 101 cases. Inter

Orthop Trauma 2010, 34:538-588.

21. Borrelli J, Prickett W, song E, Becker D, Ricci W, Extra

osseous blood supply of the distal tibia and the effects of

different plating techniques: Human candaveric study, J

Ortho Trauma 2002, 16:691-695.

22. Gupta RK, Rohilla RK, Sangwan K, Singh V, Walia S.

Locking plate fixation in distal metaphyseal tibial fracture:

series of 79 patients Inter Orthp 2010, 34:1285-1290.

23. Gao H, Zhang CQ, Luo CF, Zhou ZB, Zeng BF, Fractures

of the distal tibia treated with polyaxial locking plating.

Clin Orthop Relat Res 2009, 467:831-837.

24. Cheng W, Li Y, Manyi W, Comparison study of two

surgical options for distal tibia fractur minimally invasive

plate osteosynthesis vs. Open reduction and internal

fixation. Inter Orthop 2010, doi; 10.1007/s00264-010-

1052-2.

Percutaneous Plate Fixation in the Management of Distal Diametaphyseal Tibia Fracture 92

VOL. 31, NO. 2, JULY 2016


Original Article

INTRODUCTION

Proximal femoral fractures are one of the commonest

fractures encountered in orthopaedic trauma practice

(about 3 lakh per year 1 with mortality rate of 4.5%-22%)2.

Extracapsular proximal femoral fractures are those occurring

in the region extending from extracapsular basilar neck

region to 5 cm below lesser trochanter. Proximal femoral

fractures include intertrochanteric and subtrochanteric

fractures.3 Stable proximal femoral fractures can be

managed with conventional implant with predictable results

whereas unstable fractures are challenging, and prone to

complications. There is a lack of consensus on the

treatment for unstable proximal femoral fractures. Here we

report our experience of complex extracapsular proximal

femoral fractures with proximal femoral locking plate.

MATERIALS AND METHODS

Our study included a total 30 patients (20 males & 10

females) with unstable proximal femoral fractures (AO Type

31A2 & 31A3)3 who were subjected to management using

PF-LCP. The mean age of the patients was 65 years (36–82

years). Extracapsular proximal femoral fractures included

Proximal Femoral Locking plate in

Unstable Extracapsular Proximal Femoral

Fractures: A Retrospective Analysis

Md. Kamruzzaman1, Shakawat Hossain2, Tanvir Hossain3, MA Sabur4

ABSTRACT

Stable trochanteric femur fractures can be treated successfully with conventional implants. However comminuted

and unstable inter or subtrochanteric fractures with or without osteoporosis are challenging & prone to

complications. The PF-LCP is a new implant that allows angular stability by creating fixed angle block for treatment

of complex, comminuted proximal femoral fractures. We reviewed 30 patients with unstable inter or

subtrochanteric fractures, which were stabilized with PF-LCP. Mean age of patient was 65 years, and average

operative time was 90 min. Patients were followed up for a period of 3 years (June 2013–June 2016). Patients

were examined regularly at 3 weekly interval for signs of union (radiological & clinical), varus collapse (neck-

shaft angle), limb shortening, and hardware failure. All patients showed signs of union at an average of 9 weeks

(8–10 weeks), with minimum varus collapse (<10°), & no limb shortening and hardware failure. Results were

analysed using IOWA (Larson) hip scoring. Average IOWA hip score was 77.5. PF-LCP represents a feasible

alternative for treatment of unstable inter- or subtrochanteric fractures.

Keywords: PFLCP, Trochanteric Fracture, Extracapsular

both intertrochanteric and subtrochanteric fracture.

Intertrochanteric fractures were classified according to

Evans, whereas subtrochanteric fractures were classified

according to Seinsheimer. Open fracture, Pathological

fracture, were excluded from the study. Patients were

followed up for a period of 3 years (June 2010–June 2013).

Patients were examined regularly at 3 weekly interval for

signs of union (radiological & clinical), varus collapse

(neck-shaft angle), limb shortening, and hardware failure.

Patients were allowed non-weight bearing ambulation from

day after surgery. Toe-touch weight bearing was started

at 3 weeks and full weight being at 8 weeks (subject to

union criteria).

All the patients were evaluated for osteoporosis and were

given specific scores (1–6) according to the SINGH’S

INDEX4.

Surgical technique

PF-LCP implant is a limited contact, angular stable plate

designed for management of complex proximal femoral

fractures. [5]PF-LCP is anatomically pre-contoured to fit

the proximal femur. There are separate implants for left and

1. Assistant Professor, Dept. of Ortho Surgery, NITOR, Dhaka

2. Assistant Registrar, Dept. of Ortho Surgery, NITOR, Dhaka

3. Resident Surgeon, Dept. of Ortho Surgery, DMC, Dhaka

4. Associate Professor, Dept. of Ortho Surgery, NITOR, Dhaka

Correspondence: Dr. Md. Kamruzzaman, Assistant Professor, Dept. of Ortho Surgery, NITOR, Dhaka

93 The Journal of Bangladesh Orthopaedic Society


right side. Proximal portion is pre-contoured to fit at greater

trochanter.

Surgery is performed with the patient lying supine over

operating fracture table. Traction is applied and

anatomically satisfactory reduction is achieved

preoperatively under fluoroscopic control, in both

anteroposterior and lateral views. Lateral approach using

a straight incision extending from greater trochanter to 5–

10 cm distally, according to fracture configuration, is used.

In cases where anatomically satisfactory reduction was

achieved preoperatively the plate was inserted using the

less invasive technique, while in others open reduction

technique was used. The ultimate plate position and

screw position depends upon fracture reduction and

placement of guide wires into the femoral head and neck.

The fixed-angle wire guides are threaded to the proximal

threeholes of the plate, and the plate is approximated to

the proximal femur. Next, a guide wire was advanced

through the most proximal (95-degree) hole. The correct

path of this wire is approximately onecentimetre

inferior to the piriformis fossa into the inferior femoral

head on the anteroposterior (AP) view, and central in the

femoral head on the lateral view. A guide wire is

inserted into the next distal (120-degree) hole, and

because this is in a different plane than the first hole, the

surgeon must visualize its position on the lateral x-ray.

The third guide wire, in the 135-degree hole, is then

placed, which is in the same plane as the first hole and

may alternatively be inserted near the end of the

procedure without compromising the stability of the

construct. All three guide wires should be in

subchondral bone of the femur head before inserting

the screws which is confirmed by C-arm in the AP and

lateral views. The screw lengths are measured using an

indirect device over the guide wires with the wire

guides still attached and the appropriate, fully threaded,

cannulated screws (7.3 mm for the two proximal holes

and 5.0 mm for the third proximal hole) are

selected. These cannulated screws are inserted over the

guidewires with the guides removed. During distal screws

fixation, in subtrochantric fractures first fracture should

be reduced, then fix the non-locking screws in

compression mode followed by locking screws whereas

intertrochantric fracture can be fixed with locking screws.

After thecompletion of the fixation, thorough wash of

the wound was given with normal saline. Suction drain

was inserted at the entry point and wound closed in layers.

Postoperatively patients were put on quadriceps drill and

allowed non-weight bearing ambulation day after surgery.

Toe-touch weight bearing was started at 3 weeks & full

weight bearing at around 8 weeks, subject to union criteria

(evidence of sufficient callus in 3 out of 4 cortices on AP

and lateral views). Patients were followed up at 3 weekly

interval for the first 3 months and looked for signs of

union (Clinical & Radiological), varus collapse, limb

shortening, and hardware failure

RESULTS

The median duration of surgery was 80 min (60–130 min).

All 30 patients were available for evaluation after 3 years

of follow up.

The union rate was 80% (24/30) at 3 months follow up.

Average varus collapse was <10° (5–12°). No cases of

limb shortening and hardware failure were noted. ROM at

knee joint was full in all the cases. However there was one

case of greater trochanteric tip avulsion (case-6) in an 80

years old lady at 3 months follow. Patient had associated

abductor lurch. She was advised fixation of trochanteric

fragment, but refused. Although fracture healed in that

case in usual time .This may be due to early full weight

bearing by the patient. One patient showed delayed union

at 6 month follow up, which was bone grafted. Follow up

at 9 month showed full union in that case.

The mean blood-loss was 200 ml. The mean image

intensifier time was 5 min and mean length of incision was

10 cm .Postoperatively assessment of the procedure was

done using IOWA (Larson) Scoring system.

Fig.-1: Clinical photograph showing sub trochanteric

fracture

Md. Kamruzzaman, Shakawat Hossai2, Tanvir Hossain, MA Sabur 94

VOL. 31, NO. 2, JULY 2016


DISCUSSION

Initial treatment of the proximal femur fractures in the 1800s

was mainly non-surgical. The major advances in the

treatment of femoral fractures were first seen in 1870 when

Hugh Owen Thomas [6] developed the Thomas splint,

and advocated immobilization with prolonged bed rest.

Surgical management of the hip fractures started gaining

interest when the first Bone plate was used in 1886 when

Hanmann devised his retrievable bone plate. Lambotte,

Lane (1914) Sherman (1912) and Townsend & Gilfillan (1943)

played an important role in development of the modern

principles of osteosynthesis. [7]The real modern era of

internal fixation of hip fractures began with the invention

of the triflange nail by Smith Peterson[8]in1925. The

invention of sliding compression with a cannulated system

of drilling and insertion was invented by Godoy-Moreira

and is the precursor of this class of implants in 1938. The

desire to increase stability of unstable fracture patterns

with valgus osteotomies was popularized by Dimon and

Houston,[9]Sarmiento, Harrington in the 1960s 1970s.

Cephalomedullary implants are devices inserted with a

closed technique and fluoroscopic control with variable

femoral length geometry and enhanced proximal geometry

to permit fixation with nails or screws into the femoral

head. The Grosse-Kempf gamma nail and the Russel-Taylor

reconstruction nail were the start of two new classes of

intra-medullary devices designed for the hip region.

Locked and hybrid compression plates have been applied

Fig.-2: Clinical photograph showing position of screws

under fluoroscopic control

Fig.-3: Clinical photograph showing post oprerative x-ray

Fig.-4: Clinical photograph showing Post operative

followup x-ray

Fig.-5:Clinical photograph showing x-ray after

radiological union

95 Proximal Femoral Locking plate in Unstable Extracapsular Proximal Femoral Fractures:



recently for unstable fractures with only preliminary results

so far.

PF-LCP acts as a fixed angle internal fixator device and

achieves greater stability compared with DHS/DCS/Angle

blade plate while avoiding excessive bone removal. It is

also ideal in osteoporotic bones. PF-LCP prevents

rotational instability and allows angular stability by

creating a fixed angle block for treatment of complex,

comminuted proximal femoral fractures. 5 proximal locking

screws (5 mm,non-cannulated) provide an angular stable

construct independent of bone quality. The varied angle

of multiple screw insertions within the complex trabecular

zone of the head neck region of proximal femur provides

for an optimal mechanical stability. Further 120–135°

screws provide calcar stability and maintain neck shaft

angle (prevent varus collapse). The use of multiple screws

in the head neck area effectively increases the overall cross

sectional purchase in this anatomically peculiar area.

Our study has one limitations; it is a case series and not a

comparison between two surgical technique in a

randomized fashion. But it has two main strengths, first it

is a unique study describing a new technique with new

implant, second the data analysed here pertain to a specific

type of injury; all the fractures were unstable proximal

femoral fractures.

CONCLUSIONS

PF-LCP is an effective implant for unstable proximal femoral

fractures (osteoporosis). PF-LCP provides fixed angle

block and provide angular stability with early functional

rehabilitation.

REFERENCES

1. Ehmke L.W., Fitzpatrick D.C., Krieg J.C. Lag screws for

hip fracture fixation: evaluation of migration resistance

under simulated walking. J Orthop Res. 2005;23:1329–

1335.

2. Dobbs R.E., Parvizi J., Lewallen D.G. Perioperative

morbidity and 30-day mortality after intertrochanteric hip

fractures treated by internal fixation or arthroplasty. J

Arthroplasty. 2005;20(8):963–966.

3. Rockwood and green’s fractures in adults, vol. 2, 7th ed.

Intertrochanteric Fractures. Thomas A Russell. Page 1597–

1600.

4. Koot V.C.M., Kesselaer S.M.M.J., Clevers G.J., DeHooge

P., Weits T. Evaluation of the singh index for measuring

osteoporosis. J Bone Joint Surg [Br] 1996;78-B:831–838.

5. Hasenboehler Erik A., Agudelo Juan F., Morgan Steven J.,

Smith Wade R., Hak David J., Stahel Philip F. Treatment

of complex proximal femoral fractures with proximal femur

locking compression plate. Orthopaedics. August

2007;30(8)

6. Hugh Owen Thomas, quoted by Rockwood CA, Green

DP. Fracture in Adults, 4th ed., vol. 2, 1972–73.

7. Townsend Kenneth, Gilfillan Charles. A new type of bone

plate and screws.SurgGynecol Obstet. 1943;77:595–597.

8. Smith Peterson M. Treatment of neck of femur by internal

fixation. SurgGynecol Obstet. 1937;64:287.

9. Dimon J.H.J.C. Unstable intertrochanteric fractures of

the hip. J Bone Joint Surg Am. 1967;49(3):440–450.

10. Medoff R.M. A new device for the fixation of unstable

pertrochanteric fractures of the hip. J Bone Joint Surg

Am. 1991;73(8):1192–1199.

11. Knobe Mathias, GradlGertraud, burger Andreasladen,

TarkinIvans S., PapeHanschristoph. February 2013.

Clinical Orthopaedics and Related Research. 11999-013-

2834-9.

12. Sharma V., Babhulkar S., Babhulkar S. Role of gamma nail

in management of pertrochanteric fractures of femur. Indian

J Orthop. 2008;42:212–2

13. Simpson A.H., Varty K., Dodd C.A. Sliding hip screws:

modes of failure. Injury. 1989;20:227–231.

14. Nungu K.S., Olerud C., Rehnberg L. Treatment of

subtrochanteric fractures with the AO dynamic condylar

screw. Injury. 1993;24:90–92.

15. OzkayaUfuk, BilgiliFuat, KilicAyhan, Parmaksizoglu

AtillaSancar, KabukcuogluYavuz. Minimally invasive

management of unstable proximal femoral extracapsular

fractures using reverse LISS femoral locking plates. Hip

Int. 2009;19(2):141–147.

Proximal Femoral Locking plate in Unstable Extracapsular Proximal Femoral Fractures: 96

VOL. 31, NO. 2, JULY 2016


INTRODUCTION

Fixed flexion deformity is a common accompaniment in

advanced arthritis of the knee joint. Complete correction

of fixed flexion deformity at the time of surgery remains

challenging and technically demanding.It is estimated that

up to 90% of patients with RA will eventually have the

involvement of the knees1. Among those patients,

progressive destruction of joints leads to the occurrence

of flexion contracture in both of their knees and thus these

patients are deprived of ambulation for long periods of

time2-4. Underlying the severe flexion deformity is a usually

complex combination of musculotendinous, ligamentous,

and capsular contractures as well as often bone loss and

significant valgus. Although the total knee arthroplasty

(TKA) can be performed in this challenging patient4,5,

intraoperative correction of severe flexion deformity

presented a challenging situation for orthopedic

surgeons4,6,7.

Original Article

Total Knee Arthroplasty In Patients With

Fixed Flexion Deformity

Abdus Salam1, Golam Sarwar2, Tanvir Hasan3, Mohammad Moazzem Hossain4, Riad Majid5

ABSTRACT

Fixed flexion deformity is a common accompaniment in advanced arthritis of the knee joint. Complete

correction of fixed flexion deformity at the time of surgery remains challenging and technically demanding.

The purpose of our study was to assess the result of total knee replacement using a preset algorithm to

assess the effect that a preoperative flexion deformity has on postoperative correction. Twenty patients

with advanced arthritis and a flexion deformity underwent total knee arthroplasty. The patients were divided

in two groups. Group 1 consisted of all patients with a flexion deformity up to 30 degree. Group 2 consisted

of all patients with a flexion deformity of greater than 30 degree. All surgeries were performed using a

posterior cruciate substituting implant. An attempt to achieve maximal or complete correction of the flexion

deformity was made at the time of surgery Results: The flexion deformity was fully corrected in 20 knees. In

knees with a flexion deformity up to 30 degree, the mean improvement was from 16 degree to 1 degree. In

knees with a flexion deformity of more than 30 degree, mean improvement was from 40 degree to 15 degree.

Correction of the flexion deformity was significantly different between the two groups (mild to moderate, <30

degree and severe, >30 degree). Total knee replacement was very successful in correcting the flexion

deformity. Though our study is very short but we can give a hypothesis that the amount of preoperative

deformity adversely affects the postoperative result.

Key Words: Total Knee Replacement, Osteoarthritis, Fixed flexion deformity.

Bone cuts have to be performed according to the anatomy

and implant design and appropriate ligament balancing is

required. However, it is potentially a poor strategy, as more

bony cuts are needed to get the knee straight in the

operation of patients with severe flexion contracture,

which creates more problems with respect to instability

thereby causing pain and dysfunction8,9. However,

incomplete intraoperative correction of severe flexion

deformity would lead to more residual flexion contracture

postoperatively10. Therefore, proper soft tissue balancing

was very important in TKA for patients with flexion

contracture and valgus deformity, which do not only

achieve an obvious correction of the flexion contracture

but also effectively improve the range of motion and the

functional recovery of the knee joint after TKA11. Atilla et

al.12 reported that pre-operation flexion contracture of 27.5°

is an important threshold and patients should be operated

before that stage to gain maximum benefit with minimal

1. Associate Professor, OSD, Kustia Medical College

2. Associate Professor, Department of Orthopaedic Surgery, DMCH, Dhaka

3. Medical Officer, Lab Aid Hospital

4. Medical Officer (OSD), DGHS, Deputed NITOR, Dhaka

5. Clinical Assistant, NITOR, Dhaka

Correspondence : Dr. Abdus Salam, Associate Professor, OSD, Kustia Medical College



gait abnormalities. Mitsuyasu et al.13 reported that flexion

contracture eventually existed if the contracture was more

than 15° 3 months after TKA surgery in severe flexion

contracture of the knees. Cheng et al.14 reported that

patients with a preoperative fixed flexion deformity show

continued improvement in their fixed flexion up to 10 years

post-arthroplasty and have similar outcomes to those with

no preoperative fixed flexion.

Along with our increased understanding of the patients

with flexion contracture, special attention should be paid

to the inferior bone density, and the soft tissue needs to

be treated with special care. With the development of

technique and device of TKA, it is recommended to limit

bone resection with mandatory release of the posterior

capsule and the collateral ligaments to get the knee straight

in the operation and stable in the post-operation in the

most severe cases15. Although it has been reported that

the release of the posterior capsule and the collateral

ligaments until some flexion for severe flexion contractures

remains in patients, the debate continues as to which flexion

contractures should be totally or partly corrected in

operation10,16,17,18. It is very important for the modern

TKA not only to restore a balance between the osteotomy

and ligament release in procedures but also to maintain

the joint tension in procedures to prevent joint laxity in

the unusual condition of severe flexion contracture

deformity of the knee. The purpose of this paper was to

report our experience on knees with severe flexion

contractures performed with one-stage TKA.

PATIENTS AND METHODS

This retrospective study reviewed severe flexion

contracture of patients who underwent primary TKA and

soft tissue balancing from June 2010 to July 2016. The

data included preoperative, intraoperative, and

postoperative evaluation at standard intervals and annual

follow-up reports. All patients were diagnosed as arthritis

of knee. The inclusion criteria were knees had flexion

contracture with valgus deformity. Exclusion criteria

included pathologic conditions of the RA knee (trauma,

tumor, or infection). Four patients initially fulfilled the

study criteria. According to the criterion of flexion

contracture which is beyond or less 30°, patients available

for analysis were divided into two groups, i.e., severe

flexion group (SF) (with flexion contracture beyond 30°;

4cases initially, and moderate flexion group (MF) (with

flexion contracture less 30° and beyond 10°; 4 cases initially.

The data of age and sex distribution, flexion, range of

motion (ROM) and knee society Rating System (KSS)

score, and the course of disease are shown in Table 1.

Patient data (data expressed as means±SD)

There was no significant difference between two groups

(p>0.05).

The TKA surgical procedure included a standard

anteromedial approach, the use of an intramedullary femoral

and extramedullarytibial alignment rod, measured bone

resection, and differential ligament balance in flexion and

extension9. Measured resection implies that the amount of

bone resected from the intact compartment of the joint equals

the thickness of the implant, while restoring correct

alignment by resecting the bone perpendicular to the

mechanical axis. Based on the correct osteotomy, recovering

full extension at the end of surgery is mandatory, by first

releasing the posterior capsule and the collateral ligaments

from their osteophytes and secondly by extending the distal

femoral cut where necessary. Once the correct bony

alignment is achieved, the flexion and extension spaces are

secured equally without massive soft tissue release and an

additional distal femur cut. It is very important in procedures

not only to restore a balance between the osteotomy and

ligament release but also to maintain the joint tension to

prevent joint laxity in severe flexion contracture of knees.

All patients received low molecular weight heparin as

prophylaxis for deep vein thrombosis; the first dose was

initiated 8 h after the operation. All patients received three

doses of Meropenem 1gm daily for 7 days and

Flucloxacilline as prophylaxis for infection, with the first

dose administered at the induction of anesthesia. The same

protocol for postoperative management was utilized in

both groups, which included bedside continuous passive

motion therapy, physical therapy with partial weight

bearing, and quadriceps and hamstring strengthening

exercises starting on the second postoperative day. Splints

are supportive devices for flexion in patients until the some

residual flexion contractures were totally corrected.

The knees were assessed preoperatively and at yearly

intervals after operation using KSS19. Furthermore, AP

and lateral knee X-rays are performed to detect any

radiolucencies to measure the deformity on the X-ray film

(Figures 1 and 2).

Table 1

Group (case) Sex Age Flexion ROM KSS Course of

Male Female (years) (deg) (deg) disease (year)

SF (2) 2 2 50.32± 8.69 50.84± 17.37 31.86± 11.25 27.48± 13.29 12.16± 2.25

MF (2) 1 3 48.68± 7.58 19.67± 10.46 68.16± 15.37 43.62± 15.46 9.30± 1.08

Total Knee Arthroplasty In Patients With Fixed Flexion Deformity 98

VOL. 31, NO. 2, JULY 2016


Fig.-2: 1 Plain anteroposterior and lateral radiographs of a 49-year-old female which reveal joint destruction. This

case is a 49–year-old female patient with flexion contractures deformity. After TKA on left knee, the 53° flexion

contracture was completely corrected postoperatively.

Fig.-1: Plain anteroposterior and lateral radiographs of a 43-year-old female which reveal joint destruction. This

case is a 43-year-old female patient with flexion contractures deformity. After TKA on the left knee, the 27° flexion

contracture was completely corrected postoperatively.

Table-II

Clinical outcomes (data expressed as means±SD)

Group Flexion (deg) ROM (deg) KSS score

Pre-OP Post-OP Pre-OP Post-OP Pre-OP Post-OP

SF 50.84±17.37 1.14± 0.27a 31.86± 11.25 115.72±15.13a 27.48± 13.29 80.67±9.35a

MF 19.67±10.46 1.12± 0.35a 68.16±15.37 118.34±12.68a 43.62± 15.46 87.15±8.64a

aNo significant difference in these groups (p>0.05). OP, operation.

99 Abdus Salam, Tanvir Hasan, Mohammad Moazzem Hossain, Riad Majid



STATISTICS

All measurements were performed by a single observer

and are expressed as means ± standard deviation (SD).

RESULTS

There were no intraoperative complications in this study.

Soft tissue release surgery and additional bone cuts

were performed in all cases of severe flexion contractures.

Afterwards, cases had follow-up from 12 to 48months

(average of 24 months),

The flexion contractures and ROM were shown in Table-

II. The average flexion contractures and ROM were not

different between SF and MF groups (1.14±0.27 vs.

1.12±0.35 and 115.72±15.13 vs. 118.34±12.68). As shown

in Table-II, the KSS improved and was better in MF

group than SF group (87.15±8.64 vs. 80.67±9.35). Based

on the Hospital for Special Surgery score, the rate of

good or excellent was higher in MF group than SF group

(SF=excellent, 2 knees; good, 1 knees; general, 1knees;

and poor, 0knees; MF=excellent, 3 knees; good, 1 knees;

and general, 0 knees).

There were no infection complication and no cases with

patellar dislocation or subluxation seen in this study.

There were 1cases with mild mediolateral instability in

the SF for a massive release of soft tissue during TKA.

DISCUSSION

Knees with severe flexion contracture usually present

with posterior subluxation of the tibia, proximal tibial

bone deficiency combined with valgus deformity, and

external rotation of the tibia, which can be partially

attributed to the contracture and the traction of the

biceps muscle and iliotibial tract20. The involvement of

the periarticular soft tissues is part of the constellation

of pathology in rheumatoid arthritis. Hence, it is critical

to achieve correction of deformity, equalize the medial

and lateral soft tissue tension, and implant the

components accurately. Appropriate soft tissue

balancing in the form of ligament and capsular release

at the time of arthroplasty is essential to the success of

the procedure21,22. As to the remaining some flexion in

operation, it was especially important to properly

position the individual components and the resulting

overall alignment of the lower extremity in knee with

one-stage TKA18. In the present study, successful TKA

was performed in not only in moderate flexion

contracture patients but also in severe flexion deformity

of patients, and all cases had good clinical results.

Once the correct bony alignment is achieved, it is very

important for the success of TKA that the medial and

lateral joint laxity does not exceed more than 2 mm in

the stress test (varus and valgus stress testing) when

prostheses are implanted.

Although TKA can be performed in this challenging

patients4,5, complete intraoperative correction of severe

flexion deformity presented a challenging situation for

orthopedic surgeons4,5. Various techniques of

addressing these deformities have been described

including additional bony resection, ligamentous

releases, and the use of increasing constraint

prosthesis16. However, an ideal soft tissue balance is

difficult to obtain during surgery23. Appropriate soft

tissue balancing in the form of ligament and capsular

release at the time of arthroplasty is essential to the

success of TKA procedures, which not only achieves

an obvious correction of the flexion contracture but

also effectively improves the range of motion and the

functional recovery of the knee joint after TKA9,20.

However, indications of orthopedic procedure on the

flexion contracture were complex and required special

consideration of the adequate collateral stability and

extensive experience in TKA surgery2,24,25,26. In our

early experience on severe flexion contractures in one

patient, instability was caused by a massive release of

soft tissue during TKA procedure. Therefore,

appropriate soft tissue balancing in the form of ligament

and capsular release at the time of arthroplasty is

essential to the success of TKA procedures in severe

flexion contractures of RA patients.

Flexion contracture is a common deformity encountered

during total knee arthroplasty, and severe fixed

deformities require surgical correction with release of

the contracted soft tissues and appropriate

management of the femoral bone resection27. Traditional

methods for correcting a severe flexion deformity of the

knee during total knee arthroplasty can often lead to

the excessive release of the posterior capsule and medial

or lateral collateral ligament28. As many reports on flexion

contracture management in the knee are available in

the literature, the peroneal nerve palsy in TKA was

concerned previously2,3. Preoperative severe flexion

contracture was assumed as the risk factor for the

development of the nerve palsy after TKA29,30. In TKA,

complete intraoperative correction of severe flexion

deformity is dangerous, which can cause complications


VOL. 31, NO. 2, JULY 2016


such as the peroneal nerve palsy31. At present study,

the surgical decompression of peroneal nerve was not

performed and the transient peroneal nerve palsy had

recovered after conservative therapy. Thus, the good

result should be due to the appropriate soft tissue

balancing other than a massive release at the time of

arthroplasty.

The success of TKA in severe flexion deformity of patients

depends on many factors, including the preoperative

condition of the joint, surgical technique, and

postoperative rehabilitation32,33,34. Splints are good

supportive devices in flexion patients. The experience of

Sarokhan et al.10 has shown that the use of preoperative

and postoperative serial casts aids greatly in the correction

of severe flexion deformity of the knee. The use of dynamic

extension splinting at night is beneficial to improve flexion

contractures in this case studies. Physiotherapy is another

important component of flexion patients33. In this study,

splints are supportive devices in flexion patients until the

some residual flexion contractures were totally corrected.

Rand35 reported that the most important complication

affecting the results of total knee replacement in patients

is infection. Rates of infection have been reported to be

approximately three times greater in patients with RA than

in those with OA36,37.

CONCLUSIONS

TKA can be performed successfully in knees with severe

flexion contracture. It is very important in TKA to maintain

the joint stability in the condition of severe flexion

contracture deformity of the knee.

DECLARATIONS

Competing interests

The authors declare that they have no competing

interests.

REFERENCES

1. Kajino A, Yoshino S, Kameyama S, Kohda M, Nagashima

S: Comparison of the results of bilateral total knee

arthroplasty with and without patellar replacement for

rheumatoid arthritis - a follow-up note. J Bone Joint Surg

Am. 1997, 79A (4): 570-574.Google Scholar

2. Aglietti P, Windsor RE, Buzzi R, Insall JN: Arthroplasty

for the stiff or ankylosed knee. J Arthroplasty. 1989, 4

(1): 1-5. 10.1016/S0883-5403(89)80046-4.View Article

PubMedGoogle Scholar

3. Chmell MJ, Scott RD: Total knee arthroplasty in patients

with rheumatoid arthritis. An overview. ClinOrthopRelat

Res. 1999, 366: 54-60.View ArticlePubMedGoogle Scholar

4. Tew M, Forster IW: Effect of knee replacement on flexion

deformity. J Bone Joint Surg Br. 1987, 69 (3): 395-

399.PubMedGoogle Scholar

5. McPherson EJ, Cushner FD, Schiff CF, Friedman RJ:

Natural history of uncorrected flexion contractures

following total knee arthroplasty. J Arthroplasty. 1994, 9

(5): 499-502. 10.1016/0883-5403(94)90096-5.View

ArticlePubMedGoogle Scholar

6. Firestone TP, Krackow KA, Davis JD, Teeny SM,

Hungerford DS: The management of fixed flexion

contractures during total knee arthroplasty. ClinOrthopRelat

Res. 1992, 284: 221-227.PubMedGoogle Scholar

7. McGrath MS, Mont MA, Siddiqui JA, Baker E, Bhave

A: Evaluation of a custom device for the treatment of

flexion contractures after total knee arthroplasty.

ClinOrthopRelat Res. 2009, 467 (6): 1485-1492. 10.1007/

s11999-009-0804-z.PubMed CentralViewArticlePub

MedGoogle Scholar

8. Abe S, Kohyama K, Yokoyama H, Shigeru M, Yasuhiro

T, Natsuko N, Yasuhiro S, Hiroyuki F: Total knee

arthroplasty for rheumatoid knee with bilateral, severe

flexion contracture: report of three cases. Mod Rheumatol.

2008, 18 (5): 499-506. 10.1007/s10165-008-0079-3.View


9. Massin P, Petit A, Odri G, Ducellier F, Sabatier C,

Lautridou C, Cappelli M, Hulet C, Canciani JP, Letenneur

J, Burdin P, Sociétéd’orthopédie de l’oues: Total knee

arthroplasty in patients with greater than 20 degrees flexion

contracture. OrthopTraumatolSurg Res. 2009, 95 (4 Suppl

1): S7-S12.View ArticlePubMedGoogle Scholar

10. Sarokhan AJ, Scott RD, Thomas WH, Sledge CB, Ewald

FC, Cloos DW: Total knee arthroplasty in juvenile

rheumatoid arthritis. J Bone Joint Surg Am. 1983, 65 (8):

1071-1080.PubMedGoogle Scholar

11. Ito J, Koshino T, Okamoto R, Saito T: 15-year follow-up

study of total knee arthroplasty in patients with

rheumatoid arthritis. J Arthroplasty. 2003, 18 (8): 984-

992. 10.1016/S0883-5403(03)00262-6.View ArticlePub

MedGoogle Scholar

12. Atilla B, Caglar O, Pekmezci M, Buyukasik Y, Tokgozoglu

AM, Alpaslan M: Pre-operative flexion contracture

determines the functional outcome of

haemophilicarthropathy treated with total knee

arthroplasty. Haemophilia. 2012, 18 (3): 358-363.

10.1111/j.1365-2516.2011.02695.x.View ArticlePub

MedGoogle Scholar

13. Mitsuyasu H, Matsuda S, Miura H, Okazaki K,

Fukagawa S, Iwamoto Y: Flexion contracture persists if

the contracture is more than 15 degrees at 3 months after

total knee arthroplasty. J Arthroplasty. 2011, 26 (4): 639-

643. 10.1016/j.arth.2010. 04.023.View ArticlePubMed

Google Scholar

14. Cheng K, Ridley D, Bird J, McLeod G: Patients with

fixed flexion deformity after total knee arthroplasty do

just as well as those without: ten-year prospective data.

IntOrthop. 2010, 34 (5): 663-667. 10.1007/s00264-009-

0801-6.PubMed CentralViewArticlePubMedGoogle

Scholar

101 Abdus Salam, Tanvir Hasan, Mohammad Moazzem Hossain, Riad Majid



15. Koshino T, Okamoto R, Takagi T, Yamamoto K, Saito T:

Cemented ceramic YMCK total knee arthroplasty in

patients with severe rheumatoid arthritis. J Arthroplasty.

2002, 17 (8): 1009-1015. 10.1054/arth.2002.35826.View


16. Berend KR, Lombardi AV, Adams JB: Total knee

arthroplasty in patients with greater than 20 degrees flexion

contracture. ClinOrthopRelat Res. 2006, 452: 83-87.View


17. Goudie ST, Deakin AH, Ahmad A, Maheshwari R, Picard

F: Flexion contracture following primary total knee

arthroplasty: risk factors and outcomes. Orthop. 2011,

34 (12): e855-e859.Google Scholar

18. Quah C, Swamy G, Lewis J, Kendrew J, Badhe N: Fixed

flexion deformity following total knee arthroplasty. A

prospective study of the natural history. Knee. 2012, 19

(5): 519-521. 10.1016/j.knee.2011.09.003.View


19. Insall JN, Dorr LD, Scott RD, Scott WN: Rationale of the

Knee Society clinical rating system. ClinOrthopRelat Res.

1989, 248: 13-14.PubMedGoogle Scholar

20. Tanzer M, Miller J: The natural history of flexion

contracture in total knee arthroplasty. A prospective study.

ClinOrthopRelat Res. 1989, 248: 129-134.PubMedGoogle

Scholar

21. Ojima T, Yokogawa A, Yamakado K, Ogawa K, Kobayashi

T, Nakashima A, Ogawa H: Bilateral total knee arthroplasty

after spontaneous osseous ankylosis in rheumatoid

arthritis. Mod Rheumatol. 2005, 15 (2): 139-143. 10.1007/

s10165-005-0380-3.View ArticlePubMedGoogle

Scholar

22. Smilowicz M, Jung L: Total knee arthroplasty in patients

with severe deformities due to rheumatoid arthritis.

OrtopTraumatolRehabil. 2005, 7 (6): 673-679. Pub Med

Google Scholar

23. Whiteside LA: Selective ligament release in total knee

arthroplasty of the knee in valgus. ClinOrthopRelat Res.

1999, 367: 130-140.View ArticlePubMedGoogle Scholar

24. Kim JM, Moon MS: Squatting following total knee

arthroplasty. ClinOrthopRelat Res. 1995, 313: 177-

186.PubMedGoogle Scholar

25. Laskin RS, O’Flynn HM: The Insall Award. Total knee

replacement with posterior cruciate ligament retention in

rheumatoid arthritis. Problems and complications.

ClinOrthopRelat Res. 1997, 345: 24-28.View


26. McAuley JP, Engh GA: Constraint in total knee

arthroplasty: when and what?. J Arthroplasty. 2003, 18

(3 Suppl 1): 51-54.View ArticlePubMedGoogle Scholar

27. Scuderi GR, Kochhar T: Management of flexion contracture

in total knee arthroplasty. J Arthroplasty. 2007, 22 (4

Suppl 1): 20-24.View ArticlePubMedGoogle Scholar

28. Meftah M, Blum YC, Raja D, Ranawat AS, Ranawat CS:

Correcting fixed varus deformity with flexion contracture

during total knee arthroplasty: the “inside-out” technique:

AAOS exhibit selection. J Bone Joint Surg Am. 2012, 94

(10): e66-View ArticlePubMedGoogle Scholar

29. Knutson K, Leden I, Sturfelt G, Rosen I, Lidgren L: Nerve

palsy after knee arthroplasty in patients with rheumatoid

arthritis. Scand J Rheumatol. 1983, 12 (3): 201-205.

10.3109/03009748309098533.View ArticlePubMed

Google Scholar

30. Omeroglu H, Ozcelik A, Turgut A: Bilateral peroneal nerve

palsy after simultaneous bilateral total knee arthroplasty.

Report of a case with rheumatoid arthritis. Knee Surg

Sports TraumatolArthrosc. 2001, 9 (4): 225-227. 10.1007/

s001670100211.View ArticlePubMed Google Scholar

31. Lu H, Mehdi G, Zhou D, Lin J: Simultaneous bilateral

total knee arthroplasty for rheumatoid arthritis. Chin Med

J (Engl). 1996, 109 (12): 937-940.Google Scholar

32. Figgie HE, Brody GA, Inglis AE, Sculco TP, Goldberg

VM, Figgie MP: Knee arthrodesis following total knee

arthroplasty in rheumatoid arthritis. ClinOrthopRelat Res.

1987, 224: 237-243.PubMedGoogle Scholar

33. Papotto BA, Mills T: Treatment of severe flexion deficits

following total knee arthroplasty: a randomized clinical

trial. OrthopNurs. 2012, 31 (1): 29-34. 10.1097/

NOR.0b013e3182419662.View ArticlePubMedGoogle

Scholar

34. Smilowicz M: Problems involved in total knee arthroplasty

for rheumatoid arthritis patients. OrtopTraumatolRehabil.

2000, 2 (4): 27-31.PubMedGoogle Scholar

35. Rand JA, Ilstrup DM: Survivorship analysis of total knee

arthroplasty. Cumulative rates of survival of 9200 total

knee arthroplasties. J Bone Joint Surg Am Vol. 1991, 73

(3): 397-409.Google Scholar

36. Poss R, Thornhill TS, Ewald FC, Thomas WH, Batte NJ,

Sledge CB: Factors influencing the incidence and outcome

of infection following total joint arthroplasty.

ClinOrthopRelat Res. 1984, 182: 117-126.PubMedGoogle

Scholar

37. Wilson MG, Kelley K, Thornhill TS: Infection as a

complication of total knee-replacement arthroplasty. Risk

factors and treatment in sixty-seven cases. J Bone Joint

Surg Am. 1990, 72 (6): 878-883.PubMedGoogle Scholar


VOL. 31, NO. 2, JULY 2016


Original Article

Evaluation of Result of Treatment of

Epidural Steroid Injection in Lumbar

Radiculopathy

Apel Chandra Saha1, Muhammad Awlad Hossain2

ABSTRACT

The objective of this study was to investigate the clinical effectiveness of Epidural steroid injections (ESIs) (i.e.

2ml of triamcinolone 80mg and 2ml of injection 2% lignocaine) for lumbar radiculopathy in patient with lumabr

disc herniation or spinal stenosis. We included 24 patients (M-9, F-15), age ranged from 25-60 years (average

37.5), clinical & MRI findings positive (19 disc herniation & 5 spinal stenosis) treated with Epidural steroid

injections (ESIs) 16 patients (66.67%) had complete resolution of pain within 1 week, 6 (25%) patients had 50-75%

relief of symptoms. No improvement or less than 50% symptoms relief was found in 2 (8.33%) patients. So

Epidural steroid injections (ESIs) for lumbar radiculopathy due to lumbar disc herniation or spinal stenosis is a

simple, safe and effective modality of treatment.

Keywords: Epidural Steroid, Lumbar radiculopathy, Safe and effective treatment

1. Jr. Consultant, Upazilla Health Complex, Debidwar, Comilla

2. Jr. Consultant, OSD DG attached to Kurmitola General Hospital, Dhaka

Correspondence: Dr. Apel Chandra Saha, Junior Consultant, Upazilla Health Complex, Debidwar, Comilla

INTRODUCTION

Epidural steroid injections (ESIs) are a common method of

treating inflammation associated with low back related leg

pain when spinal nerves become inflamed due to

narrowing of the passage where the nerves travel as the

pass down or out of the spine1.Epidural steroid injections

(ESIs) have been endorsed by the North American Spine

Society and the Agency for healthcare Research and

Quality (formerly the Agency for Health Care Policy and

Research) of Department of Health and Human Services

as an integral part of nonsurgicalmanagement of radicular

pain from lumbar spine disorders1.

Lumbar epidural medication injections was first performed

using caudal approach in 1901when cocaine was injected

to treat lumbago sciatica3(De. Pasquier and

Leri).According to reports, epidural from the 1920s-1940s

involved using high volume of normal saline and local

anaesthetics3. Injection of corticosteroids into the epidural

space for the management of lumbar radicular pain was

first recorded in19523 (Robecchi and Capra).

Lumbar disc herniation causes spinal nerve root

compression that causes pain, dermato malhypoesthesia,

weakness of muscle groups innervated by the involved

nerve root.

In degenerative spinal stenosis there is calcification and

hypertrophy of ligamentum flavum. The end result reduces

spinal canal dimension and compression of neural

elements. The resultant venous congestion and

hypertension are responsible for the symptoms complexes

known as intermittent neurogenic claudication.

Treatment options either operative or non-operative. We

had chosen those people in whom other treatment attempts

(eg. medications, physiotheraphy) have failed and are

interested on non-operative treatment.


This is a prospective observational study carried out at

NITOR and different Private Hospitals in Dhaka from

January 2009 to December, 2009. The patients had an

unequivocal morphological imaging finding explaining the

radiculopathy. The following inclusion criteria were

required: (1) monoradicular leg pain with minor sensory/

motordeficit (MRC grade>M3), (2) unequivocal

morphological correlate at MRI, (3) duration of symptoms

less than 6 months. Exclusion criteria were: (1) relevant

motor deficit (MRC<M3), (2) Cauda equina syndrome

(necessitating immediate surgical decompression), (3)

Previous spinal surgery.

103 VOL. 31, NO. 2, JULY 2016


A total 24 patients of lumbar radicular pain were selected

consecutively.Cases were diagnosed onclinical and MRI

findings. Both sexes, age ranged from 25-60 years were

included. The average duration of symptoms was 10 weeks

(range 4-20 weeks). Patients were followed up at 2, 3, 6

weeks and at 6months and 9 months.

TECHNIQUE:

Under all aseptic precautions patients lie in operation table

on their side in a slightly curled position. The skin in the

low back area wascleaned andthen numbed with a local

anaesthetic agent (2% lignocaine). Then insert an1 8

gaugetuhey epidural needle through skin of affected

lumbar intervertebral space and directed towards

epiduralspace. After confirming the epidural space by loss

of registance technique an injection of 4ml volume

(Injection Triamcinolone 80 mg(2ml)with injection 2%

lignocaine2ml) in the epidural space. The injection was

again given after 1month. Successive 3 injections were

given.

RESULT:

This prospective study of treatment of Epidural Steroid

injection in lumbar radiculopathy was carried out in 24

patients to find out the common cause of lumbar

radiculopathy, age and sex incidence and to propose a

protocol for treating such cases. The result of Epidural

Steroid injection in lumbar radiculopathy was evaluated

on the basis of subjective resolution of symptoms.

Complete resolution of symptoms was considered as

excellent outcome, 50-75% resolution of symptoms was

evaluated as good and no improvement or less than 50%

symptoms relief was considered as poor outcome.

Set of materials for Epidural steroid injections (ESIs)

Table-I

Age distribution of the patients (n=24)

Age in years Number Percentage (%)

<30 2 8.33

30-39 11 40.23

40-49 6 25

>50 5 20.83

Mean SD 38.19 Range 28-26

Table-II

Distribution of symptoms of leg pain (n=24)

Site Number Percentage (%)

Left 16 66.67

Right 8 33.33

Table-IIIDuration of symptomsof patients(n=24)

Duration of

symptoms Minimum Maximum Average

(in weeks)

4 20 10

Table-IV

Duration of hospital stay (n=24)

Hospital stay Minimum Maximum Average

(in hours) 2 6 3

Table-V

Duration of follow up (n=24)

Minimum Maximum Average

Follow up in months 2 9 6

Table-VI

Location of disc herniation and spinal stenosis

L3-L4 L4-L5 L5-S1 Total

Disc herniation 2 10 7 19

Spinal stenosis 0 3 2 5

Table-VII

Complications of epidural steroid injection

Complications Number Percentage (%)

Nausea and Vomiting 8 33.33

Painful injection site 2 8.33

Dural Puncture 1 4.2

Evaluation of Result of Treatment of Epidural Steroid Injection in Lumbar Radiculopathy 104

VOL. 31, NO. 2, JULY 2016


Table-VIII

Functional outcome of the study (n=24)

Result Number of patients Percentage (%)

Excellent 16 66.67

Good 6 25

Poor 2 8.3

Table-IX

Final outcome of the study (n=24)

Result Number of patients Percentage (%)

Satisfactory 22 91.67

Unsatisfactory 2 8.33

Among 24 patients 16(66.67%) cases were excellent, 6 (25%)

cases were good, &2 (8.3%) case was poor. The overall

result was analyzed by categorizing satisfactory (excellent

and good) 22 (91.67%) cases and unsatisfactory ( poor) 2

(8.33%) cases.

DISCUSSION

Epidural steroid injections (ESIs) are a common treatment

option for many formsof low back pain and leg pain. They

have been used for low back problem since 19523 and are

still an integral part of non-surgical management of sciatica

and low back pain.

In low back pain and radicular pain,itwas initially thought

to be due to compression of the nerve secondary to

degenerative lumbar disc diseases. Continued study has

centered on the effects of leakage of the contents of

nucleus pulposusand the nerve supply of annulus

fibrosus. The pulposus leak causes the release of

severalneuropeptides such as substance P,Vasoactive

intestinal peptide, calcitoningene-related peptide and also

Nitricoxide (NO) and tumournecrosis factor alpha,

production of hyperalgesic prostaglandins thromboxanes

and leukotrienes1. This is further enhanced by attraction

of lymphocytes, macrophages and fibroblasts. The

associated ischaemia and inflammation may sensitize free

nerve endings producing back pain1. The biological

components may also-sensitize the adjacent nerve root &

dorsal root ganglion thereby creating nerve root

symptoms1.

The use of Epidural steroid injections (ESIs) helps decrease

inflammation by decreased synthesis or release of pro-

inflammatory substancesas well as causing a reversible

local anaesthetic effects1.

There are three processes of Epiduralsteroid injections

(ESIs)–Transforaminal, interlaminar and caudal. In our

series we used interlaminar approach.

In our series total 24 patients were included, among them9

(37.5%) were male &15 (62.5%) were female age ranged

from 25-60 years average 38.19years.

Regarding radicular pain, symptoms were more in left leg

16 (66.6%).Regarding hospital stay, minimum period was 2

hours &maximum 6 hours, average 3 hours. Patients were

followed up at 2, 3, 6, 12 weeks &at6 months and at 9

months. Minium follow up period was 2 months and

maximum 9 months, average 6 months.

Regarding complication 8 patients (33.33%)had nausea

and vomiting, 2 (8.33%) patients had painful injection site,

1 (4.2%) patient had dural puncture.

Regarding the subjective assessment of this study

excellent outcome was found in 16 (66.67%) patients, good

in 6 (25%)patients and poor in 2(8.33%)patients.

In our series a satisfactory result was found in

22(91.67%)patients and unsatisfactory in 2 (8.33%)

patients.

CONCLUSION

Based on the result shown above it is concluded that

result of Epidural steroid injections (ESIs) due to lumbar

radiculopathy is a simple, safe and effective modality of

treatment. It is a minimally invasive procedure that can

help relieving back and leg pain caused by inflamed spinal

nerves10.

REFERENCES

1. Emedicine. medscape.com/article/325733-overview.

Author– Bouing Chen. MD. PhD. Clinical Associate

Professor, Department of physical medicine and

rehabilitation, Rutgess New Jersey Medical School.

2. Berman, Garbarino JL, Jr, Fisher SM, Bosacco SJ. The

effects of epidural injection of local anesthetics and

corticosteroids on patients with lumbosciatic pain. Clin

Orthop Relat Res. 1984;188:144-151. [PubMed]

3. Epidural steroids–CEACCP-Oxford Journals. https/

ceaccp, Oxfordjo....... continuing Education in Anaesthesia,

Critical Care by N.Collighan-2010, December 15, 2009.

4 Cuckler JM, Bernini PA, Wiesel SW, Booth RE Jr,

Rothman RH. Pickens GT: The use of epidural steroids in

the treatment of lumber radicular pain: a prospective,

randomized double blind study: J Bone Joint Surg Am

67:63-66,1985.Dilke TFW, Burry HC, Grahame R:

105 Apel Chandra Saha, Muhammad Awlad Hossain



Extradural corticosteroid injection in the management of

Lumbar/ nerve root compression: BMJ 2:635-637,1973.

5. Dinaggio A, Mooney V: The Mckenzie program: exercise

effective aga inst back pain. J Musculoskel Med Dec;

4(12):63, 1987a.

6. Goebert HW, Jr, Jallo SJ, Gardner WJ,Wasmuth CE.

Painful radiculopathy treated with epidural injections of

procaine and hydrocortisone acetate; results in 113

patients. AnesthAnalg. 1961; 40:130-134.[PubMed].

7. Koes BW, Scholten RJ, Mens JM, Bouter LM. Efficacy

of epidural steroid injections for low-back pain and sciatica:

a systematic review of randomized clinical trials Pain.

1995;63:279-288. [ PubMed]

8. Koes BW, Secholten Rj, Mens JM, Bouter LM. Efficacy

of spinal steroid injection for low back ache and sciatica:

an updated systemic review of randomized control trial.

Pain Digest. 1999;9:241-247

9. LutzGE, VAd VB, Wisneski RJ: Flurosicopic transforminal

lumber epidural steroids: an outcome study. Arch Phys

Med Rehabil 79:1362-1366,1998.

10. Weinstein SM, Herring SA: NASS. Lumber epidural

injections. Spine J 3(3) Suppl): 37S-44S, 2003.

Evaluation of Result of Treatment of Epidural Steroid Injection in Lumbar Radiculopathy 106

VOL. 31, NO. 2, JULY 2016


Evaluation of the Results of

Decompression and Stabilization of

Traumatic Lower Cervical Incomplete

Spinal Injury by Cervical Plate and Screw

Abdur Rob1, AKM Zahiruddin2, Shakawat Hossain3, Riad Majid3, Abdul Khaleque4, Mohammad

Mahbubur Rahman Khan5, Ripon Kumar Roy6

,

ABSTRACT

The purpose of this study was to evaluate the efficacy of anterior decompression, fusion and titanium plate

fixation in lower cervical spinal injury in respect of neurological outcome, post operative stability and early

rehabilitation. This study was conducted at NITOR, Dhaka from July 2013 to July 2015. Patients with traumatic

incomplete lower cervical spinal injuries were the study population. A total of 12 patients aged over the 15 years

were included in the study. Patient with open fracture, aged over 55 years, associated head injury, beyond 3

weeks of injury were excluded from the study. All cases were evaluated for their clinical features. During initial

phase, level and degree of neurological injury was assessed by ASIA impairment scale. Cervical traction was

applied to all patients. Patients with injury to C3 to C7 underwent decompression, fusion, stabilization by anterior

cervical plates & screws. The follow up range from 5 to 12 months with clinical and radiological assessment. The

mean age of the patients was 33 ± 12.15 years with age range from 16-32 years. Majority of the patients were

male (91.17%) and most commonly affected people were farmers (33.3%). Most of the occurrence were in rural

areas (66.7%). Bearing load on the head was the most common (50.0%) cause. Most commonly involved level of

injury was C5/C6 (33.3%). Subluxation/dislocation was the most common type of injury (33.3%). Majority of the

patients were operated in a single level (66.7%). Ruptured disc comprises the main bulk (41.7%) of per operative

findings. Among the complication, hemorrhage was the most common preoperative complication (16.7%). Other

complications included dysphagia (41.7%), temporary hoarseness (16.7%) and neck pain (33.3%). No reoperation

was required in any patient. Overall improvement was noted in (91.7%) cases. Result of bony fusion is highly

satisfactory having 100% success rate. No death occurred in the series. Mean hospital stay was 24.7 ± 5.77 days.

Evaluation of final outcome revealed 66.7% patients had satisfactory result and unsatisfactory result in 33.3%

patients. So, anterior decompression, fusion and stabilization by cervical plate and screws is an effective

method with good neurological and radiological outcome.

Keywords: Lower Cervical, Incomplete spinal injury, Fixation

Original Article

1. Associate Professor, Ortho Surgery, SSMC, Dhaka

2. Associate Professor, Ortho Surgery, NITOR, Dhaka

3. Assistant Registrar, Ortho Surgery, NITOR, Dhaka

4. Registrar, Ortho Surgery, NITOR, Dhaka

5. Assistant Registrar, Ortho Surgery, NITOR, Dhaka

6. Medical Officer, Ortho Surgery, NITOR, Dhaka

Correspondence: Abdur Rob, Associate Professor, Ortho Surgery, SSMC, Dhaka

INTRODUCTION

Acute injury to the spine and spinal cord are one of the

most common causes of severe disability and death after

trauma2. One third of these patient have injury that involve

the cervical spine11. For this reason, proper evaluation

and treatment of the injury to the spine and spinal cord

demand a systematic approach that is integrated into the

overall management of the traumatized patient.

The injury can be caused by any trauma to the cervical

spine that can result from motor vehicle accidents, fall,

sports injuries (particularly diving into shallow water),

gunshot-wounds, assaults and other. A seemingly minor



injury can cause spinal cord trauma if the spine is weakened

(e.g., from rheumatoid arthritis or osteoporosis). Cervical

spinal injury occurs most frequently in the young male

patient with an average age of 35 years4.

Cervical spinal cord injury may be complete resulting in

quadriplegia and incomplete resulting in anterior cord

syndrome, central cord syndrome, Brown-Sequard

syndrome, and specific nerve root injury. Spinal

concussion can also occur consisting of complete or

incomplete spinal cord dysfunction that is transient and

generally resolving within 1 or 2 days. Approximately 40%

of cervical spinal cord injury patients presents with

complete spinal cord injuries and 20% with either no cord

or only root lesions10.

Cervical spinal trauma complicated by injury to spinal cord

is a devasting event on a personal and family level as well

as tremendous financial burden to society because of its

attendant morbidity, the expensive and prolonged

necessary treatment regime and the patient life long

dependence on medical ancillary staff and resources6.

Surgical treatment involves decompressive surgery in the

spinal cord and stabilization of unstable spine following

management of patient’s cardiopulmonary and general

medial status5,8. Tractino is also frequently applied as a

decompressive method either alone or followed by

surgery1,3.

Recent advancement in anterior cervical instrumentation

in the treatment of subaxial cervical spinal injury shows

significant neurological & functional improvement occurs

in patient with incomplete cervical spinal injury9.

MATERIALS AND METHOD:

It was a Quasi experimental study carried out in NITOR,

Dhaka, Bangladesh. The study was conducted from July

2013 to July 2015. A total of 12 consecutive patients who

undergone anterior decompression and stabilization for

incomplete cervical spinal injuries included in the study.

Open fracture of cervical vertebrae and associated head

injury excluded from this criteria.

MANAGEMENT OF CERVICAL SPINAL INJURY:

History:

The most common causes of cervical spinal trauma are

bearing heavy weight on head, fall from height, motor

vehicle accident, diving, gunshot wounds, fall of heavy

object over body.

Physical examination:

General examination- Detailed general examinations was

done.

Local examination- The patient is “log-rolled” to avoid

further injury of spinal cord. The spine is inspected for

deformity, penetrating injury, haematoma or bruising. The

bone and soft-tissue structures are palpated. A haematoma,

a gap or a step are signs of instability.

Neurological examination:

Neurological status greatly impacts treatment option and

prognoses. The American spinal injury association (ASIA)

Scoring system assisted in documenting monitoring and

treating the patients. During motor examination it is

important to differentiate between complete and

incomplete spinal cord injuries. Evidence of sacral spearing

can establish the diagnosis of an incomplete spinal cord

injury. Intact perianal sensation suggests a partial rather

than complete lesion7.

Radiological evaluation:

• Pain-X-ray: Initial radiographic assessment includes

antero-posterior (AP) and lateral spine films.

• CT-Scan

• MRI.

RESULTS

Table-I

Causes of injury

Cause Number %

Fall while carrying heavy weight on head 6 50

Fall from height 3 25

RTA 1 8.3

Fall on the ground 1 8.3

Other 1 8.3

In this study, fall while carrying heavy weight on head

6(50%) was the most common cause of injury. Other cause

of injury were fall from height 3 (25%), RTA 1 (8.3%), fall

on the ground 1 (8.3%).

Table-II

Type of injury

Findings Frequency %

Subluxation/dislocation 4 33.3

Presence of bone or disc fragment 2 16.7

compressing atneriorly

Fracture-Dislocation 3 25

Compression fracture 3 25

Evaluation of the results of decompression and stabilization of traumatic lower cervical incomplete spinal injury 108

VOL. 31, NO. 2, JULY 2016


Shows the distribution of patients according to findings

of imaging. Subluxation/dislocation 4 (33.3%) was the most

common cause.

Table-III

Distribution of patients according to level of injury

Level of injury Frequency %

C3/C4/C5 1 8.3

C4/C5 2 16.7

C5/C6 4 33.3

C6 1 8.3

C6/C7 3 25

C7/T1 1 8.3

In this series, most common level of injury was in C5/C6

level, 4 (33.3%) followed by C6/C7 level, 3 (25%), then C4/

C5 level, 2 (16.7%). Only one case was seen in C3/C4/C5

level and C6 & C7/T1 level. No case was seen in C3, C3/C4,

C4, C5 & C7 vertebra level.

Table-IV

Early post operative complications

Complications Frequency %

Dysphagia 5 41.7

Temporary hoarseness 2 16.7

Respiratory problem 1 8.3

Regarding early post operative complication, it was

observed that 5 (41.7%) patients developed dysphagia, 2

(16.7%) patient had temporary hoarsenessness & 1 (8.3%)

patient had respiratory problem. There was no infection

or thrombo-embolic manifestation or graft migration.

Table-V

Neurological status at discharge

ASIA Grade No. of Patient %

C 2 16.7

D 7 58.3

E 3 25

Shows the distribution of patient’s neurological status at

discharge. Highest no of patients 7 (58.3%) were occupied

in ASIA grade D followed by ASIA grade E in 3 (25%)

patients and ASIA grade C in 2 (16.7%) patients.

DISCUSSION:

The present study has been undertaken in NITOR from

July 2013 to July 2015 to evaluate the results of anterior

surgical decompression, fusion and stabilization by

cervical plate and screws in traumatic lower cervical spinal

injury with incomplete neurological involvement.

In the study, the age range of patients was from 16-60

years, with mean age of 33 ± 12.15% years. Male population

in the study constituted 91.7% of cases, In this study, the

most involved occupational group was farmers (33.3%)

followed by manual labour (25%). Study in our country

showed that most common cause of injury was due to

bearing load in head or fall from height. In this study most

involved level of spine was C5/C6 (33.3%); Next common

involved level was C6/C7 (25%). Vafa et al, (2009) also

showed that most involved level of spine is C5(30.8%)

and C6 (23.1%). Singhal et al, (2008) showed most common

involved level is C5/C6(32.4%). Among the early post

operative complication, temporary dysphagia was highest

in 5 (41.7%) patients. The result of bony fusion by this

anterior cervical plating is highly satisfactory with no

failure.

From a neurological point of view, shows the distribution

of patient’s neurological status at discharge. Highest no

of patients 7 (58.3%) were occupied in ASIA grade D

followed by ASIA grade E in 3 (25%) patients and ASIA

grade C in 2 (16.7%) patients. In this study, mean hospital

stay was 24.7 ± 5.77 days (range 12-35 days).

In this study, overall results were classified as excellent,

good, fair and poor. Satisfactory (excellent + good) results

were noted in 8 (66.7%) patients and unsatisfactory (fair +

poor) results were noted in 4 (33.3%) patients.

CONCLUSION

The study shoes that the anterior surgical decompression,

fusion & stabilization by cervical plate & screws are a

relatively easy, safe and an effective procedure for unstable

lower cervical spinal injuries with good neurological and

radiological outcome.

REFERENCES:

1. Aebi, M. Molher, J, Zach, GA, 1986, Indication surgical

technique, and results of 100 surgically treated fractures

and fracture-dislocations of the cervical spine, Clin Orthop,

vol. 203, pp- 244-257.

2. Bohlman, HH, Eismont, FJ, 1981, Surgical techniques of

anterior decompression and for spinal cord injuries, Clin

Orthop, Vol. 145, pp-57-67.

109 Abdur Rob, AKM Zahiruddin, Shakawat Hossain, Riad Majid, Abdul Khaleque, Mohammad Mahbubur Rahman Khan et al



3. Cotler, JM, Herbinson, GJ, Nasuti, JF, 1993. Closed

reduction of traumatic cervical spine dislocation using

traction weights up to 140 pounds, Spine. Vol. 18, pp-

386-90.

4. Elaine, T, Kiriakopoulos, 2001. Epidemiology,

demographics and pathophysiology of acute spinal cord

injury, Spine. Vol. 26, pp- 102-112.

5. Hadley, MN, Fitzpatricl, BC, Sonntag, VK, 1992), Facet

fracture-dislocation injuries of the cervical spine,

Neurosurgery, vol. 30, pp- 661-666.

6. Heiden, JS, Weiss, MH, Rosenberg, AW, 1975.

Management of cervical spinal cord trauma in southern

California, J Neurosurg, vol. 43, pp- 738-760.

7. Leventhal, MR, 2003. Fractures, dislocation and fracture-

dislocation of spine, in Campbell’s Operative orthopaedics

11th ed. ST Canale, Mosby, London. vol. 2, pp- 1597-

1690.

8. Levi, L, Wolf, Rigamonti, F, 1991. Anterior decompression

in cervical spine trauma. Does the timing of surgery affect

the outcome?, Neurosurgery, vol. 29, pp- 216-222.

9. Norrel, H, Wilson, CB, 1970. Early anterior fusion fro

injuries of the cervical portion of the cervical portion of

spine, JAMA. vol. 214, pp- 525-530.

10. Rizzolo, Vaccaro, AR, Cotler, JM, 1994. Cervical spine

trauma, Spine, vol. 19, pp- 2288-2298.

11. Trafton, PC 1982. Spinal cord injuries, Clin Surg. North

Am, vol. 62, pp- 61-72.

Evaluation of the results of decompression and stabilization of traumatic lower cervical incomplete spinal injury 110

VOL. 31, NO. 2, JULY 2016


Original Article

INTRODUCTION

Cauda Equina Syndrome is symptom complexes due to

large disc prolapse and compression over cauda equina

of cord consists of abladder and bowel incontinence,

perineal numbness, bilateral sciatica, lower limb weakness

and crossed straight-leg raising sign(1). Decompression

by discectomy along with laminectomy provides full relief

of pressure on cauda equina. A case series of 52 patients

of cauda equina syndrome presented in CMH Dhaka and

decompression and laminectomy was done. This study

reveals their outcome.


Fifty two patients (34 males, 18 females) who presented to

CMH with Cauda equina syndrome and underwent

decompression by discectomy and laminectomy were

evaluated prospectively between 2011 and 2016. The mean

follow-up period was 27.6 months (range, 12-82 months).

The mean age of the patients was 42 years (range, 15-72

years). Cauda equina syndrome score was performed

before the surgery in all patients. Patients were evaluated

with respect to age, time to surgery, Cauda equina

syndrome score before and after operation. Patients with

Outcome of Surgical Management of

Cauda Equina Syndrome in Combined

Military Hospital (CMH), Dhaka

Md. Salim-Ur-Rahman1, S.M. Iqbal Hossain2, Saihan Arefin Rony3, Mohd. Reza-ul-Karim4, Md. Al

Amin Salek5, Md. Aminul Islam5, RU Chowdhury5

ABSTRACT

This prospective study was conducted on fifty two patients (34 males, 18 females) who presented to CMH with Cauda

Equina syndrome and underwent decompression by discectomy and laminectomy between 2011 and 2016. The mean

follow-up period was 27.6 months (range, 12-82 months). The mean age of the patients was 42 years (range, 15-72

years). Cauda equina syndrome score was performed before the surgery in all patients. Patients were evaluated with

respect to age, time to surgery, Cauda equina syndrome score before and after operation. Patients with fractures,

compression due to other than disc prolapse excluded from the study. Those who were operated within 48 hrs and

those after 48 hrs showed significant difference in outcome (P<0.05). There was infection in 02 cases.08 patients had

persistent back pain. 14 patients had lower limb weakness in delayed operative group.

Keywords: Cauda Equina Syndrome, Surgical Management, Symptom improved significantly

1. Department of Orthopaedics & Spine, CMH, Dhaka

2. Orthopaedic Surgeon,CMH, Bogra

3. Surgical Specialist, Field Amb

4. Advisor Specialist Orthopaedic and Spine, CMH, Dhaka

5. Neurosurgeon, CMH, Dhaka

Correspondence: Md. Salim-Ur-Rahman, Department of Orthopaedics, CMH, Dhaka

fractures, compression due to other than disc prolapse

excluded from the study.

Decompression laminectomy with discectomy was performed

in all cases. Approach was posterior midline. Intravenous

antibiotic prophylaxis was used per and postoperatively for

three days, and third generation cephalosporin was preferred.

Cauda equina scoring system was applied. Statistical analysis

was made using a computer software program, the Statistical

Package for the Social Sciences (SPSS). A value of p<0.05

was accepted to indicate statistical significance.

RESULTS

Fifty two patients with cauda equina syndrome who were

treated by decompression laminectomy with discectomy were

evaluated. The mean age was 42 years (range, 15-72 years).

The patient groups were homogeneous with regard to age,

gender, level of disc prolapse and time of operation. All patients

had cauda equina syndrome due to disc prolapse.

Those who were operated within 48 hrs and those after 48

hrs showed significant difference in outcome (P<0.05).

There was infection in 02 cases.08 patients had persistent

back pain. 14 patients had lower limb weakness in delayed

operative group.



Time Number of patients %

More than 48 hours 16 31

Less than 48 hours 36 69

Neurological signs No of patients

Low back pain 19

Unilateral or bilateral sciatica 11

Saddle and perineal hypoesthesia or anesthesia 10

Bowel and bladder disturbances 06

Lower extremity motor weakness and 03

sensory deficits

Reduced or absent lower extremity reflexes 03

Level of lesion Number of patients

L1-2 03

L4-5 35

L5-S1 14

Outcome of Surgical Management of Cauda Equina Syndrome in Combined Military Hospital (CMH), Dhaka 112

VOL. 31, NO. 2, JULY 2016


DISCUSSION

Cauda equina syndrome is not uncommon. This is usually

treated by discectomy with decompression laminectomy.1-

3,9] The prognosis for cauda equina syndrome (CES)

improves if a definitive cause is identified and management

is instituted early. Surgical treatment is necessary for

decompression or tumor removal, especially if the patient

presents with acute onset of symptoms. Surgical

decompression should be performed if the patient is

medically stable and able to undergo the procedure.1,2,3,4

In acute compression of the conus medullaris or cauda

equina, surgical decompression as soon as possible

becomes mandatory. In a more chronic presentation with

less severe symptoms, decompression could be performed

when medically feasible and should be delayed to optimize

the patient’s medical condition; with this precaution,

decompression is less likely to lead to irreversible

neurological damage.

The timing of surgical decompression is controversial,

with immediate, early, and late surgical decompression

showing varying results. In acute compression, the dictum

was to operate emergently within 6 hours for CES,5 but

several authors have argued over the clarity of the data

supporting this practice.1,2,4,6-8. Hussain et al reported no

differences at a 16-month follow-up among patients who

underwent surgery within 5 hours and those who

underwent surgery within 24 hours9. Furthermore, a recent

small prospective study reported no difference in outcome

at 3 and 12 months after surgical decompression performed

at less than 24 hours, at 24-48 hours, and within more than

48 hours after the onset of CES10. We found better result

in those who were operated within 72 hrs than those who

were operated later. We used posterior midline approach

in all cases and decompression by laminectomy and

discectomy was performed.

Younger patients had better result than the older group.

Single level disc prolapse showed better result than

multilevel disc prolapsed.

Low back pain persisted in 08 patients but neurological

symptoms relieved in all cases of early operation and most

of the late cases. Bowel bladder problem remained in 07

cases who were operated late but none of early cases

REFERENCES

1. Solomon, L., Warwick, D. & Nayagam, S.,2010. Apley’s

System of Orthopaedics and Fractures. 9th ed. London:

Hodder Arnold.

2. Kostuik JP, Harrington I, Alexander D, Rand W, Evans D.

Cauda equina syndrome and lumbar disc herniation. J Bone

Joint Surg Am. 1986 Mar. 68(3):386-91. [Medline].

3. Hussain SA, Gullan RW, Chitnavis BP. Cauda equina

syndrome: outcome and implications for management. Br

J Neurosurg. 2003 Apr. 17(2):164-7. [Medline].

4. Gleave JR, Macfarlane R. Cauda equina syndrome: what

is the relationship between timing of surgery and outcome?

Br J Neurosurg. 2002 Aug. 16(4):325-8. [Medline].

5. Shapiro S. Cauda equina syndrome secondary to lumbar

disc herniation. Neurosurgery. 1993 May. 32(5):743-6;

discussion 746-7. [Medline].

6. Kim JS, Lee SH, Arbatti NJ. Dorsal extradural lumbar disc

herniation causing cauda equina syndrome : a case report

and review of literature. J Korean Neurosurg Soc. 2010

Mar. 47(3):217-20. [Medline]. [Full Text].

7. Qureshi A, Sell P. Cauda equina syndrome treated by

surgical decompression: the influence of timing on surgical

outcome. Eur Spine J. 2007 Dec. 16(12):2143-

51. [Medline].

113 Md. Salim-Ur-Rahman, S.M. Iqbal Hossain, Saihan Arefin Rony, Mohd. Reza-ul-Karim, Md. Al Amin Salek, Md. Aminul Islam et al



Original Article

Experience in the Management of Cases

of Neglected Ruptured Achilles Tendon

Repair in Community Based Medical

College Hospital

Md. Saiful Islam1, Md. Tufael Hossain2, Md. Nasir Uddin3, Md. Anwarul Hoque3, Mamunur Rashid

Chowdhury4, Md. Sabbir Hasan5

ABSTRACT

To share our experience in the management of chronic rupture of Achilles tendon with the use of two innovativetechniques. Achilles tendon ruptures are best managed acutely. Management of neglected Achilles tendonrupture is a challenging situation. A prospective study was done from 2009 to 2014 on neglected cases ofAchilles tendon rupture followed up over a period of 3 to 5 years after operation in Community Based MedicalCollege Hospital. Patients were divided into two groups based on clinical judgment. In Group A the repair wasdone with combination of Abraham E. Pankovich technique and strengthening by Gastrocnemius-Soleus turndownflap. In Group B the repair was done by modified Kessler technique with free Plantaris tendon auto-grafting. Datawas collected by direct interview and examination. Outcome was assessed clinically and patient’s evaluation bymodified Rupp’s score. The study subjects were 10 patients who made a delay of 2 to 4 months to come toHospital after Achilles tendon rupture; mean age 35.8 yrs, SD 12.87 yrs, range 20 yrs to 55 yrs; 7 male, 3 female.Surgical repair was done by two techniques and followed up over a period of 3 to 5 years in Community BasedMedical College Hospital. Steroid injection (6/10) (60%) was the commonest cause of chronic rupture as thesepatients were having tendinitis in the past. Post-operative complications were (4/10) (40%). Overall evaluation bymodified Rupp’s scoring system were excellent (5/10) (50%), good (3/10) (30%) and fair (2/10) (20%). Group Apatients were younger than group B patients (mean age 33 yrs versus 40 yrs). Group-age paired sample T-teststatistically significant (.000). There were more male than female in both groups. There were less complications(2/6) (33%) in Group A than (2/4) (50%) in Group B. As per modified Rupp’s score excellent was equal in bothgroups, good was predominant in Group A (2/6) (33.33%) than Group B (1/4) (25%). Based on clinical judgment andpatient’s evaluation by Modified Rupp’s score the outcome was similar to other studies. People should be motivatedto come to health care facility as soon as they get Achilles tendon rupture. The two techniques are new andsimple and have been found to be useful for the repair of chronically ruptured Achilles tendon. The study supportedour hypothesis that the technique of Gastroc- Soleus turndown flap augmented with v-y plasty would be asefficacious as the simple end to end repair of divided Tendo Achilles repair augmented with plantaris.

Key-words: Neglected, Ruptured, Achilles Tendon repair, Community Based Medical College Hospital.

1. Assistant Professor, Orthopedic Surgery, Community Based Medical College Bangladesh.

2. Assistant Professor, Community Medicine, Community Based Medical College Bangladesh.

3. Associate Professor, Orthopedic Surgery, Community Based Medical College Bangladesh.

4. Assistant Professor, Orthopedic Surgery, Community Based Medical College Bangladesh

5. Orthopedic Surgery, Community Based Medical College Bangladesh

Correspondence: Dr. Saiful Islam, Assistant Professor, Orthopedic Surgery, Community Based Medical College Bangladesh.

Email: [email protected]

INTRODUCTION

A stitch in time saves nine. This is true for rupture of the

Achilles tendon. For acute rupture the management is easy

and simple. Immediate suture and immobilization of the

leg with ankle joint plantar flexed and knee joint flexed is

sufficient. With a delay of 4 weeks or more the case is

considered as neglected. Management of neglected rupture

of the tendon is difficult and challenging demanding

patience of both the patient and the surgeon. Neglected

rupture of the Achilles tendon is an important cause of

foot and ankle impairment leading to disability and

physically handicapped person. The Achilles tendon is

the thickest and strongest tendon in the human body

which connects the calf muscles to the heel bone

VOL. 31, NO. 2, JULY 2016 114


(calcaneum). It maintains posture of the body, is a powerful

plantar flexor of the ankle joint, provides the main forward

propulsive force in walking and running by using the foot

as a lever and raising the heel off the ground. Rupture of

this tendon is common in middle-aged men and frequently

related with sports, games and athletics. It is the third

most frequent tendon rupture in USA. Most commonly,

the mechanisms of Achilles tendon rupture are pushing

off with the weight bearing forefoot while extending the

knee, sudden unexpected dorsiflexion of the ankle, and

violent dorsiflexion of the plantar flexed foot, as in a fall

from a height. Disruption also can occur from a direct

blow to the contracted tendon or from a laceration.1, 2, 3

Rupture can occur spontaneously also. Spontaneous

ruptures of the tendon of Achilles was first described by

Pare in 1575.4In neglected case of Achilles tendon rupture

running, jumping and activities such as ascending or

descending stairs are severely compromised. The

Thompson squeeze test is positive in acute case for

complete rupture when there is no plantar flexion of the

ankle. The Thompson test may be negative in neglected

rupture of the Achilles tendon because of a bridging scar.1,

2, 3 Repair of injured Achilles tendon in neglected cases is

one of the difficult and challenging procedures for surgeon

which can be repaired and reinforced by several

techniques; the pioneer personalities in this field being

Lynn, Abraham and Pankovich, Wapner, Lindholm and

Kessler. 3, 5-9Success of procedure selected in a given

case is dependent upon patient’s age, activity level, amount

of functional impairment, surgeon’s skills, nature of defect,

patient’s compliance, adequacy of repair, availability of

graft reinforcement and proper rehabilitation. We had

opted two techniques: (1) V-Y tendinous flap for repair as

described by Abraham and Pankovich and strengthening

by Gastrocnemius-Soleus turndown flap, (2) Modified

Kessler technique with free plantaris tendon autografting.

We hypothesized that the technique of Gastroc-Soleus

turndown flap augmented with v-y plasty would be as

efficacious as the simple end-to-end repair of divided

Tendo Achilles augmented with plantaris. Since chronic

Achilles tendon injuries are more difficult to manage due

to surrounding tissue fibrosis, larger defect and muscle

wasting, augmentation of repaired tendon in one way or

the other would perhaps be desirable.


A post-intervention prospective study was done in

Community Based Medical College Hospital, Orthopedics

department from 2009 to 2014. The cases were cases of

neglected ruptured Achilles tendon. Tools of diagnosis

were Thompson test/Simmonds test3, 10 palpating a defect

in continuity of Tendo Achilles and ultrasonogarphy to

assess the defect and detection of presence or absence of

plantaris tendon.3 20 cases were enrolled and 10 cases

were selected. Inclusion criteria: chronic rupture at least 6

weeks old, unilateral rupture and skeletal maturity.

Exclusion criteria: bilateral injury, fresh ruptures, avulsion

of bone and absence of plantaris tendon. 10 patients with

chronic Tendo Achilles rupture were followed up over a

period of 3 to 5 years after operation. Patients were divided

into two groups A and B based on clinical judgment. In

Group A the repair was done with combination of Abraham

and Pankovich technique and strengthening by Gastroc-

Soleus turndown flap. In Group B the repair was done by

modified Kessler technique with free plantaris tendon.

Instrument of data collection: history taking, Hospital

records on admission and during stay and questionnaire

for Rupp’s score. Method of outcome assessment:

Clinically and patients evaluation by modified Rupp score.

Anatomical basis: Gatrocenemius, plantaris and soleus

forms the superficial group of muscles of posterior fascial

compartment of the leg. The Achilles tendon is the common

tendon of gastrocnemius and soleus; connects the calf

muscles to the heel bone (calcaneum). Gastrocnemius

originates from lateral condyle of femur and medial head

from above medial condyle, inserts via tendocalcaneus

into posterior surface of calcaneum. Plantaris originates

from lateral supracondylar ridge of femur, inserts into

posterior surface of calcaneum. Soleus originates from

shafts of tibia and fibula, inserts via tendocalcaneus into

posterior surface of calcaneum. 1, 2, 3

Figure 1: V-Y repair of neglected rupture of Achilles tendon

(a) (b) (c)

115 Md. Saiful Islam, Md. Tufael Hossain, Md. Nasir Uddin, Md. Anwarul Hoque, Mamunur Rashid Chowdhury, Md. Sabbir Hasan



Procedure basis: The patients were subjected to repair by

one of the two proposed techniques.

• Gastroc-Soleus Turn-down with V-Y plasty (GTVP):

the repair was done with combination of Abraham

and Pankovich technique and strengthening by

Gastroc-Soleus turndown flap. Patient with the prone

position and under tourniquet control Achilles

tendon is explored by a lazy S incision under spinal

anesthesia; Sural nerve is identified and retracted,

the gap between two ends of ruptured or divided

ends is identified. A sliding tendinous flap is

developed over the proximal portion of the tendon

by making an inverted V incision on the proximal

gastrocnemius partially elevated from the underlying

soleus and twisted 180 degrees on itself to augment

the repair. Base was 2.5 cm proximal to cut end and

flap dimension 14 cm × 2cm. After augmentation the

final repair was in a Y-fashion.3, 11, 12, 13Post-operative

management: The patients were immobilized in above

knee and below ankle plaster splint for 2 weeks each

with a foot in plantar flexion. Neutral position of ankle

joint was achieved gradually over the next 2 weeks.

Passive physiotherapy and partial weight bearing

were allowed in further 3 weeks. This was followed

by total weight bearing with restriction of strenuous

exercise postoperatively.

• Modified Kessler technique with free plantaris

tendon: Primary End-to-End Repair with Kessler’s

Suture and Free Plantaris Autografting (KFPA): Ends

of the tendons were trimmed and mobilized. Plantaris

tendon was harvested. Modified Kesslers’s stitch

with number 1 prolene was applied between two

divided ends of tendon and epitenon was repaired

with 4-0 prolene with the foot in plantar flexion. Sewing

of plantaris tendon in spiral fashion away from the

epitenon suture was additionally done. Postoperative

management was similar to previous technique.

Majority of neglected cases with gaps e” 3 cm were

managed by GTVP technique. Mean operative time was

72 minutes for GTVP and 58 minutes for KFPA

technique.

Evaluation: All patients were followed up for assessment

of integrity of repair and functional status. At each follow

up, ankle range of movements was measured by

goniometer. The calf thickness was measured and

compared with contra-lateral limb. The neurological status

of foot, single limb hopping and strength of plantar flexors

with heel raised standing and ability to perform repeated

heel raises were assessed. At the final follow-up, patient’s

satisfaction was assessed with Kerkhoffs’ Modified Rupp

scoring system which consists of patient satisfaction, pain

experience during weight bearing, pain independent of

weight bearing, decrease of ankle function, fear of rupture,

limitation of work, limitation of sports activity: each

component having excellent bears 5, good 1, fair -1 and

poor -5. Results of this scoring were rated as excellent (e”

30 points), good (15-29 points), fair (5-14 points) and poor

(<5 points). 14

Fig.-2: Suture techniques of tendon repair. Figure B is Kessler’s technique.

(a) (b) (c)

Experience in the Management of Cases of Neglected Ruptured Achilles Tendon Repair in CBMCH 116

VOL. 31, NO. 2, JULY 2016


RESULTS

The study was hospital based post-intervention

prospective study. The study subjects were 10 patients

who made a delay of 2 to 4 months after Achilles tendon

rupture to come to Hospital; mean age 35.8 yrs, SD 12.87

yrs, range 20 yrs to 55 yrs, 7 male and 3 female. Surgical

repair was done by two techniques in Community Based

Medical College Hospital and followed up in the same

institution by repeated follow-up visits after operation

over a period of 3 to 5 years (average 4 yrs). Steroid

injection (6/10) (60%) was the commonest cause of chronic

rupture as these patients were having tendinitis in the

past. Post-operative complications were (4/10) (40%).

Overall evaluation by modified Rupp’s scoring system

were excellent (5/10) (50%), good (3/10) (30%) and fair (2/

10) (20%). Group A patients were younger than group B

patients. There were more male than female in both groups.

No patient in these groups ever had sural nerve

neuropraxia. There were less complications (2/6) (33.33%)

in Group A than (2/4) (50%) in Group B. As per modified

Rupp’s score excellent was equal in both groups, good

was predominant in Group A (2/6) (33.33%) than Group B

(1/4) (25%) i.e. outcome was better in GTVP group than

KFPA group. Table I shows patients characteristics, mode

of injury, post-operative complications and post-operative

follow-up evaluation.

Ankle range of movement and calf diameter was found to

be within 95th percentile of the operated and normal limb

in both the groups. At final follow up all the patients could

return to their daily activities and could perform single leg

hopping, repeated heel raising and heel standing. There

was no significant difference between the two groups with

regard to pain, stiffness of ankle joint, muscle weakness,

range of ankle motion and overall outcome.

DISCUSSION

In this study sample size was 10, male 7 and female 3; in

Group A there were 6 patients and in Group B 4 patients.

Mean age of patients was 35.8 yrs with SD 12.87 yrs (range

20 yrs to 55 yrs). Group A patients were younger (mean

age 33 yrs with SD 13.71 yrs) than Group B patients (mean

age 40 yrs with SD 12.03 yrs. There were more male than

female in both groups. Male: female ratio in group A was

200:100 and in group B 300:100. In different studies sample

size ranged from 1 to 81. 5-7, 9, 11-12, 14-23In Bangladesh we

don’t have documented prevalence and incidence of

Achilles tendon injury in general population. A cross-

sectional study among players of renowned sporting clubs

at Dhaka in 2012 found prevalence of Achilles tendon

injury to be 11.5% among players of football, cricket and

badminton. 24Population based studies in Canada were

8.3 ruptures, 18 ruptures and 29.3 ruptures per 100,000

person-years and in Sweden 47 and 55.2 in men and 12

and 14.7 in women per 100,000 person-years.25-27Based

on the above facts our sample size was acceptable. The

sample was younger than text book cited figure 40-50 yrs

age group and in different studies mean age ranging from

51 to 56 yrs. 2, 3, 6, 9, 18, 20 About gender our finding was

similar to most of the studies where male were more affected

than female.

In our study time since injury was within the range of 2 to

4 months (mean delay 2.8 months), in Group A the delay

Table I

Patient’s characteristics, mode of injury, post-operative

complications and post-operative follow-up evaluation

Status Group A Group B Total

Age in years Mean 33, Mean 40, Mean 35.8,

SD 13.71 SD 12.03 SD 12.87

20-29 3 1 4

30-39 1 1 2

40-49 1 1 2

50 and above 1 1 2

Gender

Male 4 3 7

Female 2 1 3

Side involved

Right 4 2 6

Left 2 2 4

Delay in arrival in months

Less than 3 2 2 4

3 3 1 4

More than 3 1 1 2

Mean delay 2.83 2.75 2.8

Follow-up in years

3 2 1 3

4 3 1 4

5 1 2 3

Mean follow-up 3.83 4.25 4

Mode of injury

Steroid injection 4 2 6

Traumatic injury 1 1 2

Cut injury 1 1 2

Complications

Superficial suture point infection 1 2 3

Superficial marginal necrosis 1 0 1

No complications 4 2 6

Modified Rupp’s score

Excellent 3 2 5

Good 2 1 3

Fair 1 1 2

Poor 0 0 0




was within the range of 2 to 4 months (mean delay 2.83

months), in Group B the delay was also within the range of

2 to 4 months (mean delay 2.75 months). The patients

were followed up after operation over a period of 3 to 5 yrs

(average 4 yrs), in Group A the follow up was for 3 to 5 yrs

(average 3.83 yrs), in Group B, the follow up was also for 3

to 5 yrs (average 4.25 yrs). A delay of 4 weeks and more is

considered as a neglected case in Achilles tendon rupture.

In different studies the delay ranged from 4 weeks to 5

yrs.6, 11, 12, 20- 23A reasonable follow-up is necessary for

neglected cases of Achilles tendon rupture. In different

studies follow-up ranged from 9 months to 16 yrs.5, 7, 11,

12, 17-23Our follow-up period was optimal. In follow-up all

patients were re-examined to assess postoperative range

of motion, scar healing, sensation, motor strength and

subjective satisfaction was examined by completion of a

questionnaire. Per-operative risk of sural nerve damage

was minimal as we stayed posteromedially to the ruptured

Tendo-Achilles. Postoperative complications were

superficial suture point infection (3/10) (30%) and

superficial marginal necrosis (1/10) (10%). In Group A

complication was observed in 2 patients (2/6) (33.33%).

The complications were: superficial suture point infection

1, superficial marginal necrosis 1. In Group B complication

was observed in 2 patients (2/4) (50%). The complications

were superficial suture point infection. Group A had less

complication. All patients had a satisfactory return of

function. As per modified Rupp’s score excellent was equal

in both groups, good was predominant in Group A (2/6)

(33.33%) than Group B (1/4) (25%). Our hypothesis that

the technique of Gastroc-Soleus turndown flap augmented

with v-y plasty would be as efficacious as the simple end-

to-end repair of divided Tendo Achilles augmented with

plantaris was thus proved by less complication and better

Modified Rupp’s score. In Abraham and Pankovich,

strength regained in 3 patients (3/4) (75%). Calf

circumference decreased in all patients. The mentioned

complication was 1 case of sural nerve damage. 3, 11, 21 In

Rush, heel-to-floor distance decreased in 2 patients (2/5)

(40%), calf width decreased in 3 patients (3/5) (60%). The

mentioned complications were (2/5) (40%). The

complications were 1 swollen heel, 1 wound slow to heal.12,21Lynn et al found excellent result in 61.11% of patients.5In

Wapner et al there were no postoperative infections, skin

losses, or re-ruptures. All patients had a satisfactory return

of function. One patient required a molded foot-ankle

orthosis for extended ambulation but was able to play

golf. 3, 6Lindholm et al found excellent clinical and

functional outcome.28 In a study where transfer of flexor

hallucis longus tendon was carried by transtendinous

technique and in transosseous technique; both

techniques provided good to excellent result.9Perez

Teuffer’s operative technique was 100% satisfactory for

athletes and the wound healing was better.16 Maffuli et al

in one study found significantly decrease in calf

circumference, decrease in calf strength. Complications

were (7/38) (18.42%).22Maffuli et al in another study found

excellent results (4/22) (18.18%), good results (9/22)

(40.91%), fair results (3/22) (13.64%). 23Olsson et al found

that the majority of patients with an Achilles tendon rupture

not recovered fully 2 years after injury. The patients appear

to have adjusted to their impairments.20With follow-up

for 3 to 5 years our outcome ranged from good to excellent.

In our study steroid injection (6/10) (60%) was the

commonest cause of chronic rupture as these patients

were having tendinitis in the past and the steroid was

used for treatment of tendinitis. There are many risk factors

for tendon rupture, but the most common predisposing

factor for individuals involved in physical development,

and particularly competitive bodybuilding and strength

competition, is the use of anabolic steroids. These drugs

lead to increased muscle strength, as well as weakening of

the tendons.29For treatment of tendinitis steroid injection

and ciprofloxacin are avoided in developed countries.30

Achilles tendinopathy is linked with obesity, diabetes

mellitus, hypertension, the supplemental use of estrogen,

and exposure to local or systemic steroids. In a study

these diseases cumulatively contributed 98% of Achilles

tendinopathy.31Achilles tendinitis is the fore-runner of

Achilles tendon rupture. So for prevention of Achilles

tendon rupture early diagnosis and treatment of Achilles

tendinitis is essential. Internationally accepted

management protocol is RICE, Rest, Ice application,

Compress and Elevation of the foot. RICE protocol should

be followed for 48–72 hours. Then the patient should be

referred to Orthopedic Surgeon for further evaluation.32

Surgical repair of Achilles tendon repair dates back to

India in 6th century BC by Sushruta, the father of Plastic

Surgery. His works were translated into Arabic language

in 750 AD.33In 10th century an Arabian physician performed

operative repair of ruptured Achilles tendon. In Europe

from 12th century onwards there was debate in favor and

against operation leading to abandon of operation. At last

operative repair was advocated in 1888 by Gustave

Potaillon.34In Abraham and Pankovich, the repair method

was V-Y tendinous flap. In Group A we have used Abraham

and Pankovich repair method.3, 11, 21 In Rush, the repair

method is turn-down flaps (Gastroc-Soleus aponeurosis

tube). We used Rush repair method at the beginning first


VOL. 31, NO. 2, JULY 2016


two cases.12, 21 Then we switched to P Ponnapula and RR

Aaranson method using a combination of fascial

advancement techniques, the V-Y advancement and the

gastrocnemius-soleus fascia turndown graft.13In an Indian

study Gastroc-soleus turndown flap was accompanied

with planataris augmentation. Plantaris tendon graft was

passed through coronal slit and sutured with turn-down

flap.15In our study we raised an inferiorly based and

centrally situated tendon flap attached for 2.5 cm at the

distal part of proximal cut end of the tendon like Bosworth

but in our method harvested central strip was much broader

and shorter in length (14 cm × 2 cm) as compared to

Bosworth 17.5 cm to 22.5 cm × 1.5 cm.37This was done

with the logic of tendon viability, strength of repair, ease

of handling and lesser residual weakness. We sutured raw

surfaces together after passing it through the slit made in

proximal healthy part of distal cut end of the tendon.

Secondly, we further strengthened our repair by V-Y plasty.

V-Y advancement flap and flexor hallucis longus tendon

transfer is good for defects ranging from 2 cm to 8 cm. 8

In Group B we have used polypropylene (Prolene) as

because catgut loses tensile strength too rapidly, while

silk causes excessive tissue reaction. In tendon repair

continuous suture is used with an additional finer

continuous suture inserted circumferentially in the

paratendon.10, 35 Commonly used techniques for end-to-

end tendon suture are: conventional Bunnell stitch, Criss-

cross stitch, Mason-Allen (Chicago) stitch, Kessler

grasping stitch, Modified Kessler stitch with single knot

at repair, Tajima modification of Kessler stitch with double

knots at repair site.3 We have used modified Kessler

technique which is convenient and effective. Local tissue,

local tendons and allograft can be used to reconstruct the

tendon, and end-to-end repair is possible if the gap is <2.5

cm.36In our patients we found larger gaps (> 2 cm) between

two cut/.ruptured ends of Achilles tendon. For

management of neglected rupture Achilles tendon rupture

with significant gap, the basic requirement is to bridge the

defect by tissue or synthetic materials which can unite the

cut wounds with satisfactory strength and allow full range

of tendon excursion. Lindholm reinforces the sutures with

living fascia which is useful for significant tendon gap. 3,

7, 28 Bosworth technique is also helpful for tendon defects

with significant gap. But the disadvantage of Bosworth is

that the application of Bunnel’s suture has the

disadvantage of knots being left exposed on the tendon

surface.37In our study we used primary repair with

Kessler’s suture technique and free plantaris auto-grafting.

Lynn reinforced Achilles tendon by plantaris tendon

stretched into a membrane. Our technique offered

advantage as because fanning the tendon in membrane

might lose the tensile strength of repair.5Wapner et al used

flexor hallucis longus tendon, Perez Teuffer, White and

Kraynic, Maffuli used peroneus brevis tendon for repair

of Achilles tendon rupture. 3, 6, 16, 23, 38We decided neither

to sacrifice flexor hallucis longus nor peroneus brevis.

Flexor hallucic longus is a deep muscle, during transfer

there is risk of injury to tibial nerve and artery. This muscle

flexes distal phalanx of big toe, plantar flexes foot at ankle

joint and supports medial longitudinal arch of the foot.

Peroneus brevis is an important stabilizer of ankle joint. It

plantar flexes foot at ankle joint, everts foot at subtalar

and transverse tarsal joint; supports lateral longitudinal

arch of foot.2Plantaris tendon is the most useful locally

available tendon for further strengthening of Achilles

tendon repair. White and Kraynic also utilized the plantaris

tendon strengthening after repairing the Achilles tendon

by bridging the gap with peroneus brevis tendon.38 In

contrast to Kraynik’s modification of Perez Teuffer’s

technique, we did primary repair with modified Kessler’s

intratendinous suture to reduce intratendinous ischemia

caused by classical Bunnel’s suture and instead of

increasing the bulk of repair by doing a figure of eight

threading of plantaris tendon, we passed the graft spirally.

We also repaired epitenon separately from the spiral graft

in order to improve the vascularity of repair. We have

done augmentation of repair. In a prospective study it was

found that augmented repair does not have any advantage

over simple end-to-end repair.17Surgical management of

open neglected Achilles tendon injury and damaged

overlying skin is very demanding. Mohanty et al managed

a case by tendon debridement, reconstruction and

resurfacing with a distal posterior tibial artery perforator

based turn-over adipofascial flap covered with a split

thickness skin graft.18 Fong et al managed a case by a

distally based fascial turnover flap supplied by the

perforators of the posterior tibial and peroneal arteries.19

Both the techniques were easy and had excellent outcome.

Prevention is better than cure. We should focus on

prevention which is linked with proper nutrition, physical

activity, adequate rest, wearing proper shoe and training.30, 32

CONCLUSION

Our technique was simple, newer, surgeon friendly,

relatively easy and useful for Achilles tendon repair in

neglected cases with large gap. We have managed the

cases efficiently. The results were similar but the age group

involved was younger which is of grave concern

influencing productivity. If we take care of our legs, ankle




and foot, give training on sports, games and athletics we

can earn money like Brazil as we have a large young

population.

REFERENCES

1. Susan Standring, Gray’s Anatomy, The Anatomical Basis

of Clinical Practice, International Edition, Forty-First

Edition, Elsevier, 2016, Chapter 83, Leg, Posterior (Flexor)

Compartmetn, Chapter 84, Ankle and Foot, Calcaneal

(Achilles) tendon,1409-1410, 1440.

2. Richard S. Snell, Clinical Anatomy By Regions, 9th Edition,

Lippincott Williams & Wilkins, 2012, Chapter 10, The

Lower limb, The Back of the leg, The region of ankle, 487-

490.

3. S. Terry Canale & James H. Beaty, Campbell’s Operative

Orthopedics, Eleventh Edition, Mosby Elsevier, 2008,

Chapter 46, Traumatic Disorders, Achilles tendon injuries,

2748- 2759, Chapter 63, Flexor and Extensor Tendon

Injuries, 3854-3864, 3886.

4. T.C. Thompson, J.S. Doherty, Spontaneous rupture of

tendon of Achilles: a new clinical Diagnostic test. The

Journal of Trauma. 1962; 2: 126-129.

5. T.A. Lynn. Repair of the torn Achilles tendon, using the

plantaris as a reinforcing membrane. Journal of Bone and

Joint Surgery. 1966; 48 (2) 268-272.

6. K.L.Wapner, G.S. Pavlock, P.J. Hecht. F. Naselli, R.

Walther. Repair of chronic Achilles tendon rupture with

flexor hallucis longus tendon transfer. Foot and Ankle.

1993; 14 (8) 443-449.

7. M. Takao, M. Ochi, K. Naito, Y. Uchio. M. Matsusaki,

K. Oae. Repair of neglected Achilles tendon rupture using

gastrocnemius fascial flaps. Archives of Orthopedic and

Trauma Surgery. 2003; 123 (9): 471-474.

8. N. J. Bevilacqua. Treatment of the neglected Achilles tendon

rupture. Clinics in Podiatric Medicine and Surgery. 2012;

29 (2): 291-299.

9. S. Rahm, C. Spross, F. Gerber, M. Farshad, F. M. Buck,

N. Espinosa. Operative treatment of chronic irreparable

Achilles tendon ruptures with flexor hallucis tendon

transfers. Foot & Ankle International. 2013; 34: 1100-

1110.

10. Norman S. Williams, Christopher J.K. Bulstrode & P.

Ronan O,Connell. Bailey & Love’s Short Practice of

Surgery, 26th Edition. International Students’ Edition.

2013. Chapter 4, Basic surgical skills and anastomoses.

Wound closure. Pages 34- 42, Chapter 29, Extremity

Trauma, Achilles tendon rupture, Pages 381-382.

11. Abraham E. Pankovich AM, Neglected rupture of the

Achilles tendon. Treatment by V-Y tendinous flap. J Bone

Joint Surgery AM. 1975; 53: 253-255.

12. Rush JH. Operative repair of neglected rupture of the

tendo Achilles. Australia New Zealand J Surgery. 1980;

50: 420-422.

13. Ponnapula P, Aaranson RR. Reconstruction of Achilles

tendon ruptures with combined V-Y plasty and

Gastrocnemius-Soleus Fascia turndown graft. The Journal

of Foot and Ankle Surgery. 2010; 49 (3): 310-315.

14. G.M.M.K. Kerkoffs, P.A.A. Struijs, E.L.F.B.

Raaymakers, R.K. Marti. Functional treatment after

surgical of acute Achilles tendon rupture: wrap vs walking

cast. Archives of Orthopedic and Trauma Surgery. 2002;

122 (2): 102-105.

15. Pradeep Jain et al. Clinical study. Management of neglected

Achilles tendon division: assessment of two novel and

innovative techniques. Advances in Orthopedic Surgery.

2014, Article ID 729397, 6 pages.

16. A. Perez Teuffer. Traumatic rupture of the Achilles tendon.

Reconstruction by transplant and graft using the lateral

peroneus brevis. Orthopedic Clinics of North America.

1974; 5 (1): 89-93.

17. A. Pajala, J. Kangas, P. Sitra, P. Ohtonen, J. Leppilaht.

Augmented compared with non-augmented surgical repair

of a fresh total Achilles tendon rupture: a prospective

randomized study. Journal of Bone and Joint Surgery.

2009; 91 (5) : 1092-1100.

18. A. Mohanty, P. Jain, Reconstructing and resurfacing open

neglected Achilles tendon injury by distal posterior tibial

artery perforator based adipofascial flap. European Journal

of Plastic Surgery. 2004; 27 (4): 196-199.

19. E.P. Fong, R.P.G. Papini, M.V. McKiernan, G.S. Rao.

Reconstruction of an Achilles tendon skin defect using a

local fascial flap. European Journal of Plastic Surgery.

1997; 20 (5): 266-269.

20. N. Olsson et al. Major functional deficits persist 2 years

after acute Achilles tendon rupture. Knee surgery. Sports

Traumatology Arthroscopy. 2011; 19 (8): 1385-1393.

21. Mohammed Hadi, Jonathan Young, Lisa Cooper, Mathew

Costa, Nicola Maffulli. Surgical management of chronic

ruptures of the Achilles tendon remains unclear; a

systematic review of the management options. British

Medical Bulletin. 2013; 108 (1): 95/345887.

22. Maffuli N, Longo UG, Denaro V.. Minimally invasive

Achilles tendon reconstruction using the peroneus brevis

tendon graft. Tech Foot Ankle Surgery. 2010; 9: 38-42.

23. Maffuli N, Spiezia F, Pintore E, et al. Peroneus brevis

tendon ttransfer for reconstruction of chronic tears of the

Achilles tendon: a long-term follow-up study, Journal Bone

Joint Surgery American. 2012; 94: 901-5.


VOL. 31, NO. 2, JULY 2016


24. Khan MJ, Giasuddin AS, Khalid MI. Risk factors of

Tendo-Achilles injury in football, cricket and badminton

players at Dhaka, Bangladesh. Bangladesh Medical

Research Council Bulletin. 2015; 41(1): 19-23.

25. Suchak AA, Bostick G, Reid D, Blitz S, Jomha N. The

incidence of Achilles tendon ruptures in Edmonton, Canada.

Foot Ankle Int. 2005; 26(11): 932.

26. Sheth U, Wassertein D, Jenkinson R, Moineddin R, Kredur

H, Jaglal SB. The epidemiology and trends in management

of acute Achilles tendon rupture in Ontario, Canada: a

population based study of 27607 patients. Bone Joint

Journal. 2017; 99B (1): 78-86.

27. Huttunen TT, Kannus P, Rolf C, Fellander-Tsai, Matilla

VM, Acute Achilles tendon ruptures: incidence of injury

and surgery in Sweden between 2001 and 2012. American

Journal of Sports Medicine. 2014; 42 (10): 2419-23.

28. A. Lindohm. A new method of operation in subcutaneous

rupture of the Achilles tendon. Acta Chirurgica

Scandinavica. 1959; 117: 261-270.

29. Robert G. Marx, MD MSc FRCSC, Anabolic Steroids:

Tendon Ruptures, Sports Medicine Update: Tendon

Ruptures. http://anabolicminds.com/forum/steroids/

102824-anabolic-steroids-tendon.html Access date:

August 5, 2017.

30. Achilles tendon rupture, Wheeless’ Textbook of

Orthopedics. http://www.wheelessonline.com/ortho/

achilles_tendon_rupture. Access date: August 5, 2017.

31. Holmes GB, Lin J. Risk factors associated with

symptomatic Achilles tendinopathy. Foot Ankle Int. 2006;

27 (11): 952.

32. Achilles tendon injuries Fact sheet. Sports Medicine

Australia. http://sma.org.au/resources-advice/injury-fact-

sheets/achilles-tendon-injuries/ Access date: August 5,

2017.

33. Plastic Surgery. Revolvy version. Access date: August

5, 2017.

34. N. Maffuli. Current concepts review. Rupture of the

Achilles tendon. Journal of Bone and Joint Surgery

American. 1999; 81(7): 1019-36.

35. Margaret Farquharson and Brenda Moran, Farquharson’s

textbook of Operative Surgery. Ninth Edition, International

Students Edition 2005. Chapter 3 Soft tissue surgery:

muscles, tendons, ligaments and nerves. Tendon repair,

elective tendon surgery. Pages 38-42.

36. N. Maffuli, Ajis A. Management of chronic ruptures of

the Achilles tendon. Journal of Bone and Joint Surgery

American. 2008; 90 (6): 1348-60.

37. D.M. Bosworth. Repair of defects in the tendoachilles.

The Journal of Bone and Joint Surgery. 1956; 38: 111-

114.

38. R.K. White, B.M. Kraynic, Surgical uses of peroneus

brevis tendon. Surgery, Gynecology and Obstetrics, 1959;

108: 117-121.




Original Article

Study of Serum Cholesterol and Serum

Creatinine Level In Polytraumatic

Patient

Farzana Khondoker1, Md. Anisur Rahman2, Major Tohmina Aktar3, Afreen Ferdous4

ABSTRACT

Early biochemical changes such as serum cholesterol and serum creatinine level are associated with polytrauma.

To observe serum cholesterol & serum creatinine level in patients with polytrauma. The study was carried in

patients who attended the trauma intensive care unit of Rangpur Medical College Hospital, Rangpur between

January 2015 and December 2016. A total number of 50 subjects were included in the study comprising of 25

cases and 25 controls. The following parameters were analyzed in the total serum cholesterol and serum

creatinine level. This cross sectional study was carried out in the Department of Biochemistry, Rangpur Medical

College Hospital, Rangpur, from January 2015 and December 2016. The age range of the patients was 20 to 50

years. For statistical analysis independent sample “t” test was performed by computer based software SPSS

17.0 version for windows. Serum cholesterol level highly significantly decreased (P<0.0001) and serum creatinine

level highly significantly increased in patients with polytrauma. The management of the polytraumatized orthopedic

patient remains a challenging issue. In recent years many efforts have been made to develop rescue techniques

and to promote guidelines for the management of these patients.

Key words: Polytrauma, Serum cholesterol, Serum creatinine

1. Assistant Professor and Head of the Dept. of Physiology, Rangpur Army Medical College, Rangpur.

2. Junior Consultant (Ortho-surgery), Upazilla Health Complex, Parbotipur, Dinajpur.

3. Assistant Professor and Head of the Dept. of Biochemistry, Rangpur Army Medical College, Rangpur.

4. Assistant Professor, Dept. of Physiology. East West Medical College.

Correspondence: Dr. Farzana Khondoker, Assistant Professor and Head of the Dept. of Physiology, Rangpur Army Medical College,

Rangpur.

INTRODUCTION

Trauma is a major worldwide unprecedented health

problem. It is one of the leading causes of death and

disability in both industrialized and developing countries.1

Polytrauma defined by the Veterans Health Administration

(VHA) as “Two or more injuries to the physical regions or

organ systems, one of which may be life threatening,

resulting in physical, cognitive, psychological or

psychosocial impairments and functional disability”.2 It

is the clinical state followed by injury leading to profound

physio-metabolic changes involving multisystems. The

effect of single system injury may not be life threatening

but multisystem injury, however may threaten life.3

Polytrauma occurs when a person experiences injuries to

multiple body parts and organ systems often, but not

always, as a result of blast-related events. Traumatic Brain

injury (TBI) frequently occurs in polytrauma in combination

with other disabling conditions, such as amputation, burns,

spinal cord injury, auditory and visual damage, spinal cord

injury (SCI), post-traumatic stress disorder (PTSD) and

other medical conditions. Due to the severity and

complexity of their injuries, Veterans and Service Members

with polytrauma require a high level of integration and

coordination of clinical care and other support services.4

Mortality in traumatized patients depends to a great extent

on the mechanism and severity of injury.5 Early assessment

of injury severity is important in trauma. Several trauma

scores have been devised to predict injury severity and

risk of mortality. They do not include any measure of

physiological compromise, which is a fundamental

component of clinical severity assessment. Regardless of

the accuracy of trauma scores, it is abundantly clear that

their use in clinical decision making is limited.6

VOL. 31, NO. 2, JULY 2016 122


It has been known for more than 40 years that severe

polytrauma gives rise to striking changes in metabolism.7

There is also a suggestion that serum cholesterol correlates

with organ failure and sepsis.8 Early detection of renal

dysfunction in ICU patients is important and creatinine

measurement in plasma is the most commonly used marker

of renal dysfunction.9 Hypocholesterolemia in these

patients may be considered a significant prognostic marker

of mortality. The causes of hypocholesterolemia may be

explained by a lower production of cholesterol precursors

in the liver, by faster catabolism or faster utilization by

damaged tissues during regeneration but not caused by

simple hemodilution.10

Therefore the present case-control study was designed

to find out the relationship of serum cholesterol and serum

creatinine level in polytraumatic patient. This study

demonstrated metabolic alterations in trauma patients,

emphasizing that even commonly requested laboratory

tests can estimate the metabolic alterations. Suitable

treatment for polytraumatized patients may be a challenge

for the clinician, who must be alert to metabolic changes

in these patients. Based on these alterations, the clinician

can intervene early and make every effort to achieve a

successful clinical result to prevent morbidity and

mortality.11

MATERIALS AND METHOD

The present cross-sectional analytical study was carried

out in the department of Biochemistry, Rangpur Medical

College Hospital, Rangpur from January 2015 to December

2016. A total subjects of 50 was taken in this study. Study

subjects were divided into two groups. There were 25

normal healthy control subjects in Group A and 25

polytraumatic patients in Group B. Data that was collected

included age, sex, detailed medical history including

conventional risk factors, clinical examinations and relevant

investigations. Subjects with a past medical history of

diabetes mellitus, kidney and heart diseases and also

pregnant women were excluded from the study.

After selection of subjects, the purpose of the study was

explained to each subjects. When they agreed for

participation, then informed written consents were taken

from the subjects. Detailed family history and medical

history were taken. Ten (10) ml of venous blood was

collected from antecubital vein from each subject under

all aseptic precaution by a disposable syringe. Then blood

was taken for haemoglobin concentration and the needle

detached from the nozzle and blood was immediately

transferred into a deionized test tube with a gentle push to

avoid haemolysis. Test tubes were kept in standing position

till formation of clot. Serum was separated by centrifuging

the blood at 3000 rmp for 5 minutes. The clear supernatant

was taken and kept in an ependorfs. Tests were carried

out as early as possible. All data were recorded

systematically in a preformed history sheet and all

statistical analysis was done by computer using the

software SPSS 17.0 version for windows. Serum cholesterol

and serum creatinine level was determined by Enzymatic

colorimetric method and Bichromatic end point technique

method respectively. Data were expressed as mean ±SD.

For statistical analysis independent sample “t” test were

performed.

RESULTS AND OBSERVATION

A total 50 patients of polytrauma and 25 healthy controls

were included in this study. The age range of the patients

was from 20 to 50 years with a mean of 35.24 ± 6.79 years.

Serum cholesterol was highly significantly decreased

(P<0.0001) in polytraumatic patients in Group B (case) and

serum creatinine level were also highly significantly

increased in polytraumatic patients in Group B (case).

SERUM CHOLESTEROL

Results are expressed as below:

Mean serum cholesterol level … mg/dl.

The mean ± SD serum cholesterol levels were 175.44 ±

4.80mg/ml in Group A (control) and 152.72 ± 2.35 mg/dl in

Group B (case).

The mean serum cholesterol level was compared between

Group A (control) and Group B (case).

Serum cholesterol is highly significantly decrease

(P<0.0001) in polytraumatic patients in Group B (table-l).

Table-I

Showing serum cholesterol level in two groups.

Serum cholesterol level

Group Mean ± SD ng/ml ‘t’ ‘P’

Range ( L - H ) ng/ml value value

A (control) 175.44 ± 4.80

n= 25 (170 - 185) 21.26 < 0.0001HS

B (case) 152.72± 2.35

n= 25 ( 150-158)

n= Number of subjects.

SD= Standard deviation.

t= Unpaired ‘t‘ test.HS= Highly significant.

L= Lowest value.

H= Highest value.

#= Normal range of serum cholesterol level is <200 mg/dl.

123 Farzana Khondoker, Md. Anisur Rahman, Major Tohmina Aktar, Afreen Ferdous



SERUM CREATININE

Results are expressed as below

Mean serum creatinine level …mg/dl.

The mean ± SD serum creatinine levels were 0.9332±

0.0168mg/d in Group A (control) and 1.2120 ± 0.0781mg/dl

in Group B (case).

The mean serum creatinine level was compared between

Group A (control) and Group B (case). There was significant

difference (P>0.0001s) between two groups (table-II).

Table-lI

Showing serum creatinine level in two groups.

Serum creatinine level

Group Mean ± SD mg/dl. ‘t’ ‘P’

Range ( L - H ) mg/dl value value

A (control) 0.9332 ± 0.0168

n= 25 (0.91 – 0.95) 17.45 < 0.0001 HS

B (case) 1.2120 ± 0.0781

n= 25 (1.1 – 1.3)

n= Number of subjects.

SD= Standard Deviation.

t= Unpaired ‘t‘ test.HS= Highly significant.

L= Lowest value.

H= Highest value.

#= Normal range of serum creatinine level is 0.7 – 1.4 mg/dl

DISCUSSION

The present study is the description of the effect of

metabolic factors in polytrauma. The state of hyper

catabolism after severe injury leads to severe

complications associated with post traumatic

hyperglycaemia, lactic acidosis and hypocholesterolemia

and increased level of serum creatinine. The presence and

significance of these metabolic changes must be

recognised and appreciated in severely injured patients.7

In our analysis- a highly significant difference in serum

cholesterol level in between normal and polytruamatic

patient. The level of serum cholesterol was highly

significantly decreased in Group B (case) in comparism to

Group A (control). Our study is correlated with a study

done by Yamamotova A et al10 and Vungarala T et al11.

Yamamotova A et al10 found that hypocholesterolemia in

these patients may be considered a significant prognostic

marker of mortality. The causes of hypocholesterolemia

may be explained by a lower production of cholesterol

precursors in the liver, by faster catabolism or faster

utilization by damaged tissues during regeneration but

not caused by simple hemodilution.

Vungarala T et al11 found that the cause of the low

cholesterol levels in acute illness is most likely

multifactorial, involving both decreased synthesis and

enhanced catabolism. It was not clear whether

hypocholesterolemia was a secondary manifestation of

trauma or it actively contributed to metabolic deterioration.

In our analysis the levels of creatinine was highly

significantly increased in Group-B (case) compared with

Group-A (control). Our study is correlated with a study

done by Vungarala T et al11.

They found that serum creatinine is produced by

nonenzymatic hydrolysis of tubules. Decreased creatinine

is a sensitive indicator of reduced glomerular filtration

rate creatine. The raised serum creatinine levels suggested

decreased renal elimination of creatinine thus showing

decreasing values of creatinine clearance. As of date there

is no other study which describes this pattern of

modification in trauma population.

From the above discussion, it may be concluded that the

reality of the utility of simple biochemical parameters that

can help in estimating the severity of metabolic alterations

in traumatized patients. Based on these alterations, the

clinicians can intervene early and make every effort to

achieve a successful clinical result.

CONCLUSION

The management of the polytraumatized orthopedic patient

remains a challenging issue. In recent years many efforts

have been made to develop rescue techniques and to

promote guidelines for the management of these patients.

In this study we demonstrated the utility of simple

biochemical parameters that can help in estimating the

severity of metabolic alterations in traumatized patients.

Based on these alterations, the clinicians can intervene

early and make every effort to achieve a successful clinical

result.

REFERENCES

1. Townsted CM, Beauchamp RD, Evers BM. Mattox KL.

Sabiston Text book of Surgery. The Biological Basis of

Modern Surgical Practice. 19th Edition. Philadelphia USA,

Saunders 2012 page no: 59.

2. Lew HL, Otis JD, Tun C, Kerns RD, Clark ME, Cifu DX.

Prevalence of chronic pain, posttraumatic stress disorder,

and persistent post concussive symptoms in OIF/OEF

veterans: Polytrauma clinical triad. J Rehabil Res

Dev.2009; 46,(6):697–702.

Study of Serum Cholesterol and Serum Creatinine Level In Polytraumatic Patient 124

VOL. 31, NO. 2, JULY 2016


3. Polytrauma/TBI System of Care. Available from the

website http://www.polytrauma.va.gov/understanding-tbi/

definition-and-background.asp)

4. Corstjens AM, Vander Horst IC. Hyperglycaemia in

critically ill patients: marker or mediator of mortality?

Crit Care. 2006, 10: 216-19.

5. Cervoic O, Golunovic V. Relation between injury severity

and lactate levels in severely injured patients. Intensive

Care Med. 2003, 29: 1300 -5.

6. Sammour T, Kahokehr A, Caldwell S, Hill AG. Venous

glucose and arterial lactate as biochemical predictors of

mortality in clinically severely injured trauma patients—

A comparison with ISS and TRISS Injury. Injury.2009;

40: 104-8.

7. Shenkin A, Neuhauser M. Biochemical changes associated

with severe trauma. Am J Clin Nutr.1980; 33 (10):2119-

27.

8. Dunham M.C, Fealk M.H. Following severe injury,

hypocholesterolemia improves with convalescence but

persists with organ failure. Crit Care 2003;7 :145-153.

9. Hoste E.J, Damen J, Vanholder R.C. Assessment of renal

function in recently admitted critically ill patients with

normal serum creatinine. Nephrol Dial Transplant 2005;

20: 747–753.

10. Yamamotova A, Sramkova T and Rokyta R. Intensity of

pain and biochemical changes in blood plasma in spinal

cord trauma. Spinal Cord (2010) 48, 21–26;

11. Vungarala T D, Badikillaya V U. Early biochemical changes

in patients with polytrauma Indian Journal of Basic and

Applied Medical Research; September 2014: Vol.-3, Issue-

4, P. 134-141.

125 Farzana Khondoker, Md. Anisur Rahman, Major Tohmina Aktar, Afreen Ferdous



Original Article

Bacteriological Study of Surgical Site

Infection Following Emergency

Abdominal Surgery

Shahidul Huq1, Prabir Chowdhury2, Farhana Mahmood3, Mohammad Sanaullah4, Md. Jalal Uddin5

ABSTRACT

Postoperative wound infection are common, serious and expensive complications after major abdominal surgery

and emerging as a challenge to the surgeons. We have conducted this study to determine the influence of

bacteria in surgical site infection following emergency abdominal surgery. This study was cross-sectional

comparative study was conducted in Chittagong Medical College and Hospital. Based on predefined selection

criteria a total of 58 subjects were consecutively included in the study. The test statistics used to analyse the

data. Twenty eight of 58 patients (48%) were done peritoneal toileting. The serosanguinous was collected from

60.7% of patients followed by serous from 19.6%, pus from 3.6% and other specimens from 16.1% of patients for

bacteriological investigations. Antibacterial profile demonstrates that nearly 30% of patients had a history of

received ciprofloxacin, 36.2% cefuroxime and another 36.2% ceftriaxone in preoperative and postoperative period.

In terms of isolated organism, E.coli was the predomonent organism followed by 24.1% pseudomonas, 19%

staphylococcus aureus, 8.6% klebsiella, 5.2% proteus. No growth was found in 5.2% of patients. The sensitivity

pattern of antibiotics were seen in postoperative period which reveals imepenum (54.5%), ciprofloxacin (34.5%),

and amoxicillin(100%).Nearly half of the patients took antibiotic orally and the remaining 51.7% took injectable

antibiotic. Most(40%) of the patients needed 4 days to control infection.17% of patients needed further change of

antibiotics. About 64% of the patients needed extra procedure after taking antibiotics. Postoperative surgical site

infection remains a considerable cause of morbidity and mortality among surgical patients. The increasing

prevalence of multi-drug resistant bacterial and fungal isolates must be taken into account, especially in infected

patients after extended surgical procedures.

Keywords: Surgical site infection, Clean contaminated ,Dirty, Post-operative, Wound infection.

1. Associate Professor Surgery, Cox’s Bazar Medical College,Cox’s Bazar.

2. Ex-Asst. Professor Surgery,BBMH,USTC,Chittagong.

3. Asst.Professor Medicine & Consultant ICU, Chattagram Maa-o-Shihu Hospital Medical College.

4. Asst. Professor Neurosurgery, Cox’s Bazar Medical College, Cox’s Bazar.

5. Consultant Surgeon, ENT

Correspondence: Dr. Shahidul Huq, Associate, Professor Surgery, Cox’s Bazar Medical College, Cox’s Bazar. E-mail- [email protected]

INTRODUCTION

Surgical site infections remain a major source of

postoperative morbidity, accounting for about a quarter

of the total number of nosocomial infections. Infectious

complications are the main cause of postoperative

morbidity in abdominal surgery.1 It is reported that 14-

16% of the estimated 2 million nosocomial infections

affecting hospitalized patients in the United States.2

Surgical site infections(SSIs) are associated not only with

increased morbidity but also with mortality. Seventy-seven

percent of the deaths of surgical patients were related to

surgical site infection.3 However, the rate of postoperative

site infection is found to vary with types of operation,

circumstances in which the patients were operated ,the

disease for which they were operated. Identification of

these risk factors, which could be avoided in the

perioperative period, may reduce the rate of postoperative

infectious complications. The present study intends to

compare the rate of postoperative site infection between

elective and emergency abdominal surgery and the factors

with site infection.

VOL. 31, NO. 2, JULY 2016 126



A cross-sectional comparative study was conducted in all

the general surgical wards of Chittagong Medical College

Hospital and laboratory works were done in the

microbiology department of the hospital for a period of six

months from October 2007 to March 2008 in order to identify

the causative organisms responsible for surgical site

infection and to find out appropriate antibiotics against

microorganisms following emergency abdominal surgery.58

patients were included in the study. The inclusion criteria

were all patient of both sexes 18-54 years age with surgical

site infection following emergency abdominal surgery

carried out for acute appendicitis, burst appendix,

perforated peptic ulcer, ileal perforation, acute intestinal

obstruction, strangulated inguinal hernia. Patients with

coexisting medical disease like diabetes mellitus, COPD,

tuberculosis, malignancy, steroid therapy and

chemotherapy and those cases that had infection in other

sites of body (like abscess, cellulites, gangrene)

preoperatively were excluded from the study.

Informed consent was taken from all patients before

enrollment into the study. All operated patients were

checked on 3rd to 5th postoperative days to see the surgical

sites and if there was discharge from wound incision or

signs and symptoms of inflammation ( pain, redness,

tenderness, localized swelling, raised local temperature)

were selected as a case. With all aseptic precausion the

incision were deliberately opened and specimens were

collected for bacteriological study aseptically by cotton

wool swab stick enclosed in a sterile tube for culture.

Data were collected by observation, face to face interview

and by measurement of clinical and laboratory variables

at baseline and on completion of treatment. Prescribed

case record form (CRF) was used for collection of data.

Statistical analysis

Collected data were processed and analyzed using SPSS

(Statistical Package for the social Sciences) (Software

version 11.5) for windows.

RESULTS

The study was conducted between October 2007 to March

2008.A total number of 58 patients were included in the

study.

Table I

Distribution of patients by age (n=58)

Age Frequency Percentage

<30 23 39.7

30-40 24 41.7

> 40 11 19.0

Mean age=(32.6+/- 8.6) years;range=(18-54) years.

Table II

Distribution of patients by operation and its category (n=58)

Disease OperationPerformed Category of surgery No

Acute appendicitis Appendisectomy Clean contaminated 10

Burst appendix Appendisectomy with Dirty 10

peritoneal toileting

Duodenal ulcer Repair of perforation with Contaminated 12

perforation through peritoneal toileting

Small intestinal Laparotomy with division Clean 03

obstruction due to bands of bands and adhesions

& adhesion

Small intestinal Resection and Clean contaminated 05

obstruction due to other anastomosis

causes

Ileal perforation Repair and peritoneal Dirty 08

toileting

Volvulous of sigmoid Resection and Contaminated 02

colon anastomosis

Obstructed inguinal Herniotomy and Clean 08

hernia herniorrhaphy

127 Shahidul Huq, Prabir Chowdhury, Farhana Mahmood, Mohammad Sanaullah, Md. Jalal Uddin



Table III

Distribution of patients by preoperative shaving

(n=58)

Preoperative shaving Frequency Percentage

Yes 29 50.0

No 29 50.0

Time of shaving

At night 17 58.7

In the morning 12 41.3

Place of shaving

At preoperative room 06 50.0

On OT table 06 50.0

Table IV

Distribution of patients by use of drainage (n=58)

Use of drainage Frequency Percentage

Used 32 55.2

Not used 26 44.8

Table V

Distribution of patients by nature of wound infection

(n=58)

Operation performed Nature of Wound infection

Superficial Deep

Appendisectomy for acute 8 (22.8) 2 (8.7)

appendicitis

Appendisectomy with peritoneal 4 (11.5) 6 (26.2)

toileting for burst appendix

Repair of perforation of duodenal 5 (14.2) 7 (30.5)

ulcer with through peritoneal toileting

Laparotomy with division of 3 (8.6) 0 (0.0)

bands and adhesions

Resection and anastomosis 4 (11.5) 1 (4.3)

of small bowel

Repair and peritoneal toileting 3 (8.6) 5 (21.7)

of ileal perforation

Resection and anastomosis 1 (2.8) 1 (4.3)

of large bowel

Herniotomy and herniorrhaphy 7 (20.0) 1 (4.3)

Total 35 23

Table VI

Distribution of patients by nature of collection

(n=58)

Nature of collection Frequency Percentage

Pus 02 3.6

Serous 11 19.6

Serosanguinous 34 60.7

Others 09 16.1

Table VII

Distribution of patients by time of collection of swab

(n=58)

Time of collection of swab Frequency Percentage

3rd postoperative day 12 20.7

4th postoperative day 16 27.6

5th postoperative day 30 51.7

Table VIII

Criteria of suspicion of wound infection and wound

inspection (n=58*)

Criteria Frequency Percentage

Wound pain 26 44.8

Fever 30 51.7

Soaking of dressing 15 25.9

*Total will not correspond to 100%for the presence of >1

criteria in many patients

Table IX

Distribution of patients by antibacterial profile

(n=58)

Antibacterial profile Frequency Percentage

Preoperative antibiotics

Ciprofloxacin 16 27.6

Cefuroxime 21 36.2

Ceftriaxone 21 36.2

Postoperative antibiotics without c/s


Cefuroxime 21 36.2

Ceftriaxonem 21 36.2

Bacteriological Study of Surgical Site Infection Following Emergency Abdominal Surgery 128

VOL. 31, NO. 2, JULY 2016


Table X

Antibiotics administered on availability of culture

report (n=58)

Antibacterial profile Frequency Percentage

after culture report


Cefuroxime 12 20.7

Ceftriaxone 10 17.2

Gentamycin 08 13.8

Amikacin 09 15.5

Azithromycin 07 12.1

Vancomycin 03 5.2

Imepenum 01 1.7

Table XI

Distribution of patients by isolated organism (n=58)

Organism Percentage

E.coli 37.9

Pseudomonas 24.1

Klebsiella 8.6

Proteus 5.2

Staphylococcus aureus 19

No growth 5.2

Table XII

Distribution of patients by sensitivity of antibiotics

(n=58)

Sensitivity to Sensitive Moderately Resistant

antibiotics sensitive

Gentamycin 5 (9.1) 12 (21.8) 38 (69.1)

Amikacin 21 (38.2) 16 (29.1) 18 (32.7)

Vancomycin 10 (18.5) 1 (1.9) 43 (74.1)

Imepenem 30 (54.5) 9 (16.4) 16 (29.1)

Azithromycin 00 6 (11.1) 48 (88.9)

Cefradin 00 3 (5.5) 52 (94.5)

Flucloxacillin 00 3 (5.5) 52 (94.5)

Amoxicillin 00 00 55 (100.0)

Ciprofloxacin 4 (7.3) 19 (34.5) 32 (58.2)

Cefuroxime 3 (5.4) 11 (19.6) 42 (75.0)

Ceftriaxone 5 (9.1) 8 (4.5) 42 (76.4)

Cefazidim 6 (11.3) 16 (30.2) 31 (58.5)

Table XIII

Distribution of patients by time needed to control

infection (n=58)

Time needed to control Frequency Percentage

infection

3 days 11 19.0

4 days 23 39.7

5 days 18 31.0

6 days 06 10.3

DISCUSSION

Surgical infection is still a subject of controversy and a

problem all over the world. Different workers in this field

have given their own thoughts and ideas for control of

infection. In the present study, 23(39.7) were below 30

years of age, 41.7% between 30-40 years and 19% 40 or

above 40 years of age. The mean age of patients was

32.6+/-8.6 years and the lowest and highest ages were 18

and 54 years respectively. About 60% of the patients was

male and the remaining 41% female giving a male to female

ratio of roughly 2:1. Masaadeh 6 showed that the occurance

of infection was higher in young group than in the other

group. deSa 7 defined in his study the overall rate of wound

infection was 18.92% and the infection rate in males and

females was almost similar.

Half of 58 patients had a history of preoperative shaving.

Twenty eight of 58 patients(48%) were done peritoneal

toileting. Over 60% developed superficial wound infection

and rest develop deep wound infection. The

serosanguinous was collected from 60.7% of patients

followed by serous from 19.6%, pus from 3.6% and other

specimen from 16.1% of patients for bacteriological

investigations. Antibacterial profile demonstrates that

nearly 30% of patients had a history of received

ciprofloxacin, 36.2% cefuroxime and another 36.2%

ceftriaxone in preoperative and postoperative is similar to

that found reported in the literature of Oluwafemi.9

E.coli was the predominant organism followed by 24.1%

pseudomonas, 19% staphylococcus aureus, 8.6%

klebsiella, 5.2% proteus. No growth was found in 5.2% of

patients. The sensitivity pattern of antibiotics in

postoperative wound infection- the highest percentage

sensitivity, moderate sensitivity and resistance were

showing to imepenem (54.5%), ciprofloxacin (34.5%) and

amoxicillin (100%). Masaadeh 6 reported the most

causative agent of postoperative infections was P.

aeruginosa 32 isolates (27.8%). Following E.coli 18 isolates

(15.6%). The lowest causative agents of postoperative

129 Shahidul Huq, Prabir Chowdhury, Farhana Mahmood, Mohammad Sanaullah, Md. Jalal Uddin



infections were Streptococcus pyogenes, Enterococcus

faecalis and Citrobacter freundii. Also reported the

organism was sensitive to amikacin,gentamycin,

tobramycin, ciprofloxacin and aztreonam with amikacin

showing highest percentage of sensitivity. Bertrand 10

documented 16.8% for Pseudomonas aeruginosa and 5.6%

for Staphylococcus aureus.

In our study, 28 (48.3%) of the patients took antibiotic

orally and the remaining 51.7% in injectable form. The

main antibiotics used on availability of culture and

sensitivity report were cefuroxime (20.7%), ceftriaxone

(17.2%), amikacin (15.5%), ciprofloxacin and gentamycin

(each 13.8%) and azithromycin (12.1%). About 40% of the

patients those were encountered emergency abdominal

surgery needed 4 days to control infection, followed by

31% 5 days, 19% 3 days and the rest 10.3% 6 days.

Seventeen percent of the patients needed further change

of antibiotics. In contrast, majority (83%) of patients not

required to change antibiotics.

CONCLUSION

Postoperative bacterial and fungal infections are a rising

problem in critically ill patients after surgery. The decisive

factors for a favorable outcome of infected patients are

early diagnosis, competent source control, as well as a

prompt and adequate anti-infective therapy. Only high

potent broad-spectrum anti-infective agents are suitable

for the empirical treatment of septic critically ill patients

after surgery, accompanied by supportive and adjunctive

therapeutic strategies.The increasing prevalence of multi-

drug resistant bacterial and fungal isolates must be taken

into account, especially in infected patients after extended

surgical procedures.

REFERENCES

1. Passaux P and Msika S. Risk factors for postoperative

infectious complications in Noncolorectal Abdominal

Surgery.Arch Surg 2003;138:314-324.

2. Emori TG, Gaynes RP.An overview of nosocomial

infections including the role of the microbiology laboratory.

Clin Microbiol Rev 1993; 6(4):428-42.

3. Mangram AJ, Horan TC, Pearson ML. Guideline for

prevention of surgical site infection, Hospital Infection

Control Practices Advisory Committee. Infect Control

Hosp Epidemiol 1999 Apr;20(4):250-78;quiz 279-80.

4. Kirkland KB, Briggs JP, Trivette SL. The impact of surgical

–site infections in the 1990s: attributable mortality, excess

length of hospitalization, and extra costs. Infect Control

Hosp Epidemiol 1999;20(11):725-30.

5. National Nosocomial Infections Surveillance (NNIS)

system. NNIS report, data summary from January 1992

to June 2002,issued August 2002.Am J infect Control

2002;30(8):458-75.

6. Masaadeh HA and Jaran AS. Incidence of Pseudomonas

aeruginosa in Postoperative wound infection. American

Journal of Infection Disease 2009;5(1):1-6.

7. deSa LA, Sathe MJ, Bapat RD. Factors influencing wound

infection. Postgrad Med 1984;30:232-6.

8. Lewis CM and Zervos MJ. Clinical manifestations of

enterococcal infection. Eur. Clin. Microbial Infec.

Dis.1990;9:111-7.

9. Oluwafemi O, Oguntibeju and Nwobu RAU. Occurance

of pseudomonas aeruginosa in postoperative wound

infection. Pak. J Med.Sci. 2004;20:187-191.

10. Bertrand X, Thouverez M, Patry C, Balvay P and Talon

D. Pseudomonas aeruginosa :antibiotic susceptibility and

genotypic characterization of strains isolated in the

intensive care unit. Clin Microbiol Infect. 2002;7:706-8.

Bacteriological Study of Surgical Site Infection Following Emergency Abdominal Surgery 130

VOL. 31, NO. 2, JULY 2016


Original Article

Audit of Anaesthetic Management for

Total Hip Replacement with Ankylosing

Spondylitis in NITOR

Nasir Uddin Ahmed1, Suhel Ahmed2, Nuzhat Nadia3, Md. Golam Sarwar4, Abdus Salam5,

M A Gani Mollah6

ABSTRACT:

Total hip replacement surgery for Ankylosing spondylitis of hip associated with spinal involvement is challenging

to Anaesthetist as well as to Surgeon. Type of Anaesthesia was proposed after proper anaesthetic assessment.

Regional anaesthesia is considered better tolerated, safe benefit than general anaesthesia. The aim of this audit

was to evaluate safe, benefit of regional anaesthesia (spinal, caudal epidural) over general anaesthesia for total

hip replacement of Ankylosing Spondylitis patients. A total number of 24 patients were diagnosed case of

ankylosig spondylitis were admitted at NITOR from july 2013 to june 2016. Patients were classified into mild to

moderate type and severe type of ankylosing spondylitis according to x-ray reports ,indirect laryngoscopy.

Among them 17 patients (mild to moderate type) received regional anaesthesia and 7 patients were received

general anesthesia. There were 24 patients selected for this audit, 17(70.8%) patients of mild to moderate type

received regional anaesthesia and 7(29.16%) patients of severe type Ankylosing Spondylitis received general

anaesthesia. The younger age group <20-40(58.16%) predominates over age group >40 or more (41.66%). About

sex male 20(83%) predominates over female 4(17%). Type of anaesthesia received regional 17(71%) better

lolarated, safe than 7(29%) patients received general anaesthesia. Complication observed on 18(75%) patients

whereas 6(25%) patients observed no complications. Our audit were concluded that due to improved

perianaesthetic care, regional anaesthesia technique(spinal, caudal epidural) provides better outcome of

Ankylosing Spondylitis patients after total hip replacement surgery.

Key words: Total hip replacement, laryngeal mask airway, histocompatibility antigen, American society of

anaesthesiologist, noninvasive blood pressure, caudal epidural.

1. Assistant Professor (Anaesthesiology) OSD, DGHS attached to NITOR.

2. Associate Professor (Anaesthesiology), NITOR.

3. Medical Officer (Anaesthesiology), NITOR.

4. Associate Professor (Orthopedic Surgery), DMC&H, Dhaka

5. Associate Professor, OSD, Kustia Medical College

6. Professor & Director, NITOR.

Correspondence: Nasir Uddin Ahmed, Assistant Professor, Anaesthesiology, OSD, DGHS, NITOR, Email: [email protected].

INTRODUCTION

Ankylosing spondylitis is a disease characterized by

inflammation and fusion of sacroiliac joints and lumber

vertebrae; may also involve the thoracic and cervical

spine1. The disease prevalence varies with presence of

histocompatibility antigen HLA-b27. It affects

predominantly young males, usually being between 14 &

35 years of age2. In England, AS is reported to occur in 1

in 200 men and 1 in 2000 women3. AS appears to be caused

by combination of genetic and environmental factors. It

is possible the pelvic infection acts as the environmental

trigger in genetically predisposed subjects4. The most

common presenting feature is low back pain associated

with early morning stiffness in a young man progressive

restricted movement of the spine and radiologic evidence

of spine as “bamboo like” appearance. Peripheral arthritis

develop atleast 50% of patients5 and may be the presenting

features in 15%6. In about 25% patients with peripheral

joints involvement the arthritis became chronic. The joints

most commonly involved the hip (75% become bilateral)



followed by the shoulder. Functionally, hip disease may

be far more incapacitating that spinal rigidity and often

makes working impossible7. Limitation of hip movement

interferes with walking and ultimately because of flextion

contracture, posture is affected. This contracture results

in flexion of knees to maintain an erect posture and cause

the typical Z-shaped posture, first described by Marie8.

THR offers such patients a new life. To perform both

general or regional anaesthesia is challenging to

Anaesthesiologist.

Methods; This audit was conducted in the department of

Hip Arthoplasty and Anaesthesia of NITOR, over the

periods from July 2013 to June 2016. Twenty four

Ankylosing spondylitis patients who had THR included

in this audit. Informed concent were obtained from

individual patient after proper counseling and anaesthetic

plan was formulated . During preoperative visit age, sex,

body weight, ASA grading, pulse ,BP were recorded.

Preanaesthetic assessment was done by specialized

Anaesthesiologist. Then all the patients were grouped

into mild to moderate type of ankylosing spodylytis hip &

lumber spine, severe type involving multiple spinal column.

Following investigations were done in preoperative visit,

such as CBC(complete blood count),blood grouping, Rh

incompatibility, blood sugar, serum creatinine, ECG,

Echocardiography, S.electrolytes, x-ray cheast, x-ray hip,

x-ray cervical spine, X-ray lumbosacral spine, indirect

laryngoscopy specially for 7 patients with severe

ankylosing spodylitis.

There were total number of patients with ankylosing

spodylitis selected for this audit. Among them 17 were

mild to moderate ankylosing spodylitis and the rest were

severe ankylosing spodylitis . Among the 17 patients,16

were given spinal with 0.5% bupivacaine heavy 3ml with

0.5ml fentanyl. One patatient was given caudal epidural

with 0.5% plain bupivacaine14ml with iml fentanyl. Total

15ml was given as a single shot bolus(1ml/spinal segment).

Seven (7) patients received general anaesthesia. Among

them one patient received GAwith ETT and six patients

received general anaesthesia with LMA. Induction of

general anaesthesia with propofol 2mg/kg body weight

and intubation was facilated by suxamethonium 2mg/kg

body weight. Analgesia was maintained by fentanyl 2 µgm/

kg nondepolaring muscle relaxant vecuronium 1mg/kg was

used. Following parameter was observed during

perioperative period, such as NIBP, Heart rate by ECG,

SPO2 by pulse oximeter. Hartman solution and transfused

of blood 2 units for 1st 24hrs in the postoperative care unit

every patient received O2 inhalation 2-3ml by nasal canula

for 4-6hrs postoperative analgesia maintained by inj.

Pethedine 1.5mg/kg body weight was given

intramuscularly for both the groups.

Result

Table-I

Age distribution of the study patients (n=24)

Age in years Number of patients Percentage

20-30 7 29.16%

31-40 7 29.16%

40 or more 10 41.66%

Total 24 100%

Age group 20-40 years predominates over 40 years or

more.

Table-II

Sex distribution of the study patients (n=24)

Sex Number Percentage

Male 20 83%

Female 4 17%

Total 24 100%

Table-II Shows that 20 (83%) was male, 4(17%) was female.

Male predominates over female.

Table-III

Different types of anaesthesia received and severity of Ankylosing spondylitis.

Type of of anaesthesia n=24 Regional anaesthesia General anaesthesia

(Spinal, Caudal ) (n=17) (n=7)

Number % Number %

17 71% 7 29%

Mild to moderate Ankylosing spondylitis 17 71%

Severe Ankylosing spondylitis 7 9%

Audit of Anaesthetic Management for Total Hip Replacement with Ankylosing Spondylitis in NITOR 132

VOL. 31, NO. 2, JULY 2016


Out of 24 patients, 17 (71%)n of mild to moderate

Ankylosing spondylitis were received regional anaesthesia

(Spinal, Caudal epidural) and 7 (29%) of Severe Ankylosing

spondylitis were received general anaesthesia.

Table IV

Presentation of Complication

Status Number (n=24) Percentage

Complication observed 18 75%

No Complication 6 25%

Observed presentation of complication, out of 24 patients,

18 (75%) patients observed Complications whereas 6 (25%)

patients observed no Complication.

Table-V

Type of Complications (perioperative) and type of

anaesthesia. (n=18)

Type of Complications GA(n=7) Regional (n=11)

Nausea/Vomiting 2(28.15%) 1 (9.09%)

Shivering 1 (14.3%) 2(18.1%)

Hypotension 1 (14.3%) 2(18.1%)

Itching 00% 1 (9.09%)

DISCUSSION

Ankylosing spondylitis is a progressive from of

autoimmune inflammatory arthritis which lead to

spontaneous fusion of vertebrae and sacroilliac joint. It

often menifests as low back pain. Patient may develop

many problem regarding their spine, kyphotic deformity,

pockers spine,bamboo spine of lumber vertebrae, chest

deformity and TM joint ankylosis. Mild to moderate type

of ankylosing spondylitis involvement of sacroilliac joint

and lumber vertebrae. But in severe ankylosing spodylytis

it involve sacroiliac joint, lumber, thoracic, cervicle spine,

atlanto-axial joint,temperomandibular joint. The most

serious anaesthetic problem is associated with intubation

where patients with fusion of the cervical vertebral joints

and fixation of head and neck face an increased risk of

cervical fracture 9. Indirect laryngoscopy is a most useful

examination in such case and is a reliable indicator of

probable intubation difficulty from any case. THR can be

performed under regional block(spinal) and caudal block

has been successfully used for ankylosing spodylitis10.

In our audit we performed spinal anaesthesia in 16 patients

out of 17 patients and rest one was performed caudal

epidural.

We consider epidural or spinal to be contraindicated for

many reasons, 1st, ossification of intraspinous ligaments

and formation of bony bridges between the vertebrae

make the placement of a neddle difficult or impossible 11.

2nd, difficult in positioning of the patients for regional

anaesthesia. Alternate methods of intubation have been

well reviewed recently 12. These include awake intubation

under local anaesthesia, blind nasal intubation with the

patient awake as asleep, fiberoptic laryngoscopy. The

type of anaesthesia were selected according to

preanaesthetic assessment and radiological reports for

the benefit to patients. In our audit ,out of 7 patients

1patient received GA with ETT and 6 patients received GA

with LMA airway with spontaneous ventilation.

CONCLUSION

From the anaesthetic point of view, preoperative

assessment, indirect laryngoscopy and preparation to

overcome anticipated problems, should enable those

patients to be managed safely. Our audit concluded that

due to improved perianaesthetic care, regional anaesthesia

technique (Spinal and caudal epidural ) and analgesia

reduced morbidity and mortality, good outcome of the

patients after total hip replacement.

REFERENCES

1. Anaesthesia and Intensive care A-Z. And Encyclopaedia

of principles and practice 3rd edition. Steven M. Yentis.

BUTTERWORTH HEI MANN ELSEVIER LTD: 32

2. Callin A. ankylosing spodylytis. In; Kelly WN. Haris

ED. Ruddy S. Sledge CD, eds. Text book of rheumatology.

London. WB. Saunders 1981; 1072-32.

3. Wright V. Moll JMH. ankylosing spodylytis, Br.J Hosp

Med 1973;331-41.

4. Clinical anaesthesiology. G. Edward Morgan, Jr. MD,

Maged S. Mikhail MD. 4th Edition. Mc Graw-Hill

Companies ; 405

5. Sharp. Differential diagnosis of ankylosing spodylytis.

Br Med J 1957;975-8.

6. Sharp J. Ankylosing spodylytis. A review. In; Dixon Ast

J, ed. Progress in clinical reheumatology. London. Churchill

Livingstone, 1965;180.

7. Hart. F Robinson KC, Allchin FM. Maclagen NF.

ankylosing spodylytis. QJ Med 1949;18:217-34.

8. Marie, P. Sur La Spondylose rhizomelique . Reve de

medicine 1898:18:285-315.

9. Murry GC. Persellin RH. Cervical fracture complicating

ankylosing spodylytis. Am J Med 1981;70:1033-41.

10. De Board JW. Chin JN. Guilford NB, Caudal anaesthsia

in a patient with ankylosing spodylytis for hip surgery.

Anaesthesiology 1981;54:164-6

11. Sinclair JR, Mason RA. ankylosing spodylytis. The case

for awake intubation. Anaesthsia 1984;39:3-11.

12. Loach A. preoperative assessment. In; Loch A, ed.

Anaesthsia for Orthopedic patients. London: Edward

Arnold, 1983:19-36.

133 Nasir Uddin Ahmed, Suhel Ahmed, Nuzhat Nadia, Abdus Salam, Golam Sarwar, M A Gani Mollah



Original Article

Evaluation of the Treatment of Closed

Tibial Diaphyseal Fracture by SIGN

Interlocking Intramedullary Nail in

Adults

Md. Ferdous Rayhan1, Manjurul Haque Akanda Chowdhury2, Md. Abdus Sabur3, Jibananda Halder4,

Mir Shahidul Hasan5, Md. Mohoshin Sarker6

ABSTRACT

Tibia is the most commonly fractured long bone due to its superficial location. Government hospitals in Bangladesh

are so over burdened with trauma victims that most wards are full of such patients. The burden of poverty and

disasters affect the budgets health care system. The poor patients, who have no assets, suffer the most. The

Surgical Implant Generation Network (SIGN) was established in January, 1999 as a humanitarian, nonprofitable

organization in the State of Washington, USA, to provide free of cost and one of the best treatments for long bone

fractures in developing countries. To evaluate the results of management of closed tibial diaphyseal fractures in

adults by SIGN interlocking intramedullary nails. This was an observational study carried out among the patients

with closed diaphyseal fracture of tibia. The study was conducted in the Department of Orthopaedics, National

Institute of Traumatology and Orthopaedic Rehabilitation (NITOR), Dhaka, over a period of two years from July

2014 to June 2016. Mean ± SD was 36.60 ± 6.40 years. Right side are more affected. Male are more affected 17

(85%) than female 3 (15%). RTA is the leading cause of injury 15(75%). Mean duration of radiological union was 17.8

± 2.15 weeks. Anterior knee pain occurred in 3 (15%), superficial infection occurred in 1 (5%) and knee stiffness

(flexion deficit >200)occurred in 2 (10%) patient.Excellent result is found in 18 (90%) & Good is found in 2 (10%) of

the study patients according to Karlstrom-Olerud’s functional evaluation criteria out of 20 patients. Every patient

was followed up regularly up to 6 months. Closed tibial diaphyseal fractures in adults can be treated by open

reduction & internal fixation by SIGN interlocking intramedullary nail.This is an effective method of treatment.This

method enhances anatomical, clinical & functional recovery & improve functional status of knee & ankle joint

with early rehabilitation.

Key words: Tibial disphyseal fracture, SIGN nail, Good methods.

1. MS Resident (Orthopaedic Surgery) NITOR, Dhaka.

2. Ex. Professor of Orthopaedic Surgery NITOR, Dhaka.

3. Associate Professor of Orthopaedic Surgery NITOR, Dhaka.

4. Assistant Professor of Orthopaedic Surgery NITOR, Dhaka.

5. MS Resident (Orthopaedic Surgery) NITOR, Dhaka.

6. Medical officer (Pathology), UHC, Haripur, Thakurgaon.

Correspondence: Dr. Md. Ferdous Rayhan, MS Resident (Orthopaedic Surgery), NITOR, Dhaka.

INTRODUCTION

Tibialdiaphyseal fractures are the most common long bone

fractures in adults.Several studies have shown that tibial

nailing is associated with superior outcomes and less

complications compared to those obtained with open

reduction and internal fixation (ORIF) by plate, external

fixation, or nonoperative treatment in case of closed stable

or unstable fractures1.

Conventionally closed locked intramedullary nailing

requires the use of fluoroscopy and fracture tables in

addition to the implants. Fluoroscopy is unavailable in

most resource poor hospitals in low income countries5.An

invention of a locked IM nailing system that can be used

without fluoroscopy and fracture table has been long

awaited for. SIGN IM nailing system that was initially

designed for tibia shaft fractures has proved handy and

VOL. 31, NO. 2, JULY 2016 134


applicable to surgeons in the developing world2.The

Surgical Implant Generation Network (SIGN) solid,

stainless steel nail was designed for use in the tibia and it

is strong enough for slots rather than holes to

accommodate the interlocking screw. The nail is straight

but the proximal and distal ends of the nail have a 9 and 1.5

degree apex posterior bend, respectively. The nail is also

used for femoral intramedullary (IM) nailing and these 2

bends create an effective radius of curvature which closely

approximates that of the normal human femur3

Solid nail like SIGN nail has advantage of less chances of

implant failure as nail is more stronger.Jigs for both

proximal & distal interlocking screws decrease dependence

on image intensifier and also decreases operating time.4

MATERIAL AND METHODS

Adult patients with closed diaphyseal fracture of tibia

attending the emergency, outpatient and admitted patients

of NITOR fulfilling exclusion and inclusion criteria were

included in this study population. Inclusion criteria:1.

Closed tibialdiaphyseal fracture in adults within 10 days

of injury 2. Both sex3. Age >18 yearsupto 60 years

Exclusion criteria:1. Open fracture 2. Non union of tibial

fracture3. Mal union of tibial fracture4. Closed

tibialdiaphyseal fracture in adults more than 10 days of

injury.A total of 20 patients were consecutively included

in the study.

OPERATIVE TECHNIQUE

After proper reduction by opening the fracture site, a small

sized SIGN reamer was passed in the medullary canal until

it reached the physeal scar or subchondral bone near the

ankle joint. Gradually increased sized reamers were now

passed in the medullary canal for gradually increasing

diameter of tibia. We used SIGN nails ranging from 280 mm

to 360 mm in length (mainly 300 and 320 mm) and diameter

8 mm to 10 mm (mainly 8 mm and 9 mm).

AFTER CARE

After operation, limb was kept elevated over pillows for 24

hours. Parenteral antibiotics were continued for 2 days

followed by oral antibiotics until stitch removal or wound

healing. Quadriceps exercises and ankle exercises were

encouraged after subsidence of pain (2-3 days). Active

knee bending allowed after stitch removal (12-14 days).

Partial weight bearing was allowed after 4 weeks. Full

weight bearing was allowed only after evidence of clinical

and radiological union (average 17-18 weeks.).

RESULTS

Nine out of 20 patients (45%) were below 31years old, 3

(15%) were 31-40 years and the remaining 8 (40%) were

>40 years old. Mean ± SD was 36.60 ± 6.40.out of 20

patients, 17 (85%) patients were male and 3 (15%) were

female. Out of 20 patients 3 (15%) were housewives, 2

(10%) were service holder, 3 (15%) were students, 5 (25%)

were farmers and 7 (35%) were daily labourers.Thirteen

(65%) patients had closedtibialdiaphyseal fracture in right

side and 7 (35%) had in left. Fifteen (75%) patients were

admitted due to road traffic accident. History of physical

assault was second common cause which was 3(15%) and

History of fall 2 (10%). out of 20 study patients 4 (20%)

Case Report - 2

Final follow up full squatting

135 Md. Ferdous Rayhan, Manjurul Haque Akanda Chowdhury, Md. Abdus Sabur, Jibananda Halder, Mir Shahidul Hasan, Md. Mohoshin Sarker



spiral fracture, 9 (45%) oblique fracture, 5 (25%) transverse

fracture, 2 (10%) segmental. out of 20 study patients

anterior knee pain occurred in 3 (15%), superficial infection

occurred in 1 (5%) and knee stiffness (flexion deficit >200

occurred in 2 (10%). Mean duration of radiological union

was 17.8 ± 2.15 weeks. In this study no patient developed

delayed or non union.Excellent result is found 18 (90%) &

Good is found 2 (10%) of the study patients according to

Karlstrom-Olerud’s functional evaluation criteria score6.

Every patient was followed up regularly up to 6 months.

DISCUSSION

In this series any fracture pattern in the tibial diaphysis

from 4// below the knee and 3// above the ankle was fixed

by SIGN interlocking intramedullary nail. According to

Grosse Kempf, interlocking nail can be applied in any

fracture if at least 3 to 4 cm of bone is intact proximally and

distally to the fracture site7. Khan et al. (2013) used SIGN

nails in tibia when fracture located 7 cm below knee joint

to 7 cm above ankle joint.

In the study of Court Brown et al. (1990) also showed

most of victims were in 32.4 years ranged16 to 80. Akhter

et al. (2013) showed mean age of the patient was 35.75±

13.16 & age range (18-70) years. These group represent,

the most young age group having high activity. In this

study 2 patients age 60 years & this 2 patients develop

knee stiffness (flexion deficit >20°). This may be due to

the fact that post.operative joint stiffness common in older

age group patients.

In this study we found out of 20 patients, 17 (85%) patients

were male and 3 (15%) were female. In the study of Court-

Brown et al. (1990) 100 were male and 23 women; male

female ratio approximately (4:1). Khan et al.(2013) showed

out of 50 patients, 44 (88%) patients were male and 6 (12%)

patients were female. Akhter et al. (2013) showed male to

female ratio was 4 : 1.This may be due to the fact that

female are less exposed to road traffic accidents in the

country.

In this study most of the occupation of the patients was

daily labourer which was 7(35%),second most was farmer

which was 5(25%) others was 3 (15%) housewives, 2

(10%) service holder, 3 (15%) student.This may be due to

the fact that daily labourer are more exposed to outdoor

activities.

Most of the side of injury patients was in right side of

diaphysis of tibia out of 20 study patients which was 13

(65%) and left side 7 (35%). Akhter et al. (2013) showed

right sided tibial injury in 17 cases & left sided tibial injury

in 13 cases.

In this series the most common cause of injury was road

traffic accident.Bone and Johnson, (1986) showed 90%

injury due to road traffic accidents. Court-Brown et al.

(1990) showed 31.2% fractures followed road traffic

accidents, 36% followed sports and 28% occurred after

fall from height. In the study ofSmet et al. (2000) 89%

fractures were sustained in road traffic accident and 10%

in sports accident.In the study of Akhter et al. (2013)

common mechanism was RTA (n= 21, 70%) followed by

fall (n=6, 20%) assault or violence (n=3, 10%)

Case Report - 1

Table-1

Evaluation of outcome at final follow up (n=20)

Outcome Number of patients Percentage (%)

Excellent 18 90%

Good 2 10%

Fair 0 0%

Poor 0 0%

Total 20 100%

Evaluation of the Treatment of Closed Tibial Diaphyseal Fracture by SIGN Interlocking Intramedullary Nail in Adults 136

VOL. 31, NO. 2, JULY 2016


Most of the fracture pattern of the study patients was

oblique type which was 9 (45%), second most common

was transverse fracture which was 5 (25%). Pintore et al.

(1992) showed that grade 4 comminution (44.26%) were

more common. Akhtar et al. (2013) showed fracture types

according to geometry were transverse (n=12; 40%),

oblique (n=05; 16.6%) and spiral (n=13; 43.3%). But in our

study oblique fracture was more common. Early weight

bearing was allowed in transverse fractures while for

oblique & segmental fractures weight bearing was delayed

until bridging callus was seen on radiograph. In this study

oblique fractures united early than spiral fractures &

segmental fractures took more time of union.

Most common complication of study patients was anterior

knee pain (no pain in fracture site) which occurred in 3

(15%) patients, superficial infection occurred in 1 (5%)

and knee stiffness with flexion deficit >200 occurred in 2

(10%) patients. Katsoulis et al. (2006) showed that after

intramedullary nailing in tibia incidence of anterior knee

pain varies from 10% to 86%. Akhtar et al. (2013) showed

restricted ROM in knee & ankle joint in 5 patient out of

total 30 patients. In my study there was no other

complication like malreduction,malalignment and implant

failure.

In this series the mean union time of fracture was 17.8

weeks and the lowest and the highest time were 14 and 23

weeks respectively. None of the patient required

dynamization. Soren, (2009) showed mean union time by

using SIGN nail was 18.5 weeks. Shah et al. fixed 36 tibial

fractures with intramedullary interlocking SIGN nail & his

overall union rate was 97.2% & mean time to union was 22

weeks. The early union rate in this study may be due to

the fact that no open fractures incuded in my study.

REFERENCES

1. Jafarinejad, A.E., Bakhshi,H., Haghnegahdar,M.,

&Ghomeishi,N. (2012). Malrotation following reamed

intramedullary nailing of closed tibial fractures. Indian

Journal of Orthopaedics, vol.46, pp.312–16.

2. Soren, O.O. (2009). Outcome of surgical implant generation

network nail initiative in treatment of long bone shaft

fractures in Kenya. East African Orthopaedic Journal,

vol.3, pp.8-14.

3. Feibel, R.J., &Zirkle, L.G. (2009). Use of Interlocking

Intramedullary Tibial Nails in Developing Countries.

Techniques in Orthopaedics, vol.24, pp.233–46.

4. Khan, I., Javed, S., Khan, G.N., & Aziz, A. (2013).

Outcome of Intramedullary Interlocking SIGN Nail in

TibialDiaphyseal Fracture. Journal of The College of

Physicians and Surgeons Pakistan, vol.23, pp. 203-7.

5. Akhtar, A., Shami, A., Wani, G.R., &Gul, M.S. (2013).

Management of Diaphyseal Tibia Fractures with

Interlocking Sign Nail after Open Reduction without Using

Image Intensifier. Annals of Pakistan Institute of Medical

Science, vol.9, pp.17-21.

6. Cekic, E., Alici, E., &Yesil, M. (2014). Reliability of the

Radiographic Union Score for Tibial Fractures.

ActaOrthopaedicaTraumatologicaTurcica, vol.48, pp.533-

40.

7. Pintore, E., Maffulli, N., Petricciuolo, F. (1992).

Interlocking nailing for fracture of the femur and tibia. The

British Journal Of Accident Surgery, vol.23, pp.381-87.

137 Md. Ferdous Rayhan, Manjurul Haque Akanda Chowdhury, Md. Abdus Sabur, Jibananda Halder, Mir Shahidul Hasan, Md. Mohoshin Sarker



Original Article

INTRODUCTION

Inter-trochanteric fractures have traditionally been treated

by closed reduction and internal fixation with a dynamic

hip screw or an intramedullary device. Reduction is usually

achieved by positioning the patient on a fracture table

with the foot secured to a boot to aid in traction and rotation.

These fractures and positioning for their surgical treatment

pose a difficult problem.

When encountered in patients with below-knee

amputations. Absence of the foot and part of the leg in

these patients makes positioning on the fracture table

challenging. We highlight the difficulties encountered in

a patient with below-knee amputations undergoing fixation

of an inter-trochanteric fracture and the various techniques

available to overcome this problem.

CASE PRESENTATION

A 45years man presented to NITOR with a history of fall.

He complained of pain in the left hip especially on

Intertrochanteric Fracture Fixation in a

Patient with Below-knee Amputation

Presents A Surgical Dilemma: A Case

Report

Md. Kamruzzaman1, Shamol Chandra Debonath2, Syed Golam Samdani 3, Hamidul Islam4,

S.M.Shakawat Hossain4

ABSTRACT

Intertrochanteric fracture fixation surgery in patients with below-knee amputations poses a challenging problem

to the surgeon in terms of obtaining traction for reduction of the fracture. The absence of the foot and part of the

leg in these patients makes positioning on the fracture table difficult. We highlight this difficult problem and

suggest techniques to overcome it.

Keywords: Intertrochanteric Fracture, Below-knee Amputation, Dilemma

1. Assistant Professor, Ortho Surgery, NITOR, Dhaka

2. Associate Professor, Ortho Surgery, NITOR, Dhaka

3. Assistant Professor, Ortho Surgery, NITOR, Dhaka

4. Assistant registrar, Ortho Surgery, NITOR, Dhaka

Correspondence: Dr. Md. Kamruzzaman, Assistant Professor, Ortho Surgery, NITOR, Dhaka

movement of his hip. He had left sided below-knee

amputations following peripheral vascular disease and had

below-knee suction prostheses fitted to his lower limbs

for mobility.

Radiographs of his pelvis and left hip revealed inter-

trochanteric fracture of the femur kyle type 2.A dynamic

hip screw fixation was planned for the fracture but the

dilemma was how to position the patient on the fracture

table for the surgery.The patient was positioned on a

fracture table with a perineal post and the affected limb

supported on a radiolucent leg support .The opposite

leg was strapped securely to a leg support with the limb

placed in abduction to allow easy access for the image

intensifier .As the fracture was undisplaced, fixation of

the fracture was performed with rotation of the hip by

the assistant. The procedure was completed

satisfactorily and postoperatively the patient was mobile

with full weight-bearing after fitting prostheses to his

lower limb.

VOL. 31, NO. 2, JULY 2016 138


DISCUSSION

Inter-trochanteric fractures of the femur are quite common.

Management of these fractures is essentially surgical and

the various techniques used include dynamic hip screw

fixation, intramedullary nailing and dynamic condylar screw

fixation. Patients with below-knee amputation with inter-

trochanteric fractures pose a special problem as

positioning on the fracture table is difficult due to the

absence of the foot and part of the leg. The problem is

accentuated when there is a need to apply traction for

obtaining reduction of the fracture. There is little

information in the literature ontechniques to deal with this

problem. We describe a few methods that can be used

when this rare and unusual problem is encountered.

If the fracture is undisplaced or minimally displaced, the

limb can be placed on a radiolucent leg support with the

opposite hip kept abducted to allow access for the image

intensifier. Traction and rotation of the hip can be

Figure 1: Clinical photograph shows Preoperative x-ray, patient positioning

Fig.-2: Clinical photograph shows post operative patient

position Fig.-2: Clinical photograph shows post operative x-ray

139 Md. Kamruzzaman, Shamol Chandra Debonath, Syed Golam Samdani, Hamidul Islam, S.M.Shakawat Hossain



performed by an assistant. An alternative is to fit the

patient’s prosthesis onto the stump and secure the foot of

the prosthesis to the boot on the traction table. A

radiolucent leg support should be placed under the limb

for safety. These techniques cannot be used when the

fracture is displaced and more traction is needed.Prosthesis

fitted onto the stump and the limb secured on the boot of

the traction table.

If the fracture is displaced and greater traction is

anticipated, the method of shortening the traction arm

and inverting the boot to accommodate the flexed knee

and stump, as described by Al-Harthy et al. [5], can be

used. A standard boot should be used and the stump

should be 12 cm or more (below the tibial tuberosity). If

the stump is long, the boot tongue can be inverted for the

stump to protrude. Upper tibial skeletal traction can be

used if the stump is short but this method has some

drawbacks. The skeletal pins may ‘cut out’ of the bone,

which is usually osteoporotic, on applying traction. The

other option is to use a distal femoral skeletal traction

which would assist in traction.

CONCLUSIONS

Intertrochanteric fracture fixation surgery in patients with

below-knee amputations is a difficult and challenging

problem for the surgeon. The dilemma is on how to provide

the traction and rotation required for reduction of the

fracture. We believe that the techniques mentioned here

to overcome this problem are safe and give the surgeon

various options to handle this situation.

REFERENCES

1. Fogagnolo F, Kfuri M, Jr, Paccola CA. Intramedullary

fixation of pertrochanteric hip fractures with the short

AO-ASIF proximal femoral nail. Arch Orthop Trauma

Surg. 2004;124:31–37. doi: 10.1007/s00402-003-0586-9.

2. Hardy DC, Descamps PY, Krallis P, Fabeck L, Smets P,

Bertens CL, Delince PE. Use of an intramedullary hip-

screw compared with a compression hip-screw with a

plate for intertrochanteric femoral fractures. A prospective,

randomized study of one hundred patients. J Bone Joint

Surg Am. 1998;80:618–63.

3. Sadowski C, Lübbeke A, Saudan M, Riand N, Stern R,

Hoffmeyer P. Treatment of reverse oblique and transverse

intertrochanteric fractures with use of an intramedullary

nail or a 95 degrees screw-plate: a prospective, randomized

study. J Bone Joint Surg Am. 2002;84A:372–381.

4. Valverde JA, Alonso MG, Porro JG, Rueda D, Larrauri

PM, Soler JJ. Use of the gamma nail in the treatment of

fractures of the proximal femur. Clin Orthop Relat Res.

1998;350:56–61. doi: 10.1097/00003086-199805000-

00007.

5. Al-Harthy A, Abed R, Campbell AC. Manipulation of

hip fracture in the below-knee amputee. Injury.

1997;28:570. doi: 10.1016/S0020-1383(97)00118-6.

Intertrochanteric Fracture Fixation in a Patient with Below-knee Amputation Presents A Surgical Dilemma 140

VOL. 31, NO. 2, JULY 2016


Original Article

ABSTRACT:

Tibiotalocalcaneal arthrodesis is a salvage procedure for the treatment of severe ankle and subtalar

arthropathywhere no options left for keeping those joints mobile.SIGN nail is used here for attaining tibiotalocaneal

fusion in a retrograde way with minimally invasive technique. ThisSIGN Nail fusionhas not been previously reported

yet, despite of the traditional intramedullary nail system. This study aimed to evaluate the clinical outcomes of

patients undergoing tibiotalocalcaneal arthrodesiswith SIGN nailto attain painless, stablehind foot to

improvepatients’ quality of life. From June 2015to December 2016, 12 patients with severe ankle and subtalar

arthropathy underwent tibiotalocalcanealarthrodesis. These patients were 27 to 46 years(mean 37.33 years) old;

the duration of their disease was 3-12 months (mean 5.33 months). The study populationincluded 12 males and

no females; 4 patients underwent surgery on the left and 8 on the right. Indications forsurgery included avascular

necrosis of the talus (n = 6), severe ankle & subtalar arthritis (n=2), Pilon fracture nonunion (n = 4),post traumatic

deformity (n =2). A small incision was performed at non weightbearing part of the sole 1.5 cm in front of

weightbearing calcaneum to reach the entry point of the nail, no other incision is made.Then under the guidance

of C armappropriate sized SIGN nail introduced through calcaneum,talas and Tibia for arthrodesis of

tibiotalocalcaneal joint. Patients were followed up at 6 weeks and 3, 6 and9 months after surgery; they were

evaluated by Roles and Maudsley patient satisfaction scores, the AmericanOrthopaedic Foot & Ankle Society

(AOFAS) Ankle-Hindfoot Score, visual analogue scale (VAS) score andradiographic evaluation. Twelve patients

were studied, with a mean follow-up time of 4.5 months (range 5–18). The meanRoles and Maudsley patient

satisfaction score was 1.41 at the last follow-up; most of the patients were satisfiedwith the surgery results. The

mean preoperative AOFAS Ankle-Hindfoot Score was 28.25 (range 26–31), while the meanlast follow-up AOFAS

Ankle-Hind foot Score was 70.08 (range 60–79). The VAS score for preoperative functional pain was5.58 (range

3–8) compared to 1.16 (range 0–3) postoperatively.The mean time to union was 3.8 months (range 3–12 months);

fusion of the ankle and subtalar joint wassuccessful in all patients. One patient experienced shortening of about

2cm. Tibiotalocalcaneal arthrodesis with retrograde SIGN nailing for the treatment of severe arthropathyof the

ankle and subtalar joint is an effective treatment that is minimally invasive and is associated with a high fusion

rate, low incidence of complications and good postoperative recovery.

Keywords: Tibiotalocalcaneal, Arthrodesis, Ankle, Subtalar, Fusion,Abbreviations: VAS, Visual analogue scale;

AOFAS, American Orthopaedic Foot & Ankle Society.SIGN-Surgical international generation network.

Innovating Minimally Invasive

Retrograde Tibiotalocalcaneal

Arthrodesis using SIGN Nail

S. Anwaruzzaman1, M. Asraf Ul Matin2, M. M. R. Bhuiyan3

1. Professor, Department of Orthopaedic surgery, Comilla medical college, Comilla, Comilla, Bangladesh

2. Junior Consultant, Orthopaedic Surgery, Shahidnagar Trauma Center, Daudkandi, Comilla, Bangladesh

3. Resident, Orthopaedic Surgery, Comilla Medical College and Hospital, Comilla, Bangladesh.

Correspondence: Dr. S. Anwaruzzaman, Professor, Department of Orthopaedic surgery, Comilla Medical College, Comilla, Bangladesh

BACKGROUND

Several treatment options are available for pain and

disability due to post traumatic condition, arthritis and

deformities of ankle.Severe ankle and subtalar arthritis is

the end stage ofarticular cartilage damage and

malformation caused bymany factors, such as trauma,

failure of ankle arthrodesis,talar ischemia and necrosis,

adult-acquired flat foot, grossosteoarthritis, severe

rheumatoid arthritis, infection,failure of ankle replacement,

severe talipes equinovarusdeformity, other congenital



deformities, Charcot’s diseaseand neuromuscular disease.

Patients with gross ankleand subtalar arthritis often suffer

pain or have difficultywalking, which seriously impacts

their daily life1,2.When conservative treatment becomes

ineffective, surgeryis the final treatment option.

Tibiotalocalcaneal arthrodesis is a surgical procedurethat

aims to alleviate pain, restore the walking gait andimprove

the patient’s quality of life. Fusion of both theankle and

subtalar joints is performed at the same timeto maintain

the stability of the hind foot and to correctthe hind foot

alignment3,4. Early in 1906, Lexer performed

tibiotalocalcaneal arthrodesis with boneallograft5.

Subsequently, with continuous technological

improvements, fixation using screws, external fixators,

intramedullary nails and plates have further alleviated

thepain and improved the function of patients6,7,8,9,10.

We prefer SIGN nail as it has some advantages over

traditional nails in perspective of stoutness, inborn

mechanics of proximal bend of 90 with 3 dynamic holes

and a static hole.Lesschance of forming biofilm and

economic benefits.

a prospectiveexperimental type of study. These patients

were 27 to 46 years(mean 37.33 years) old; the duration of

their disease was 3-12 months (mean 5.33months). The

study populationincluded 12 males and no females; 4

patients underwent surgery on the left and 8 on the

right.We have treated the patients who wasmaltreated,

undertreated or even untreated for open or closed peri-

ankle fractures or the consequences of trauma &

degenerative changes. We didn’t do any tibiotalocalcaneal

fusion in any fresh acute fractures rather treated

accordingly as protocol.We only treated those who came

with arthropathy following peri-ankle pathologies as stated

in table1.3 patients had open fractures got treated by

traditional bone setters.They had painful,unstable

deformed ankle. 5 patients had previous surgeries like

closed reductions and pinning with shanz screws,k wires,

surgical toileting and back slabs.Two patients treated with

external fixators but most of them failed to unite&

eventually no relief of symptoms.Patients were evaluated

by Roles and Maudsley patient satisfaction scores, The

AmericanOrthopaedic Foot & Ankle Society (AOFAS)

Ankle-Hindfoot Score, visual analogue scale (VAS) score

andradiographic evaluation.

Table-I

Disease for tibiotalocalcaneal arthrodesis

Disease Number of percentage

patients

Talar Ischaemia 4 33.33%

Pilon fracture non union 4 33.33%

Severe Arthrthitis of Ankle & 2 16.66%

Subtalar Joint

Maltreated deformed ankle 2 16.66%

(flexible varus or valgus)

SURGICAL TECHNIQUE

Patients were kept in supine position with a bolsterunder

the affected hip to facilitate internal rotation ofthe extremity.

A pneumatic tourniquet was routinelyused with a pressure

of 300 mmHg. As the old maltreated peri-ankle fractures

brings upunstable,non-united & deformed(flexible varus

or valgus) ankle, we can easily mobilize it manually under

anesthesia. After manual correction of any deformitya 2.5cm

incision was performed at non weight bearing part of the

sole 1.5 cm in front of weightbearing calcaneum at the

crossing point of two line trajectory along the both

maleolus and the axis of 2nd metatarsal to reach the entry

point of the nail, no other incision is made anywhere.

Fig. 1: SIGN Nail with screws

Therefore, we attempted to perform tibiota local caneal

arthrodesis with SIGN nails in retrograde fashion.This

studyaimed to evaluate the clinical outcome of

tibiotalocalcaneal arthrodesis with SIGN nails for

treatingsevere advanced ankle and subtalar arthropathy.

METHODS

Clinical data: From June 2015to December 2016, 12

patients with severe ankle and subtalar arthropathy

underwent tibiotalocalcanealarthrodesis in orthopaedic

department of comilla medical college and hospital. It was

Innovating Minimally Invasive Retrograde Tibiotalocalcaneal Arthrodesis using SIGN Nail 142

VOL. 31, NO. 2, JULY 2016


Then with or without the guidance of C-Arm an awl

tracedand broached the entry point atcalcaneum.

Areamerwas inserted throughout calcaneum,talus up to

the medullary canal of lower half of tibia. Appropriate sized

SIGN nail was introduced keeping thealignment and foot

plantigrade with 10-150 external rotation. First screw was

placed in the os calcis in static hole then keeping manual

pressure over the nail in long axis the other screws placed

in the dynamic hole in tibia from medial to lateral side.

After the operation foot kept elevated and injectable

cephalosporin added for 7 days. The suture wasremoved

on 14th post-operative day. The affected limbs

wereprotected from weightbearing for 6 weeks after

surgery, and functional exercisewas started once the pain

was alleviated. Regular visitswere made at 6 weeks, 3,6

and 9 months postoperatively. Weight bearing was

allowed based onthe physical examination and radiological

evaluation atthe follow-up visits.

RESULTS:

All 12 patients included into the study were followed foran

average of 4.5 (5-18) months. One patient experienced

shortening of 2cm who was given raised shoes. No

complications such as infection, instability, breakage of

nails or forefoot numbness caused bythe injury of lateral

plantar nerves and vesselsor irritation of soft tissueswere

observed.

Subjective evaluation:

Roles and Maudsley patient satisfaction scores were

1.41on average at the last visit, indicating that most

patientsexperienced satisfactory functional improvement

aftersurgery.

Clinical efficacy evaluation:

The patients VAS pain scores decreased from 5.58(3–8)

preoperatively to 1.16 (0–3) at the time of thelatest follow-

up. At the last visit, the AOFAS Ankle-Hindfoot Score

was 70.08 /100 (60–79), which was significantly higher

28.25/100 (26–31) before surgery.

Fig. 2: Operative Method (a, b) and preoperative, postoperative (c, d) radiographs after tibiotalocalcaneal

arthrodesis & (e) final clinical follow-up.

Fig1: Roles and Maudsley patient satisfaction scores at

the last visit

143 S. Anwaruzzaman, M. Asraf Ul Matin, M. M. R. Bhuiyan



Table-II

AOFAS Ankle-Hindfoot Scores and VAS pain

scoresbefore operation and at the last visit.

Score Before operation At the last visit

AOFAS score 28.25±1.81 70.08±6.88

VAS pain score 5.58±1.68 1.16±0.93

IMAGING EVALUATION:

We have to restrict our imaging evaluation of fusion only

with plane radiograph. Doing CT scan would be better but

the expense is not bearable for every patient in every follow

up .All patients achieved bony fusion at a mean union

timeof 3.8 (3–12) months. The tibiotalocalcaneal alignment

and external rotation of foot was maintained in all cases.

DISCUSSION

There are many forms of fixation for tibiota local caneal

arthrodesis, including screws, plates, intramedullary

nailsand external fixators. In this study we usedSIGN nail

for Tibiotalocalcaneal fusion for stabilization and clinico-

radiological wellbeing of the patients having unstable and

painful ankle.We have done fusion on a pathological ankle

joint, which was disorganized by previous trauma &

following maltreatment or untreatment. The joint was not

weight bearing for long time. As a result articular cartilages

might be softened or denuded .During operation we did

incremental reaming of the bone and marrowcavity,the

reamed marrow tissue was dispersed in the residual space

of the joint which is rich in bone morphogenic protein

(BMP). That might initiate bone formation and thereby

augment the fusion for arthrodesis. Furthermore following

interlocking of the SIGN nail on both ends, one static

screw in calcaneum and two screws in dynamic hole at

tibia enhance dynamization in long axis of the fusion site

from the outset.Achieving fusion of the joints without

being opened up and denuding the articular cartilage by

this technique has an explanation. There was no functional

movement at the joint surfaces the articular cartilage is

denuded during reaming and the cartilage become

softened, macerated and disintegrated, exposing the

subchondral bone with added axial compression may

contribute fusion. Damaged articular cartilages being

denuded by reaming and interposed with BMP rich reaming

marrows followed by axial compression dynamic loading

made a summation effect for fusion of the ankle and

subtalar joint without being opened up.

As the previous reportsabout tibiotalocalcaneal

arthrodesis with intramedullarynails confirmed, the

AOFAS Ankle-Hindfoot Score was63–71, the satisfaction

rate was 78–92 % 11, VAS painscore was 1.98 on average

and Roles and Maudsleypatient satisfaction scores were

1.77 on average12.Our study results showed that after

surgery, the AOFASAnkle-Hindfoot Score was 70.08and

VAS pain score was 1.16 onaverage; Roles and Maudsley

patient satisfaction scoresat the last visit were 1.41 on

average. Nearly all patientswho underwent

tibiotalocalcaneal arthrodesis with SIGN nails experienced

satisfactory postoperativeoutcomes.

Jehan et al.13 systematically reviewed 33 studiesand

analyzed the efficacy of tibiotalocalcaneal arthrodesiswith

659 intramedullary nails in 631 patients. Theyfound that

the union rate was 86.7 %, the average uniontime was 4.5

months and the incidence of complicationswas 55.7 %.

This study shows complete union in all patients with 4.1

months average union time with incidence of complication

was 8.3%. Fang et al.11 reported that the operationtime

was 128 (72–214) min.

Our study significantly matches with the result of Gong et

al14 showedthat the hindfoot alignment was effectively

corrected for allpatients, the average union time is 3.8

months, the unionrate was 100 %, the incidence rate of

complications was 5.9 % and the operation time was 57

(42–125) min. With this technique using SIGN nailhad a

shorter operation time, a significantly lowerincidence rate

of complications, a higher union rate and ashorter fusion

time.

CONCLUSIONS:

Tibiotalocalcanealarthrodesis with SIGN nail isan effective

fixation technique for treating severe ankle andsubtalar

arthropathy. It has many advantages including

beingminimally invasive, with a short operation time, a

highfusion rate, a low rate of complications and a good

postoperativerecovery.

REFERENCES:

1. Franceschi F, Franceschetti E, Torre G, Papalia R,

Samuelsson K, et al.Tibiotalocalcaneal arthrodesis using

an intramedullary nail: a systematicreview. Knee Surg

Sports TraumatolArthrosc. 2016; 2:1316 25.

2. Vilà y Rico J, Rodriguez-Martin J, Parra-Sanchez G, Marti

Lopez-Amor C. Arthroscopic tibiotalocalcaneal arthrodesis

with locked retrograde compressionnail. J Foot Ankle Surg.

2013; 52:523-8.

3. Shah KS, Younger AS. Primary tibiotalocalcaneal

arthrodesis. Foot Ankle Clin.2011; 16:115-36.

4. Burks JB. Tibiotalocalcaneal arthrodesis. ClinPodiatr Med

Surg. 2012; 29:529–45.

Innovating Minimally Invasive Retrograde Tibiotalocalcaneal Arthrodesis using SIGN Nail 144

VOL. 31, NO. 2, JULY 2016


5. Mendicino RW, Catanzariti AR, Saltrick KR, Dombek

MF, Tullis BL, et al. Tibiotalocalcaneal arthrodesis with

retrograde intramedullary nailing. J FootAnkle Surg. 2004;

43:82–6.

6. Tsailas PG, Wiedel JD. Arthrodesis of the ankle and

subtalar joints in patientswithhaemophilic arthropathy.

Haemophilia. 2010; 16:822–31.

7. Krissen C, Sumon H, Nicholas B, Howard C, Andrew A,

et al. Tibio-talo-calcaneofusion using a locked

intramedullary compressive nail. Foot Ankle Surg.

2011;4:228–32.

8. DiDomenico LA, Wargo-Dorsey M. Tibiotalocalcaneal

arthrodesis using afemoral locking plate. J Foot Ankle

Surg. 2012; 51:128–32.

9. Jeong ST, Park HB, Hwang SC, Kim DH, Nam DC. Use

of intramedullarynonvascularized fibular graft with external

fixation for revisional Charcotankle fusion: a case report.

J Foot Ankle Surg. 2012; 51:249–53.

10. Nielsen KK, Linde F, Jensen NC. The outcome of

arthroscopic and opensurgery ankle arthrodesis: a

comparative retrospective study on 107patients. Foot

Ankle Surg. 2008; 14:153–7.

11. Fang Z, Claaßen L, Windhagen H, Daniilidis K, Stukenborg-

Colsman C, etal.Tibiotalocalcaneal arthrodesis using a

retrograde intramedullary nail with avalgus curve. Orthop

Surg. 2015; 7:125–31.

12. Thomas AE, Guyver PM, Taylor JM, Czipri M, Talbot

NJ, etal.Tibiotalocalcaneal arthrodesis with a compressive

retrograde nail: aretrospective study of 59 nails. Foot Ankle

Surg. 2015; 21:202–5.

13. Jehan S, Shakeel M, Bing AJ, Hill SO. The success of

tibiocalcanealarthrodesis with intramedullary nailing—a

systematic review of theliterature. ActaOrthop Belg. 2011;

77:644–51.

14. Ji-Cheng Gong, Bing-Hua Zhou, Xu Tao, Cheng-Song Yuan

and Kang-Lai Tang*Tibiotalocalcaneal arthrodesis with

headlesscompression screws. Journal of Orthopaedic

Surgery and Research (2016) 11:91 Page 3 of 7.

145 S. Anwaruzzaman, M. Asraf Ul Matin, M. M. R. Bhuiyan


Original Article

Glomus Tumour Excision by Nail Sparing

Jahangir Alam1, Md Mohiuddin2, Mohammad Mahfuzur Rahman3, Manosh C4, Raqiub Monjoor5,

Sajedur Reza Faruquee6, Malay Kumar Saha7

ABSTRACT

A glomus tumor is a rare neoplasm arising from the glomus body and manly found under the nail and accounts for

1 -5% of all hand tumors. Total 9 (nine)Patients with subungual glomus tumors of the hand were treated between

2011 to 2016. Surgical excision of the tumor was performed under supraclavicular block using a tourniquet.

Operation was done under loupe magnification. All patients had complete relief of pain. None had recurrence of

the tumor till the last follow up.

Key words: Glomus tumour, Nail Sparing, Loupe magnification

1. Associate Professor, Ortho. Surgery, NITOR, Dhaka

2. Assistant Professor, Ortho. Surgery, NITOR, Dhaka

3. Medical Officer, Department of Ortho Surgery, BSMMU, Dhaka

4. Registrar, Ortho. Surgery, NITOR, Dhaka

5. Junior Consultant, NITOR, Dhaka

6. Assistant Professor & R/S, Hand & Microsurgery, NITOR, Dhaka

7. Assistant Professor, Ortho Surgery, Mymensingh Medical College Hospital

Correspondence: Dr. Jahangir Alam, Associate Professor, Ortho. Surgery, NITOR, Dhaka

INTRODUCTION

The glomus tumor as separate clinical entity was described

by wood1 in1812 and pathological findings were first

described by Masson in 1924, as hyperplesia that occur in

the neuromyoarterial body.2 Account for about 1%–5% of

all hand tumors,3,4 are benign hamartomas of vascular

origin, arising from the glomus body.5-7 Which is abundent

in the finger tips mostly beneath the nail hence the

commonest site of glomus tumor.4-6,8-15,25 Diagnosis of

this excruciating painful condition is mostly clinical having

the classical symptom triad of pain, tenderness and cold

intolerance.3,6,8,18-19 Diagnostic imaging specially MRI is

helpful.12-14,18-22 Complete surgical excision is the only

known treatment option for subungual glomus tumors.25

We present our experience with 13 case of subungual

glomus tumor.

MATERIAL AND METHOD

we have treated 9 patients with subungual glomus tumors

of the hand diagnosed by clinically and with MRI

confirmation of lesion under the nail between 2011 and

2016. All case were females except one male.

The mean age of the patients was 28.88years (range 23-

35years) [Table 1]. The right hand was mostly affected in

6 patients. The index finger was the most common digit to

be involved, followed by the middle finger. The mean

duration of symptoms was 17.33 months (range 12-24

months).

Table 1

Showing the clinic profile

Case no Sex Age Side Digit Symptom X-Ray

Duration Pain Cold Love Bony Exost-

(month) sensitivity test indentation osis

1 F 23 R Index 12 + + + - -

2 M 33 R Middle 16 + _ + - -

3 F 25 L Index 22 + + + + -

4 F 35 R Ring 18 + + + - -

5 F 29 R Middle 24 + + + + -

6 F 26 L Index 12 + _ + _ -

7 F 30 R Thumb 16 + + + _ -

8 F 35 R Index 18 + + + _ -

9 F 24 L Middle 18 + + + + -

VOL. 31, NO. 2, JULY 2016 146



All patients presented with complaints of pain in the nail

bed and had localized tenderness. The pain was aggravated

during winter and working with cold water. Exquisite

tenderness demonstrated by the Love’s pin test was

positive in all. None of the patients had any nail deformity

preoperatively. no cases of recurrence was treated in this

series.

Plain radiographs revealed depression on the dorsum of

the distal phalenges in three cases.

After obtaining informed consent, surgical excision of the

tumor was performed under supraclavicular block using a

tourniquet. A nail preserving approach was used in all the

patients. the procedure is described below:

Step 1: The nail plate was carefully elevated with a nail

elevator from the lateral margin taking care to preserve the

germinal matrix of the nail but remained attached to the

base. ( Fig 1)

Step 2: The nail plate retracted with the help of a skin hook

gently and mass was identified by the bluish red

discoloration in the nail bed ( Fig 2)

Step 3: longitudinal incision was made in the nail bed over

the tumor [Fig3].

Step 4: nail bed retracted and the tumor was excised

completely and curated [Fig4].whole made by 20g needle

Step 5: the incision in the nail was approximated with 5.0

chromic catgut

Step 6: nail plate was repositioned making two smooth

hole using 20g needle suturing on the sides over the nail

bed and gentle compression dressing on the finger

[Fig 5]

Step 7: POP immobilizing in with dorsal slab of 10 days

All excised specimen were confirmed by histopathological

examination.

Postoperatively first dressing was done within 3rd to 5th

day. Suture removal was not done as cat gut were used .

All the case were followed up to 6 months.

Fig.-1 Fig.-2

Fig.-3 Fig.-4 Fig.-5

147 Jahangir Alam, Md Mohiuddin, Manosh C , Raqiub Monjoor, Sajedur Reza Faruquee



RESULTS

All patients had complete relief of pain. None of the

patients had recurrence of the tumor till the last followup.

None of the patients developed any deformity of the new

nail. Al the patient were able to do there day to day house

hold jobs.

Histopathology confirmed the diagnosis of glomus tumors

in all patients..

DISCUSSION

The diagnosis of subungual glomus tumors is mostly

clinical based on the classical triad of excruciating pain,

localized tenderness, and cold sensitivity.3,6,8,18-19 The

Love’s test which confirms the diagnosis and serves to

clinically localize the tumor preoperatively,10 was positive

in all the patients. the diagnosis can also be augmented

by MRI12-14,18-22 in localizing the lesion and post

operatively by histopathology. In the presence of the

classical clinical triad and positive love test a negative

radiological finding does not influence decision of

operation, in either way the condition needs to be explored.

The X ray is helpful in identifying the bony indentation12,

in long standing cases and exclude other condition like

exotosis.25-27 Bony indentation was found in 4 cases. No

bony exostosis found in our series.

The treatment of choice for glomus tumors is total surgical

excision23. A complete surgical excision is the only to

complete relieve of pain and prevent recurrence.26 Good

illumination, good magnification and blood less field is

prerequisite for exploration and complete excision of tiny

tumor like glomus. Regional or General anesthesia was

used on the preference of he anesthetist and patients

choice and tourniquet are used in all cases.

The transungual approach is the classical” approach

recommended by Carroll and Berman8 and Van

Geertruyden et al11 the total nail avulsion followed by

excision. Although several additional techniques have

been described to include a straightforward excision using

a nail bed margin approach*a trap-door technique* by

Pahwa et al 27 as well as a technique described by Lee et

al22 to conserve the nail plate itself3,9,22. we use nail

preserving technique where nail was not fully avulsed but

elevated as hood and after excision put back with two

hole in it.

The complications of surgery are nail deformity and

recurrence of the tumor. Recurrence of symptoms is, usually

due to incomplete excision of the lesion rather than true

recurrence of the tumor.8-12,26, or may signify presence of

multiple glomus tumor. True recurrence of the tumor is

rare. Carroll and Berman6 reported recurrence of the tumor

in two out of 28 patients and Van Geertruyden et al.9

reported recurrence in two out of 51 patients. We feel

transungual approach gives good access to the subungual

tumor, facilitating complete excision. We had no recurrence

of the lesion Therefore, meticulous care needs to be given

at the first operation to completely remove entire lesions.

The other complication after the recurrence of symptoms

is deformity of the nail. The transungual approach the

classical 4.8.11 is said to have according to the literature as

high incidence of postoperative nail deformity.9-11,26 The

incidence of nail deformity after transungual approach

varies from 3.3% to as high as 26.3%.,11-12.26 Direct

transungual approach was used by jawarkar et al5 and Lee

et al.22 have also reported no postoperative nail deformity

with the transungual approach. As mostly females ar e

affected nail deformity is complication which needs to be

addressed properly.

The limitations of our study is limited number of cases

and we have not tried other approaches ourselves.

CONCLUSION

After critical analysis they concluded that approach does

not cause nail deformity if the nail plate is carefully elevated

without damaging the germinal matrix and meticulous

repair of the nail bed is performed. The nail falls off over

the course of time and replaced by a new nail in 12 weeks.

none of our patients developed any new postoperative

nail deformity.

REFERENCES

1. Wood W: On painful subcutaneous tubercle. Edinburgh

Med Surg, 1812; 8:283-91.

2. Masson P: Le glomus neuromyo-artèriel des regions

tactiles et ses tumeurs. Lyon Chirurgical, 1924; 21:257-

80.

3. lee, W.,Kwon, S.B., Cho, S.H., Eo, S. R.,Kwon, C.; Glomus

tumour of the hand. Archives of Plastic Surgery. 2015;42(3)

295-301

4. McDermott EM, Weiss AP. Glomus tumors. J Hand Surg

Am 2006;31:1397 400.

5. Jawalkar H, Maryada VR, Brahmajoshyula V, Kotha GV.

Subungual glomus tumors of the hand Treated by

transungual excision. Indian J Orthop 2015;49:403-7.

6. Paliogiannis P.; Trignano E.; Trignano M.; Surgical

Management of Glomus tumor of the fingers: a single

Glomus tumour excision by nail sparing 148

VOL. 31, NO. 2, JULY 2016


center ecperience. Ann Ital. Chir.,2011:82: 465-468

7. Schiefer TK, Parker WL, Anakwenze OA, et al.:

Extradigital Glomus Tumors: A 20-Year experience. Mayo

Clin Proc, 2006; 81(10):1337-344.

8. Carroll, R.E.; and Berman, A.T.: Glomus tumors of the

hand. J. Bone Joint Surg., 54A(4):691-703,1972.

9. Vasisht B, Watson HK, Joseph E, Lionelli GT. Digital

glomus tumors: A 29 year experience with a lateral

subperiosteal approach. Plast Reconstr Surg

2004;114:1486 9.

10. Bhaskaranand K, Navadgi BC. Glomus tumour of the

hand. J Hand Surg Br 2002;27:229 31.

11. Van Geertruyden J, Lorea P, Goldschmidt D, de Fontaine

S, Schuind F, Kinnen L, et al. Glomus tumours of the

hand. A retrospective study of 51 cases. J Hand Surg Br

1996;21:257 60.

12. Grover C, Khurana A, Jain R, Rathi V. Transungual surgical

excision of subungual glomus tumour. J Cutan Aesthet

Surg 2013;6:196-203.

13. Fornage BD. Glomus tumors in the fingers: Diagnosis

with US. Radiology 1988;167:183-5.

14. Theumann NH, Goettmann S, Le Viet D, Resnick D, Chung

CB, Bittoun J, et al. Recurrent glomus tumors of fingertips:

MR imaging evaluation. Radiology 2002;223:143-51.

15. Kolaczek J: Ueber das angio-sarkom. Dtsch Z Chir, 1878;

9:165- 227.

16. Lee CH, Byeon JH, Rhie JW, et al. Clinical analysis of

twenty cases of glomus tumor in the digits. J Korean Soc

Plast Reconstr Surg 1995;22:169-78.

17. Netscher DT, Aburto J, Koepplinger M. Subungual glomus

tumor. J Hand Surg Am 2012;37:821 3.

18. Shih TT, Sun JS, Hou SM, Huang KM, Su TT. Magnetic

resonance imaging of glomus tumour in the hand. Int Orthop

1996;20:342 5.

19. Fujioka H., KOKUBU T., AKISUE T., NAGURA I.,

TOYOKAWA N., INUI A., SAKATA R., and

KUROSAKA M., Treatment of Subungual Glomus Tumor

Kobe J. Med. Sci., Vol. 55, No. 1, pp. E1-E4, 2009

20. Chen SH, Chen YL, Cheng MH, Yeow KM, Chen HC,

Wei FC. The use of ultrasonography in preoperative

localization of digital glomus tumors. Plast Reconstr Surg

2003;112:115-9.

21. Song M., Ko H., Kwon K Kim M.; Surgical Managemt of

subungual Glomus tumor: A unique and simple method.

Dermatol surg 2009;35(5); 786-791

22. Lee S.H.,Roh M.R., Chung K.Y.; Subungual glomus tumors:

surgical approach and outcome based on tumor location.

Dermatol Surg. 2013 Jul. 39(7):1017-22.

23. Green DP, Pederson WC, Hotchkiss RN, Wolfe SW.

Green’s Operative Hand Surgery. 5th ed. New York:

Elsevier Churchill Livingstone; 2005.

24. Kale SS, Rao VK, Bentz ML. Glomus tumor of the index

finger. J Craniofac Surg 2006;17:801-4.

25. Takemura N, Fujii N, Tanaka T. Subungual glomus tumor

diagnosis based on imaging. J Dermatol 2006;33:389-93.

26. Lin YC, Hsiao PF, Wu YH, Sun FJ, Scher RK. Recurrent

digital glomus tumor: Analysis of 75 cases. Dermatol Surg

2010;36:1396 400.

27. Pahwa M., Pahwa P.,Kathuria S. ;Glomus tumour of the

nail bed treated with the ‘trapdoor’ technique: A report of

two patients. J Dermatolog Treat. 2010 Sep;21(5):298-

300.

149 Jahangir Alam, Md Mohiuddin, Manosh C , Raqiub Monjoor, Sajedur Reza Faruquee


31 (2) 2016 - bosbd.org

Documents

Transcript of 31 (2) 2016 - bosbd.org