The Journal of Bangladesh Orthopaedic Society (JBOS)

Published by

BANGLADESH ORTHOPAEDIC SOCIETY

The Journal of

Bangladesh Orthopaedic Society (JBOS)

The Journal of


JOURNAL COMMITTEE 2012 - 2014

Chairman Dr. Ramdew Ram Kairy

Editor : Dr. Md. Golam Sarwar

Associate Editor : Dr. Mohammad Mahfuzur Rahman

Assistant Editor : Dr. Md. Wahidur Rahman

Dr. Md. Jahangir Alam

Members : Dr. Nakul Kumar Datta

Dr. Sajedur Reza Faruquee

Dr. ABM Golam Faruque

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. Perpheral 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

EDITORIAL

l How to publish your journal paper 111

Md. Golam Sarwar

ORIGINAL ARTICLES

l Functional outcome of intraarticular fractures of the distal humerus following both column 117

fixation by tension band wire

Kamruzzaman, Ripon Kumar Das, Asit Baran Dam, Swapon Kumar Paul, Zahid Ahmed,

Mohammad Khurshed Alam

l Results of One Stage Surgical Correction of Congenital Vertical Talus in Children 122

Dipankar Nath Talukder, M.A. Hannan, Ishtiaque Ul Fattah, Faruqul Islam, Mohsenuzzaman Khan

l Management of Traumatic Orbital Wall Fracture with Titanium Mesh 126

Kazi Lutfor Rahman, Ismat Ara Hayder, Mohammad Ghulam Rasul,

Anjal Lal Ghosh, Shibasis Basak

l Evaluation of the Outcome of Proximal Femoral Locking Compression Plate for the 132

Treatment of Comminuted Trochanteric and Subtrochanteric Femoral Fractures

MM Hossain, QS Alam, MFH Qasem, MTI Noman, Md. Golam Sarwar, Md. Golam Mostofa

l Result of Arthroscopic Anterior Cruciate Ligament Reconstruction by Semitendinosus & 137

Gracillis Tendon Graft

Md. Harun-Or-Rashid Khan, Mohammad Serajus Saleheen, M. Muniruzzaman,

Md.Aminul Haque Pathan, Md. Abdus Sabur, Md. Iqbal Qavi

l Management of Complex (Schatzker-Type V And VI) Tibial Plateau Fractures 142

by Ilizarov Method

Mir Hamidur Rahman, Gazi Md. Enamul Kabir, Monaim Hossen, Shaymol Deb Nath,

Md. Mofakhkharul Bari

l Management of Diabetic Foot 147

Noor Mohammad, Md. Golam Sarwar, Anjon Lal Ghosh, MA Sabur, Shibasis Basak,

Mollah Eshadul Haq, Shahidul Haq

l Removal of Dead and Infected Bone in Chronic Osteomyelitis is the Prime factor to 151

Control Infection – Early Removal Decreases Morbidity

AHM Rezaul Haque, Debashis Biswas, Shakeel Akter, Takbirul Islam, Debashis Ghosh

l Old Achilles Tendon Injury Reconstruction with Flexor Hallucis Longus Tendon-a Prospective Study 155

Md. Abdul Gani Ahsan, Kazi Md Salim, Ishtiaque-Ul-Fattah, AKM Zahir Uddin

THE JOURNAL OF BANGLADESH ORTHOPAEDIC SOCIETY

VOLUME 28 NUMBER 2 JULY 2013

l Anterolateral Chest Wall Flap as a salvage for composite wound coverage of 159

the elbow, forearm and hand

A.B.M. Golam Faruque, A.H.M. Tanvir Hasan Siddiquee, Uttam Kumar Saha, A K M Zohiruddain,

Md. Mohabbatullah, Md Zahid Ahmed

l Minimally invasive plate osteosynthesis (MIPO) for fracture of distal tibia in 18 patients 163

at BIRDEM Hospital

Anwar Ahmed, Ahmed Suparno Bahar Moni, MKI Quayyum Choudhury, M Golam Sarwar,

Anjan Lal Ghosh

l Functional Outcome of Minimally Invasive Percutaneous Plate Osteosynthesis Using Locking 167

Condylar Plates In Distal Femoral Fractures

Md. Saidul Islam, Md. Golam Mostafa, Shah Jawaher Jahan Kabir, Shahidul Haq

l Posterior Long Segment Transpedicular Screw Fixation for Unstable Thoracolumbar 170

Fractures with Incomplete Spinal Cord Injury

Syed Shahidul Islam, M R Karim, Purnendu, Meraj, Azad, Swapan, Rahman,

Rayhan Hamid, Susmita

l Management of Open Gustilo IIIB Tibia-Fibula Fractures by Soleus Muscle Flap and 174

Locally Made AO External Fixator

Abdullah Al-Mahmood Bilal, Mir Hamidur Rahman, Mohammed Abdus Sobhan,

Milon Krishna Sarker, Md.Wahidur Rahman, M Monaim Hossen

l Evaluation of Outcome of Open Intramedullary Interlocking Nailing in 181

Tibial Shaft Fracture in Adults

Mohammed Abdus Sobhan, Mir Hamidur Rahman, Abdullah Al-Mahmood Bilal,

Milon Krishna Sarker, Md.Wahidur Rahman, M Monaim Hossen

Review Article

l Upper Cervical Spinal Injuries : A Review 187

Ghosh JC, Mollah Ershadul Haq, Dulal Datta, Monaim Hossen, Noor Mhammad, Lokman Hossain

Case Report

l Health Seeking Behaviour of Road Traffic Accident Victims: A Qualitative Study among the Slum 192

Dwelling Disabled People of Dhaka City

Mohammad Mahbub Alam Talukder, Md. Ali Imam, Nasrin Akter, Nasir Uddin Sheikh

Book Review 197

Iqbal Qavi

Editorial

This paper focuses on preparing articles for publication in

journals. You must have a focus and a vision. The key to

successfully publishing an article is to get a vision-a reason

and purpose for writing. Once you have a vision, write

down and keep it in constant view to remind you of your

mission. Four areas of article preparation are to be covered:

a. When selecting a journal for your paper, what you

should be thinking about;

b. You need to follow in journal style guides;

c. Simple ways when writing paper for better clarity;

d. What happens to your paper once you send it to the

journal and the various types of responses you can

expect to receive?

1. SELECTING A JOURNAL

Ideally , you should be thinking about the journal you

want to submit your paper to before you even write the

paper, that is, when you’re still conducting the research.

It makes sense to select a journal before you commence

writing up the results of your research, given that you can

then familiarize with the journal’s format before you start

to write, these ensuring that your paper complies with

their required format. The journal’s style guide, which is

covered in more detail later, will also help you to focus

your paper and keep it within manageable word limits.

But how do you select a journal for you’re yet to be written

article?

There are thousands of academic journals out there of

varying levels of quality and reach, so below are a few

questions you can ask yourself to limit your search.

i . Will my paper appeal to a domestic or international readers?

ii. What sort of paper am I going to write ?

Main stay is to write clearly. There is no substitute for a

good idea for excellent research or for good, clean, clear

writing. Will it be a qualitative or quantitative study, a

literature review, a brief report, a meta-analysis or a

discussion of a current issue? In other words, what sort

How to publish your journal paper

Md. Golam Sarwar

Associate Professor of Orthopaedic Surgery, DMCH, Dhaka

of focus/ scope am I looking for in a journal? Journal

scopes are usually given on the imprint page of a journal.

You need to align your journal before you submit it or you

will be wasting your time!

An example is:

The journal of Bangladesh Orthopaedic Society is a fully

referred journal publishing original scholarly works in

orthopaedic surgery and development of our professional

discussion papers referring scientific, theoretical or

philosophical base.

The primary criteria for acceptance are excellence and

clarity. Papers are published in BJOS under the following

categories: research papers, scholarly articles, clinical

reports, international reviews and book reviews.

iii. Send your manuscript to the right journal.

Does my paper/research relate only to my discipline or

can I look at journal outside my discipline i.e. Who am I

trying to communicate with/who is my reader?

Knowing your audience is an important element not only

of selecting your journal, but of writing you paper. Also it

will help you to choose the style of your paper and

language.

For example, if you are going to write an article on about

orthopaedics, which you want as many orthopaedicians

as possible to read. A good way to reach these to get your

paper published in the JBOS; 6 monthly journals.

iv. What database is the journal indexed and abstracted in

i. e. how easily the other academics are able to access my

article through searches?

v. What is the journal impact factor?

The impact factor is a calculation based on the number

of times a piece of research is cited in the research of

other academics. Basically the impact factor gives you

an idea of the journal’s prestige or academic weight (found

in ISI (Institute for Scientific Information-Ref 016.5 Ins/

Sjc).

VOL. 29, NO. 2, JULY 2014 111

vi. Is the journal peer-reviewed?

Most academics will only be interested in publishing in

peer-reviewed academic journals. A simple way to check

is to go to the first database. (www.insinet.com/isi/journals)

or non-peer-reviewed in www.ulrichsweb.com

vii. Am I realistic?

Once you know the type of journal you want to target, it’s

a matter of talking to your colleagues to utilize your

knowledge of journals doing website searches of journal

lists, or browsing the shelves of the library.

It is important that you build up a knowledge-based and a

feel for the journals in your area of research. This obviously

involves not only reading the scope section of journals,

but also reading papers from the journals. Academics who

plan to publish should regularly read several journals in

their own field and at least two from related fields.

When you do read those journals, you should be looking

at the content and style of each journal. Therefore, you

will be able to determine which subjects are currently of

interest and which research topics are generating

discussion in that particular journal. Looking at writing

style will help you to familiarize yourself with the technical

language used in the journal and the level of details given

in the paper.

Finally reading other academics writing will also help you

to improve your own writing.

2. STYLING TO JOURNAL GUIDELINES

A journal guideline gives all the information you need

about writing and presenting a paper.

While editors and reviewers are most interested in the

substance of a paper, they can become distracted if you

have not followed the journals’ style requirements. Your

paper might even be rejected straight out if certain basic

requirements are not followed. So, basically, you put

yourself at a disadvantage if you do not follow journal

guidelines when writing your paper.

Journal guidelines really just provide simple points about

how to write your paper. An easy way to attach journal

guidelines is, before writing your paper, to go through the

selected journal’s guidelines and jot down the main

requirement you need to follow when writing your article.

These will include the followings:

- Maximum length of the paper

- Referencing style to follow

- Type and length of abstract to be included (that is

structured or unstructured)

- Whether keywords should be provided

- How tables and graphs should be styled and presented

- Spelling (that is US, British or Australian)

- System of units to use (e.g. SI units)

- Format to use (e.g. typeface, font size)

- Layout of the text (e.g. double spacing)

- The process of review that will take place

- Author details (e.g. address, phone and fax numbers,

email)

- How many copies of ms should be submitted and

where to send the paper

Given that most these requirements are fairly

straightforward excepts- word length, referencing and

abstracts.

I. WORD LENGTH

There are 3 reasons-

The first relates to journal budgets. Basically, it is very

expensive to publish a journal. Journal editors will set the

page extents for an issue of journal long before that issue

is printed. Because a couple of extra pages in any one

issue can totally blow out the journal budget.

The Second reason, in every paper you write, you should

be aiming to write tightly and to get rid of excess words. A

classic writing text will be; “Aim for brevity in your writing.

Omit needless words. A sentence should contain no

unnecessary words, a paragraph no unnecessary

sentences”.

The third, and perhaps most important, nobody will want

to read your paper, not the editor; not the reviewer and

finally not the reader. Therefore, a quick tip on sticking to

word limits is to do a plan so you do not go over the limit.

II REFERENCING

There are two types of referencing to which you will be

asked to adhere: The Vancouver system or the Harvard

system. For more details- Publication manual of the

American Psychological Association (5th edition, 2001) or

Australian Government Publishing Services style manual

for Authors, Editors and Printers (6th edition, 2002)

Below I will cover a couple of tricky aspects of referencing:-

The first is what to do about unpublished material that

have been sent to a journal but not yet accepted, should

not be included in the reference list. But you can include

as follows

Roy and Ram found similar discrepancies in a study of 20

dementia sufferers (R. Ram, unpublished data, 2001).

112 Editorial

The Journal of Bangladesh Orthopaedic Society

Another problematic aspect of referencing is how to

reference information downloaded from internet. For an

internet article based on a print source you can reference

the online article in the same way that you would the print

version, except that you would add “Electronic version”

in brackets after the article title, as in the followings:

e.g. Parker, G., & Roy, K. 2001. Adolescent Depression: A

review (Electronic version), Australian and New Zealand

journal of Psychiatry, 35: 572-580.

For an article in an internet- only journal, you should style

the reference in the same way as the previous example,

except that instead of using volume numbers, the online

journal might use a different numbering system.

It is important that you pay attention to the referencing

style of the journal when writing or formatting a paper.

You should Endeavour to copy it as closely as possible

and include all of the necessary information. Missing

information will result in delays once your paper has been

accepted for publication, as will use of the incorrect system

of referencing.

III. ABSTRACTS

Given that the abstract or summary may be all that most

people will ever read of a paper, it’s surprising that so little

attention is paid by authors to writing the abstract. Writing

a clear concise abstract that accurately presents the

essence of your paper will take time and thought.

What should an abstract include? It should include the

purpose of the study; a brief description of the methods

used; the key results; the main conclusion; and possibly

some recommendations, depending on the journal

requirements. A good way to learn to write an effective

abstract is to read some sample abstracts from the journal

you are targeting.

3 IMPROVING THE CLARITY OF YOUR PAPER-

I. Avoid wordiness in writing

Your aim should be to keep sentences short and to

the point. How do you keep sentences short? By

being concise and getting rid of excess words. Take

this example of unnecessary and redundant language:-

e.g. “We shout to explore …”- May right- “We

explored…”

Do not spent many words going off the tract. You do

not have to say everything about your chosen topic,

but should be confining yourself to what is relevant

to your reader.

II. Keep Jargon to a minimum

Any article or publication in a journal should be

written so that it is understandable to an intelligent

reader who is not a specialist in your particular field.

Try not to use too much Jargon, and try to write in

plain English. Your aim in writing is to communicate

your message of ideas and in accessible language

will mean that your ideas are disseminated to a wider

range of people.

III. Make sure pronouns are no ambiguous

You know, a pronoun is a word that takes the place of

a noun (This, That, It, His etc). An antecedent is the

word that the pronoun refers back to.

e.g. The decision is significant because it reflects the

splits developing within the groups.

“It” = the pronoun

“The Decision” = the antecedent

However pronoun is very obvious. Papers can

become very confusing if the antecedent for each

pronoun is not obvious.

IV. Use the definite/indefinite article correctly

The indefinite article-‘a’- is used to introduce someone

or something for the first time.

e.g. A study was conducted by Brierly and Jones…

This implies that it’s the first time that you have

mentioned that study in your paper

The definite article-‘the’- is used to refer to one or

more people or things that have already been

mentioned or that are assumed to be common

knowledge.

e.g. the study conducted by Sarwar and Gani…

This implies that you have already mentioned the

study earlier in your paper

It can be very confusing to readers if “a” and “the”

are incorrectly used !

V. Don.’t use anthropomorphism

Anthropomorphism is a literary device used to

attribute human characteristics to non-human things.

- the study said..

- environmental designs will need to consider..

Obviously, a study cannot speak and an

environmental design cannot consider..so these types

of statements need to be rephrased:

-It was apparent from the study…

-Researchers planning environmental designs will

need to consider…

How to publish your journal paper 113

VOL. 29, NO. 2, JULY 2014

VI. Avoid shortcuts in writing

By avoiding shortcuts in writing,

e.g. Making a copy..

This is a lazy approach to writing, and can result in

ambiguities. A better approach is;

Making a copy involves making an exact replica of

the article…

VII. Be consistent

When writing your paper, try to stick to the one term

to describe groups of people; that is, don’t jump from

“subject” to “respondents” to “patients” to “clients”

as this is confusing to the reader.

VIII. Use the appropriate tense

Use the past tense (e.g. “Jones showed”) or the

present perfect tense (“researchers have shown”) for

the literature review and for describing your

procedure if the discussion is of past event-but stay

within your chosen tense.

Again you may use past tense (e.g. depression

decreased significantly) to describe the results of your

study.

Use the present tense (e.g. “the results indicate”) in

the discussion to discuss your results and to detail

your conclusion, using present tense in the

discussion section allows readers to join in your

deliberation of the results.

Do not write about the study as if you are just about

to conduct it (do not use the future tense). It’s

assumed that you are writing your paper after the

study has taken place and that you are describing

things that occurred in the past not that will occur in

the future.

e.g. “our sample will consist of 25 women…”= incorrect

“Our sample consisted of 25 women…”= correct

IX. Avoid generalization

Generalizations are often used in paper based on

qualitative studies

e.g. the respondents said they were distressed…

This leaves you asking the question, “Did they all

say this or did only some say this?”Statements like

the above should be qualified so that the reader

knows whether in fact all respondents made a certain

comment or only some.

X. Be aware of time factors

You need to be careful when using terms like “recent/

recently” and “over the past decade” as these terms

date.

e.g. Recent research has indicated…. (Smith, 1995)

Obviously, 1995 is not “recent”, so the sentence would

need to be amended to:-

e.g. Research has indicated….(Smith, 1995)

Avoid finishing your paper with a long , clinched,

jumbled or sentimental last line-leaders are left with a

better impression if you finish with a short clear

sentence.

Following the above tips when writing a paper will

help you to ensure that your paper is clear and that

readers will be able to read through your paper

without having to stop to work out what you are

trying to say. Or same reviewers may recommend

submitting your paper to a different journal. “They

are not saying the article is hopeless, instead of they

are just saying that it may not be right for that journal”.

If the research needs more studies and you have a

sincere interest in that area, you can resubmit it as a

new paper, noting the differences in the cover letter.

Also keep in mind that quite often, unfortunately, a

journal will reject an article because its’ navel or new

for its time. But if you feel that it is valid and good,

then by all means, send it off to another journal.

Don’t put off the revisions

If you are invited to revise, “do it, do it fast and don’t

procrastinate”.

Ultimately, it is good to keep in mind that the road to

being published is not a langely one. All authors get

lots of rejections-including senior authors. The

challenge is to preserve and improve one’s paper over

time.

XI. Don’t panic

The overwhelming majority of initial journal

manuscripts are rejected at first. Remember to get a

lot of publications , you also will need to get lots of

rejections.

XII. Beef up your cover letter

Many authors do not realize the usefulness of cover

letter; the letter can contain the author’s rationale for

choosing the editor’s journal-especially if it is not

immediately apparent.

114 Editorial


3. WHAT TO EXPECT WHEN YOU SEND YOUR PAPER

TO A JOURNAL

There are four possible responses that you could receive

from a journal’s editor after your paper has been through

that journal’s review process:-

i. The paper is accepted as it is (very rare which almost

nobody gets)

ii. The paper is accepted on the proviso that minor

decisions be made-20%. Just make some minor

changes.

iii. The paper is rejected as it is because it needs some

major revisions-

The most usual response is about 60%, the’re still

interested in you ! This means, the paper might be accepted.

If this happens, do not be discouraged. Address the

reviewer’s comments and send a detailed letter back to the

editor.

iv. The paper is rejected outright-about 20% of papers.

Or some reviewers may recommend submitting your paper

to a different journal. “they are not saying the article is

hopeless, instead of they are just saying that it may not be

right for that journal.”

If this is happened, take the reviewer’s advice and submit

your revised paper to another journal. And, again, if this

happens, do not be discouraged as it may well be that you

have aimed to high in sending your paper to a particular

journal. Remember-Though not as good as revise and

resubmit “they still want the paper!”

REFERENCES:

1. American Psychological association, Publication Manual

of the American Psychological Association, 5th edn,

Washington, DC: American Psychological Association,

2001

2. James R & durston B, Instuctions to Contributors: Writing

for Publication, Health Promotion Journal of Australia,

accssed 20/11/01, http://vhpax.vichealth. vic.gov.au/hpja/

writing.html.

3. McInerney DM, Publishing Your Psychology Research:

A Guide to Writing for Journals in Psychology and Related

Fields, Crows Nest: Allen & Unwin, 2001

4. Saeck L & Lowe JB, Instuctions to Contributors: Writing

to be Read-Publishing the Results of Health Promotion

Activities, Health Promotion Journal of Australia,

accessed20/11/01, http://vhpax.vidhealth. vic.gov.au/hpja/

writing02.html.

5. Strunk W & White EB, The Elements of style, New York:

Macmillan Publishing Co,1972.

6. Van Teijlingen E & Hundley V, Getting Your Paper to the

Right Journal: A Case Study of an Academic Paper. Journal

of Advanced Nursing,37(6),506-511.

7. Kathryn Hewlett ,How to publish Jour Journal

Paper.sept2002, vol33, No. 8 Print version: Page 50 http:/

/www.apa.org/monitor/sep02/publish.aspx

8. Rowena Murray, Top Tips for How To start Writing

That paper, Friday 6 Sept,2013 15.30 BST, 3rd edition,

How to publish your journal paper 115

VOL. 29, NO. 2, JULY 2014

Original Article

Functional outcome of intraarticular

fractures of the distal humerus

following both column fixation by

tension band wire

Kamruzzaman1, Ripon Kumar Das2, Asit Baran Dam3, Swapon Kumar Paul4, Zahid Ahmed5,

Mohammad Khurshed Alam6

ABSTRACT

The aim of this study was to evaluate the functional outcome following internal fixation of intraarticular fractures

of the distal humerus with a minimum follow-up of one year. A retrospective evaluation with prospective clinical

review was carried out at Trauma Center, Shyamoli, Dhaka during January 2012 and june 2013.Twenty one

consecutive patients with fractures of the distal humerus were treated over a 24-month period. Their mean age

was 39 years (range, 18-68). Male-Female ratio was 3.2:1. Road traffic accident (RTA) was the most common

cause of injury in this study (57.7%) and next was fall on slippery ground (26.9%) and fall from height (15.7%).Two

patients were not available for final clinical review. Analysis of the results were based on the medical records,

pre-operative and postoperative radiographs of all 21 patients and clinical review of 19 patients at a mean follow-

up of 18 months (range,12-30 months). Twenty-0ne fractures were operated by both column fixation with tension

band wire technique. Radiographic evaluation of the quality of reduction was carried out using a grading system.

Clinical outcome was assessed using the Broberg and Morrey functional rating index. thirteen patients (70%) had

an excellent or good outcome, five patients (25%) a fair outcome and one patient (5%) had a poor result. The mean

arc of flexion was 112° (range, 85 to 122). Mean pronation was 75° (range, 60-82) and supination was 76° (range,

60-80). Fifteen patients (75%) were able to return to their pre-injury level of occupation and activity. Seventeen

patients (85%) were satisfied with the final outcome. We conclude that internal fixation of intraarticular fractures

of the distal humerus by double tension band wiring is an effective procedure with an excellent or good functional

outcome in most patient age groups. Patients have a high level of satisfaction and the majority return to their

previous level of activity.

1. Associate Professor, Bangladesh Medical College, Dhaka.

2. Junior Consultant, NITOR, Dhaka.

3. Assistant Professor, NITOR, Dhaka.

4. Assistant Professor, NITOR, Dhaka.

5. Junior Consultant, NITOR, Dhaka

6. Assistant Professor, Department of Orthopaedic Surgery, DMCH, Dhaka

Correspondence: Dr. Kamruzzaman, Associate Professor, Bangladesh Medical College, Dhaka.

INTRODUCTION

Complex intraarticular distal humerus fractures are a

considerable challenge to even the most experienced

surgeon. Previous treatment methods of closed reduction

with immobilisation, traction and limited internal fixation

have lead to significant functional impairment with loss of

range of movement4,12,17.

The functional outcome of distal humerus fractures is

related to the ability to restore the normal anatomy and to

allow early movement. Various methods of limited internal

fixation have been described using Kirchner wires, screw

fixation and single plates2,3,10. Fractures of the distal

humerus are relatively rare and large case series are rarely

reported. Comparison between the various studies is

difficult owing to the variation in fracture classification,

operative techniques and outcome measures used15.

The aim of our study was to evaluate the functional

outcome of intraarticular distal humerus fractures treated

by both column fixation with tension band wiring with a

minimum of one year follow-up.

VOL. 29, NO. 2, JULY 2014 117

PATIENTS AND METHODS

Twenty-one consecutive patients with 21 fractures of the

distal humerus seen in Tauma Center over a 30-month

period underwent internal fixation of their fracture. Same

consultant trauma surgeon with his team performed

surgery . The choice of fixation was the double column

fixation by tension band wire based on the pattern of the

fracture and presence of associated injuries as seen on

standard antero-posterior and lateral radiographs of the

elbow. All the fractures were displaced intraarticular

fractures.

Surgical Technique:

The operation is carried out under general anaesthesia in

lateral decubitus.Torniquet is applied for all patients

undergoing operation. Esmarch tourniquet is applied at

the upper arm after exsanguination of blood from hand

and forearm. A midline posterior incision was made over

the distal humerus, curving around the tip of the olecranon.

The ulnar nerve was identified and protected. An olecranon

osteotomy was used for adequate exposure of the joint

surface . The osteotomy was started with an oscillating

saw but completed using a fine osteotome through the

subchondral bone.

Reduction And Fixation of The Condyles: Fragments of

the condyle are reduced and held together firmly by towel

clip or reduction clump. 1.5mm Kirschner wire is used for

reduction and temporary fixation. Parallel to the wire,

2.5mm hole is drilled from radial to ulnar fragment or ulnar

to radial side (depending on the fracture fragment) and a

4.5 mm partial threaded cancellous screw is introduced.

Reduction And Fixation Of Reassembled Condyle To The

Diaphysis: After the articular fragments have been

anatomically reduced to form an articular block, proper

reassembly of the medial and lateral columns are resumed

and these are fixed with the diaphysis of the humerus by

bilateral cross tension band wire.

Postoperative x-ray

Table I

AO classification of intra-articular fractures of the

distal humerus

Clinical Evaluation No Follow Up

C1 6 1

C2 9 1

C3 4 O

Total 19 2

There were 2O closed fractures and one open fractures.

The mean age for the surgery group was 39 years (range

18 to 68 years). There were 16 male patients and 5 female

patients. The results were analysed using clinical and

radiographic evaluation at a mean follow-up of 18 months.

The quality of reduction was graded (A to C), based on

the postoperative radiographs by the senior author. Grade

A was an anatomical reduction, grade B a step or gap of

the articular surface of less than 2 mm and grade C

involved a step or gap of more than 2 mm. The quality of

reduction was based on the immediate postoperative plain

radiographs and operative findings. Data from the clinical

records, clinical review and examination were summarised

in a weighted grading scale (Broberg and Morrey

functional rating index) (8) as shown in table II. The grading

scale was weighted as follows : normal motion, 40 points ;

no pain, 35 points ; normal strength, 20 points ; and normal

stability, 5 points.

Olecranon osteotomy was repaired using partial threaded

cancellous screw. The stability and range of motion was

assessed per operatively. Wound is closed in layers,

keeping a drain tube. A long arm posterior slab is fixed

with the elbow at right angle.Drain is removed after 48

hours postoperatively.Stiches are removed after 14

days.Triangular sling or elbow bag is applied to each and

every patient after removal of back slab at 2 weeks. Patient

is advised to continue this sling for further 2 weeks and to

allow active limited exercise of the elbow within the sling.

After removal of the sling, range of motion was gradually

increased depending on the documented stability and

postoperative range of motion achieved.

118 Kamruzzaman, Ripon Kumar Das , Asit Baran Dam, Swapon Kumar Paul, Zahid Ahmed, Mohammad Khurshed Alam


RESULTS:

Two patients were lost to follow up. The clinical records

and radiographs were available for all 21 patients. 19

patients were assessed clinically and radiographically at a

mean of 18 months postoperative (range 12 to 30 months).

thirteen out of 19 patients (68.4%) had an excellent or a

good functional result. Five patients (26.3%) had a fair

functional outcome and one patient (5.3%) had a poor

result.

Table II

Broberg and Morrey functional rating index

Variable Points value

Motion

Degree of flexion (0.2 3 arc) 27

Degree of pronation (0.1 3 arc) 6

Degree of supination (0.1 3 arc) 7

Strength

Normal 20

Mild loss (appreciated but not limiting, 13

80% of opposite side)

Moderate loss (limits some activity, 5

50% of opposite side)

Severe loss (limits everyday tasks, disabling) 0

Stability

Normal 5

Mild loss (perceived by patient, no limitation) 4

Moderate loss (limits some activity) 2

Severe loss (limits everyday tasks) 0

Pain

None 35

Mild (with activity, no medication) 28

Moderate (with or after activity) 15

Severe (at rest, constant medication, disabling) 0

Excellent 95-100 points

Good 80-94 points

Fair 0-59 points 60-

Poor 79 points

The mean arc of movement was 112° (range 85- 122°). The

mean pronation was 75° (range, 60-82°) and supination

was 76° (range, 60-80°). The mean functional score for the

group was 85 (range, 55 to 100).

The quality of reduction based on the immediate

postoperative plain radiographs and operative findings

was grade A (15 cases), grade B (5 cases) and grade C (1

case). On the functional rating index, 11 out of 15 fractures

with an anatomical reduction (grade A) had an excellent

outcome ; three had a good outcome and one a fair

outcome. Out of five patients with a grade B reduction,

two had a good outcome and three had a fair functional

result. The one patient with loss of reduction (grade C)

had a poor result. Fourteen patients (73.6%) were able to

return to their preinjury level of occupation and activity.

Seventeen patients (89.4%) were satisfied with the final

outcome.

Table III

Complications

Number Percentage

Metalwork Prominence 5 26

Heterotopic Ossification 2 11

Wound Infection 2 11

Suture Irritation 1 5

Ulnar Nerve Palsy 1 5

Osteotomy non-union 0 0

The complications are shown in table III. Two patients

developed an early superficial wound infection. There was

one case of ulnar nerve neurapraxia, which resolved within

6 months. There was evidence of moderate osteoarthrosis

in one elbow. There were no case of olecranon osteotomy

nonunion.

DISCUSSION:

Complex intraarticular fractures of the distal humerus are

still a considerable challenge to the experienced surgeon.

Prior to the 1970’s great emphasis was laid on

conservative treatment of these fractures either by the

use of plaster or by traction on the olecranon, which led

to considerable stiffness and poor functional results12,17.

However with advances in implants and surgical

techniques, many surgeons have moved towards surgical

reconstruction of these complex fractures2,12. Many

methods of internal fixation have been described. The

results of the various treatment methods are difficult to

compare owing to the variability of the outcome scoring

systems used.

Total joint arthroplasty as a primary modality of treatment

is also an option in the elderly when the extent of

Functional outcome of intraarticular fractures of the distal humerus following both column fixation by tension band wire 119

VOL. 29, NO. 2, JULY 2014

fragmentation is beyond surgical reconstruction, when

the quality of bone stock is poor due to osteoporosis or

when antecedent arthritis (usually rheumatoid) is present

in the joint5. In our series no cases required arthroplasty.

The majority of patients had mild or no pain (85%), there

were no cases of severe pain. There were good forearm

rotational movements in these patients, the main restriction

was in flexion to extension. The mean arc of movement

was 112°, which is consistent with other studies2,3,9. There

was no correlation between age and the final functional

outcome achieved. Patients with open fractures had a lower

mean functional score, which is similar to previous

studies15.

Fourteen patients (70%) had an excellent or good

functional outcome after these complex fractures. This is

comparable with other series in the literature although

there is considerable variation depending on the outcome

scoring system used (9, 11, 13, 14, 20). There was one poor

result in a 68 year-old lady who sustained a grade 2 open

injury. She had an arc of flexion of 85° with considerable

weakness and moderate pain at latest follow-up. She was

unable to achieve her pre-injury level of activity. Overall,

five patients (25%) were unable to return to their previous

level of activity. Seventeen patients (85%) were satisfied

with their final outcome.

Olecranon osteotomy for exposure and fixation of the

distal humeral fracture was initially popularized by

Cassebaum3. Henley et al reported a 57% incidence of

complications with the transverse osteotomy, including

symptomatic prominence of the K-wire, broken tension

band wire, delayed union and non-union8. In 1982 Heim et

al described the chevron osteotomy with the point of the

“V” turned distally. In addition to providing mechanical

stability to rotational stresses the larger area of contact

between the ends of the osteotomy enhances bony

union7. We used the technique of transverse osteotomy

in our study ; we had five cases of metalwork prominence

but no cases of non-union.

Wang et al recommend routine anterior subcutaneous

transposition of the ulnar nerve using a posterior approach

(20). We have not found it necessary to perform a routine

anterior transposition and have performed an adequate

mobilisation as described by Jupiter et al11. Sodergard et

al reported a 12.5% neural complication following the

surgical fixation, 3.1% of the patients had a permanent

dysfunction of the ulnar nerve in a series of 96 adult

patients at an average follow-up of 6 years19. There was

one case of ulnar nerve palsy in our series, which recovered

by 6 months. Heterotopic ossification was seen in two

cases although much higher rates have been reported in

similar series. We believe that the olecranon osteotomy

minimizes triceps muscle trauma and combined with early

mobilisation reduces this complication.

Fratures of the distal humerus are relatively rare and large

case series are rarely reported. Comparison between the

various studies is difficult due the variation in fracture

classification, operative techniques and outcome measures

used. There is considerable variation depending on the

outcome measures used.

Internal fixation of intra-articular distal humerus fractures

using double column fixation by tension band wire is an

effective procedure with an excellent or good functional

outcome in most patient age groups. There is a long-term

reduction in grip strength in the injured arm, however

patients have a high level of satisfaction and the majority

return to their previous level of activity.

REFERENCES

1. Broberg MA, Morrey BF. Results of delayed excision of

the radial head after fracture. J Bone Joint Surgery 1986 ;

68-A : 669-674.

2. Burri C, Henkemeyer H, Spier W. Results of operative

treatment of intraarticular fractures of the distal humerus.

Acta Orthop Belg 1975 ; 41 : 227-234.

3. Cassebaum WH. Open reduction of T- and Y-fractures of

the lower end of the humerus. J Trauma 1969 ; 9 : 915-

925.

4. Charnley J. The Closed Treatment of Common Fractures,

3rd ed, 1961. Williams & Wilkins, Baltimore, pp 70-71.

5. Cobb TK, Morrey BF. Total elbow arthroplasty as primary

treatment for distal humeral fractures in elderly patients.

J Bone Joint Surg 1997 ; 79-A : 826-832.

6. Gabel GT, Hanson G, Bennett JB, Noble PC, Tullos HS.

Intraarticular fractures of the distal humerus in the adult.

Clin Orthop 1987 ; 216 : 99-108.

7. Helfet DL, Hotchkiss RN. Internal fixation of the distal

humerus : a biomechanical comparison of methods. J

Orthop Trauma 1990 ; 4 : 260-264.

8. Henley MB. Intra-articular distal humeral fractures in

adults. Orthop Clin North Am 1987 ; 18 : 11-23.

9. Holdsworth BJ, Mossad MM. Fractures of the adult distal

humerus. Elbow function after internal fixation. J Bone

Joint Surg 1990 ; 72-B : 362-365.

10. Johannson H, Olerud S. Operative treatment of

intercondylar fractures of the humerus. J Trauma 1971 ;

10 : 836-843.

120 Kamruzzaman, Ripon Kumar Das , Asit Baran Dam, Swapon Kumar Paul, Zahid Ahmed, Mohammad Khurshed Alam


11. Jupiter JB, Neff U, Holzach P, Allgower M. Intercondylar

fractures of the humerus. An operative approach. J Bone

Joint Surg 1985 ; 67 : 226-239.

12. Keon Cohen BT. Fractures at the elbow. J Bone Joint Surg

1966 ; 48-A : 1623-1639.

13. Kundel K, Braun W, Wieberneit J, Ruter A. Intraarticular

distal humerus fractures. Factors affecting functional

outcome. Clin Orthop 1996 ; 332 : 200-208.

14. Letsch R, Schmit-Neuerburg KP, Sturmer KM, Walz M.

Intraarticular fractures of the distal humerus. Surgical

treatment and results. Clin Orthop 1989 ; 241 : 238-244.

15. Nadim A,Keith W. Functional outcome following internal

fixation of intra-articular fractures of distal humerus (AO

type C).Acta Orthop. Belg.,2004, 70, 118-122.

16. McKee MD, Jupiter JB. A contemporary approach to

the management of complex fractures of the distal end of

the humerus. Hand Clin 1994 ; 10 : 479-494.

17. Riseborough EJ, Radin EL. Intercondylar T fractures of

the humerus in adult. J Bone Joint Surg 1969; 51A: 130.

18. Self J, Viegas SF, Buford WLJr, Patterson RM. A comparison

of double-plate fixation methods for complex distal

humerus fractures. J Shoulder Elbow Surg 1995 ; 4: 10-16.

19. Sodergard J, Sandelin J, Bostman O. Postoperative

complications of distal humeral fractures. 27/96 adults

followed up for 6 (2-10) years. Acta Orthop Scand 1992;

63 : 85-89.

20. Wang KC, Shih HN, Hsu KY, Shih CH. Intercondylar

fractures of the distal humerus : routine anterior

subcutaneous transposition of the ulnar nerve in a posterior

operative approach. J Trauma 1994 ; 36 : 770-773.

Functional outcome of intraarticular fractures of the distal humerus following both column fixation by tension band wire 121

VOL. 29, NO. 2, JULY 2014

Original Article

Results of One Stage Surgical

Correction of Congenital Vertical Talus

in Children

Dipankar Nath Talukder1, M.A. Hannan2, Ishtiaque Ul Fattah3, Faruqul Islam4, Mohsenuzzaman

Khan5

ABSTRACT

Congenital vertical talus(CVT) is a well known cause of severe rigid flatfoot deformity if it is left untreated. It is

more commonly associated with other neuromuscular disorders with less favourable outcome.

The aim of our study is to find out the clinical and radiological outcome of one stage surgical correction in children

having congenital vertical talus. The goal is to restoration of normal shape and function of the foot.

We report our experience of a one-stage surgical procedure for correction of congenital vertical talus. This

series consisted of 10 congenital vertical tali in 8 patients. Syndromes such as arthrogryposis multiplex congenital

and other neurological abnormality were excluded from this study. So,all are belonged to isolated CVT. All feet

were treated by 2 or 3 serial plaster prior to surgery. The male-to-female ratio was 1:1. The mean operative age

was 28.88 (13-48) months. All patients were available for clinical and radiological follow-up for a mean period of

3.1 (1.1-6) years.Colton scoring system was utilized for assessment of final outcomes.

The outcomes of 8 feet (70%) were excellent, 2 (20%) good and 1(10%) fair. All patients wear normal shoes and

were satisfied by their functional results and appearance. No talar avascular necrosis was encountered. None

required further operation. Radiologically there was a statistically significant difference of postoperative

improvement of measured angles compared to preoperative values (P < 0.005). All radiological parameters were

within normal ranges.

As a complex deformity, isolated CVT may be effectively managed with one-stage procedure for surgical correction

before the age of 4 years. The results of this study indicate that single stage surgical procedure is sufficient for

correction of deformity and no need for excision of talus or navicular.

Keywords: congenital vertical talus, single stage surgery.

1. Associate professor of ortho surgery,Sylhet MAG Osmani medical College Hospital

2. Registrar of ortho surgery,Sylhet MAG Osmani medical College Hospital

3. Associate professor of ortho surgery,Sylhet MAG Osmani medical College Hospital

4. Consultant of ortho surgery,Sylhet MAG Osmani medical College Hospital

5. Registrar of ortho surgery,Sylhet MAG Osmani medical College Hospital

Correspondence: Dr. Dipankar Nath Talukder, M.A. Hannan, Email: [email protected], [email protected]

INTRODUCTION

Congenital vertical talus is a rare foot deformity with an

incidence of 1 in 10,000.1 It is also called congenital convex

pes valgus, Persian slipper, congenital rigid rocker bottom

foot and dislocated navicular and both sexes are equally

affected. It is bilateral in 50% of cases.2,3 The exact etiology

of vertical talus is unknown and possible causes include

muscle imbalance, especially overpull of the anterior tibial

tendon in paralytic disorders, and intrauterine

compression, particularly when coupled with

arthrogryposis.4 Autosomal dominant transmission

through three generations of a family has been reported5,6.

Suggested causes include defects in central nervous

system, muscle abnormalities, genetics and acquired

deformities7,8,9.

The main pathology of congenital vertical talus is the

dorsolateral dislocation of the navicular in relation to the

talus and usually articulates with the dorsal aspect of the

122 The Journal of Bangladesh Orthopaedic Society

neck of the talus and is locked there.(1,10) The navicular

adapts to this position by becoming wedge shaped with a

hypoplastic plantar segment.(9) The talar head and neck

are flattened dorsally and deviated medially, the calcaneus

is displaced posterolaterally in relation to the talus and is

tilted into equinus.4 The talus becomes hourglass shaped

and remain in marked equinus position. So its longitudinal

axis is almost the same as that of the tibia.(11) The

talonavicular joint capsule is dorsally contracted and both

the calcaneonavicular (spring) ligament and the anterior

fibers of the deltoid ligament are stretched. There are

corresponding contractures of the tibialis anterior, long

toe extensors, peroneus brevis, and triceps surae. The

posterior tibial and peroneal tendons may be displaced

anteriorly so that they act as dorsiflexors rather than plantar

flexors5,9,12, the peroneal and tibialis anterior tendons are

contracted, and the foot is everted into a valgus, externally

rotated position1,4,9 It is characterized by hindfoot equines

and valgus, forefoot abduction, and forefoot dorsiflexion

at the midtarsal joint, this is usually recognized in the

newborn period by the rigidity of the foot.1 In congenital

vertical talus, the plantar surface of the foot is convex

creating a rocker bottom appearance.

In addition to the clinical examination, the diagnosis should

be confirmed by radiological examination.1 Congenital

vertical talus is difficult to correct and tends to recur, and

serial casting has been recommended and attempted by

many but ineffective because of the rigidity of the

deformity.9

Surgical correction is the mainstay of treatment. The exact

upper age limit for a successful open reduction is debatable.

The difficulty of surgical correction depends on the

severity of the deformity, the associated diagnosis, and

the age of the patient. Childrens are best treated by open

reduction and realignment of the talonavicular and subtalar

joints which can be performed through either a one-stage

or two-stage operation1,12 The single-stage correction can

be done through dorsal, posterior and medial approach.(1)

METHODS

A prospective study was conducted in Sylhet MAG

Osmani Medical CollegeHospital between September 2007

and August 2013, with 8 patient (10 feet) of isolated CVT

and treated with one stage surgical procedure for

correction of the deformity. After surgery, all cases were

followed up regularly for a mean period of 3.1 years

(minimum 13 months and maximum 6 years), during this

period they were clinically evaluated for subjective

complaints and objective findings focused on the range

of movement at the ankle,subtalar and midtarsal joints,

equines deformity, position of the hindfoot and the lateral

and medial boarders of the foot. Colton (1973)15 scoring

was used as a baseline indicator for the clinical

improvement. AP and lateral radiographs was for

radiological assessment of the talocalcaneal angle and

tibiocalcaneal angle. Statistical analysis was done by using

paired t test.

OPERATIVE PROCEDURE

One staged surgical procedure was used for all patients.(16)

Peritalar soft tissue release with tendons lengthening and

fixation of talonavicular joint by k wire and sometimes

tibialis anterior transfer to talar neck for elderly children

was done. With the 5cm medial straight incision parallel to

the sole of the foot, subcutaneous dissection was done

and incising the talonavicular capsule, head of the talus

was exposed, subtalar release along with division of spring

Table-I

Colton Clinical scores

Topics 4 points 3 points 2 points 1 point

Equinus Dorsiflexion above Dorsiflexion to Slight equinus Gross equinus

square square

Lateral boarder Convex Straight Slight concavity Gross forefoot

abduction

Medial talar prominence None Slight prominence Callosity over Ulceration over

prominence prominence

Mobility Useful range all tarsal Subtalar joint stiff, Stiffness of whole Rigidity of

joints Other tarsal joints mobile tarsus whole tarsus

Range of plantar-flexion Over 20 11 to 20 0 to 10 Fixed dorsiflexion

(degrees)

Lateral boarder Convex Straight Slight concavity Gross forefoot

abduction

Excellent (21 24 points), Good (16 20 points), Fair (14 15 points) and Poor (13 points or less).

Results of One Stage Surgical Correction of Congenital Vertical Talus in Children 123

VOL. 29, NO. 2, JULY 2014

ligament was done, if contracted the tibialis anterior tendon

was lengthened by Z plasty and also the contracted dorsal

talonavicular ligament was divided. Then wide posterior

capsulotomy of ankle and subtalar joints, the contracted

calcaneofibular ligament should be divided to correct the

valgus heel preserving the neurovascular bundle. By using

5cm posterior incision on medial boarder of Achilles

tendon, lengthening was done by z plasty.Lateral incision

was performed for lateral subtalar release, divide the

ligament in sinus tarsi and peroneal z plasty was done if

needed.

A k wire is then inserted in the talus in a retrograde manner

and then used as a joystick to reduce the talonavicular

joint by molding the longitudinal arch and manipulation

of forefoot into plantar flexion and inversion, after that the

k wire is advanced to secure the talonavicular joint then

advanced more to the middle or medial cuneiform. A second

k wire in some cases inserted from the posterior end the

heels through calcaneus to the reduced talus to fix the

subtalar joint.

Reconstruction of the talonavicular ligament and tight

closure of the talonavicular capsule was done.

Six weeks after the surgery the k wires were removed but

the cast were put for further 2 weeks. Then an Ankle Foot

orthosis or a Shoewear with medial arch support was

applied and encourage the child for walk.

RESULTS

There were 8 cases (10 feet), 4 boys and 4 girls and only 2

cases were bilateral. The ages ranged from 13 to 48 months

and the mean was 28.88 months. All the patients had

improvement of their foot deformities based on the

significant differences between the pre and post operative

measurements of radiological talocalcaneal and

tibiocalcaneal angles and also the significant improvement

in the clinical scores.

The results showed highly significant decrease in both

lateral talocalcaneal and tibiocalcaneal angles after surgery.

The mean of lateral right and left talocalcaneal angles

decreases from (41.90°) and (38.00°) before surgery to

(24.70°) and (25.78°) respectively on last follow up, while

the mean of right and left tibiocalcaneal angles decreases

from (122.80°) and (128.80°) before surgery to (88.90°) and

(92.67°) respectively. These difference in mean value are

significant.(p < 0.005)

The clinical picture in all cases were improved and showed

significant increase in the result of clinical scores compared

to the preoperative assessment by the same system.

Preoperatively there were only 3 feet with fair grade while

the rest 7 feet were graded as poor. After performing the

one stage surgical treatment, overall results were 70%

excellent, 20% good and 10% fair. The results is highly

significant.(paired t test, p < O.005)

One case developed superficial wound infection which

was controlled by additional antibiotic support. Pin tract

Preoperative tibio and talocalcaneal angle

Postoperative

124 Dipankar Nath Talukder, M.A. Hannan, Ishtiaque Ul Fattah, Faruqul Islam, Mohsenuzzaman Khan


infection followed by k-wire loosening and auto removal

occured in a patient. After controlloing infection, cast was

applied for 3 weeks followed by orthosis.That patient feft

pain on walking 5 months postoperatively and recovered

after 1 year with fair outcome.

During our follow up period , no patient had worsening or

recurrence of the deformity and no AVN of talus developed.

DISCUSSION:

A high index of CVT is suspected when examining any

child or infant with severe flatfeet. We found 25% cases

were bilateral where as incidence in most literature was

50%.1,9,17

Conservative treatment by serial casting should be

attempted if the child is as young as 3 4 months but we

performed surgical treatment with 2 preoperative casting

as all of our sample were between 13 to 48 months.

Our study showed highly significant decrease in both

lateral talocalcaneal and tibiocalcaneal angles post

operatively. Our results were similar or close to the study

of Saini et. al(17) , Raap and krauspe from Germany (1997)18.

In current study, satisfactory(excellent & good) outcome

was 90% and statistically significant improvement was

observed postoperatively by using Colton score. Similarly,

AAOS instructional series, Clark et al. (1977)19, Striker

and Rosen(1997)20 studies showed more than 80%

satisfactory outcome.

CONCLUSION

We can concluded from our study that one stage surgery

is very useful in children up to 4 years of age, but when

done earlier it will help to avoid a 2nd surgery with its

complication and like naviculectomy and talectomy .

Posterior ankle and subtalar capsulotomy is a keystone in

the treatment along with the division of the contracted

calcaneofibular ligament and adding a tibialis anterior

element in elderly children to the single stage surgery

obviates the need for extra-articular subtalar fusion.

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4. Herring J. A. : Tachdjian s Pediatric Orthopedics, vol 2,

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5. Stern HJ, Clark RD, Stroberg AJ,et al. : Autosomal

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Clin Genet 1989;36:42Z .

6. Seimon LP. Surgical correction of congenital vertical talus

under the age of 2 years. J Pediatr Orthop 1987;7:405 11.

7. Stanton, R. P.; Rao,N.; and Scott, C. I., Jr.: Orthopaedic

manifestations in de Barsy syndrome. J. Pediat. Orthop.,

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8. Södergård, J., and Röyppy, S.: Foot deformities in

arthrogryposis multiplex congenita. J. Pediat. Ortinop.,

1994;14: 768 72.

9. Drennan J. C.: Congenital vertical talus. J BoneJoint Surg

1995; 77 A .

10. Sarsam IM: A one stage operation to correct congenital

vertical talus deformity.Pan ArabJOrth.Traum1995;2; 667

11. Moore, Keith L.:Clinically Oriented Anatomy, 5th

Edition.2006.

12. Canale and Beaty, Campbell’s Operative Orthopaedics,

2008;11th ed.

13. Weinstein S. : Turek’s Orthopaedics: Principles and Their

Application, 6th Ed, Lippincott Williams & Wilkins 2005.

14. Szendrõi, F.and Sim, F. H. Color Atlas of Clinical

Orthopedics, 1st ed , 2009:252.

15. Christopher L. Colton: The Surgical management of

congenital vertical talus. J BoneJoint Surg 1973; 55 B.

16. Bosker B. et al.: Congenital convex pes valgus (congenital

vertical talus)The condition and its treatment : A review

of the literature. Acta Orthopædica Belgica, 2007;73 3 .

17. Saini R. et al: Results of dorsal approach in surgical

correction of congenital vertical talus: an Indian experience.

J. P iat. Orthop.B March 2009;8:63 68 .

18. P.Raap and R.Krauspe :One stage procedure for surgical

correction of congenital vertical talus. Foot and ankle

surgery , 1997;3: 71 76.

19. Clark W. et al: Congenital vertical talus treatment by open

reduction and navicular excision. J BoneJoint Surg 1977;59

A.

20. Stricker SJ, Rosen E Early one stage reconstruction of

congenital vertical talus. Foot Ankle Int 1997; 18:

535–43.

Results of One Stage Surgical Correction of Congenital Vertical Talus in Children 125

VOL. 29, NO. 2, JULY 2014

Original Article

Management of Traumatic Orbital Wall

Fracture with Titanium Mesh

Kazi Lutfor Rahman1, Ismat Ara Hayder2, Mohammad Ghulam Rasul3, Anjal Lal Ghosh4, Shibasis Basak5

ABSTRACT

The management of orbital injuries is one of the most interesting and difficult areas in maxillofacial surgery. The

improper reconstruction of the orbit frequently results in ophthalmic complications. Though a number of materials

are available for the use in orbital wall reconstruction, at present titanium mesh could be considered to be the ideal

orbital floor repair material. Ten cases of internal orbital wall defects were reconstructed by titanium mesh at the

Dept. of Oral and Maxillofacial Surgery, Dhaka Dental College and Hospital, Dhaka from January, 2013 to December,

2014 were considered for this study. The study involved patients with symptomatic zygomatico-orbital fractures

requiring orbital wall reconstruction. Under general anaesthesia the floor of orbit was explored and reconstructed

with contoured titanium mesh after repositioning of the entrapped orbital contents.The patients were on periodic

follow- up for 3 months where clinical and radiographic data were recorded. Ten male patients age ranging from

18 to 50 years ( mean 30.50 years) received titanium mesh for impure orbital fractures ( eight patients) and pure

orbital floor fractures ( two patients). The main cause of fractures was road traffic accidents. They also complained

of enophthalmos (n = 9), diplopia (n = 8), infraorbital nerve paresthesia (n = 4), dystopia (n = 1) and epiphora (n= 2).

No implant extrusion or infection was seen. The symptoms were corrected in eight patients with enophthalmos,

seven with diplopia, three with infraorbital nerve paresthesia and all patients with epiphora. Dystopia persisted

post-surgically in one patient. Titanium orbital implants were used to confirm titanium as a useful repair material

for orbital floor fractures. Their use leads to less morbidity as no donor site operation is needed. Titanium mesh

provides favourable healing as it is biocompatible.

Keywords: Orbital floor fractures · Titanium mesh · Enophthalmos · Reconstruction of floor.

1. Researcher, Dept. of Oral and Maxillofacial Surgery, Dhaka Dental College Hospital

2. Professor & Head, Department of Orthopaedic Surgery, Dhaka Dental College Hospital

3. Associatge Professor, Department of Orthopaedic Surgery, NITOR, Dhaka

4. Assistant Professor, Department of Orthopaedic Surgery, ZH Sikder Medical College

5. Registrar, Department of Orthopaedic Surgery, Dhaka Medical College, Dhaka

Correspondence to : Dr.Kazi Lutfor Rahman, M.S (Oral and Maxillofacial Surgery), PhD Researcher, Fellow IAOMS (USA),Department

of Oral and Maxillofacial Surgery, Dhaka Dental College and Hospital, Dhaka, Bangladesh, Cell: +8801711235845, E-mail:

[email protected]

INTRODUCTION

The management of orbital injuries is one of the most

interesting and difficult areas in maxillofacial surgery. The

consequences of an orbital injury are dramatic. They vary

from loss of vision, enophthalmos, diplopia,loss of an

eye, epiphora, a disturbing loss of facial sensation to an

unsightly and unacceptable appearance of the eye and

the hard and soft tissues around it.These injuries demand

careful attention to detail but they are often

underestimated and undertreated1.

Damage to the orbital walls themselves can cause

disorders such as enophthalmos, diplopia and much less

frequently vertical dystopia. It is therefore mandatory to

reconstruct the orbital floor and also repair of orbital rims

in the same time2.

Numerous materials - both naturally occurring and

synthetic substances - are available for reconstructing

damaged internal orbital walls to restore orbital volume.

This is a prospective study for the management of post-

traumatic orbital internal wall defect reconstruction by

titanium mesh implants to provide long term chemically

inert, biocompatible material which can replace autogenous

bone grafts. The demerits include the need for a donor

site and its complications.

MATERIALS AND METHODS

Ten patients (ten male patients between 18 to 50 years

of age) with internal orbital wall fractures were randomly

selected and treated at the Department of Oral and

Maxillofacial Surgery, Dhaka Dental College and Hospital,


Dhaka after obtaining ethical clearance between January,

2013 to December, 2014. The study involved patients with

symptomatic zygomatico-orbital fractures requiring

orbital wall reconstruction.

Patients presented with orthoptic symptoms including

enophthalmos, diplopia,and dystopia or other associated

symptoms like nerve paresthesia or epiphora.

All patients were operated under general anaesthesia

through nasoendotracheal tube.

All patients were evaluated by the ophthalmologist for

errors in vision, presence of enophthalmos, diplopia or

dystopia and a through clinical history was recorded.

Routine presurgical blood investigations and radiographs

or computed tomography ( CT) scans were obtained.

Diplopia charting was done clinically in all nine cardinal

positions of gaze preoperatively and postoperatively.

Following thorough skin preparation with betadine and

sprit, tarsorrhaphy was done. Infraorbital incision was

given in eight patients and subcilliary incision was given

in two patients. Dissection layer by layer done and fracture

site was exposed. The entrapped orbital tissues were

repositioned and walls were reconstructed using cut and

contoured 0.2 mm titanium mesh [Medicon Mesh

Plate,contourable, Pure Titanium]. The mesh was fixed to

the infraorbital rim using 2 mm screws to ensure graft

stability.

The surgical skin defect was closed primarily in layers

taking care to prevent any tension across suture line.

All patients were evaluated for the correction of their

preoperative complaints through clinical and radiological

Fig.-1: Case 1 pre-operative and post-operative profile

view

Fig.-2: Case1 preoperative and postoperative coronal

CT scan

Fig.-3: Case 1 before and after intra operative reconstru-ction

examinations for a period of 3 months. Coronal CT scans

with 3D reconstruction was done in all cases

postoperatively following reconstruction ( Figs. 1,2, 3, 4,

5, 6, 7, 8, 9,10 ).

Management of Traumatic Orbital Wall Fracture with Titanium Mesh 127

VOL. 29, NO. 2, JULY 2014

RESULTS

The main aim of the investigation was to evaluate clinically

the efficiency of use of titanium mesh for the

reconstruction of orbital floor post traumatically.

In this study, the most common mode of injury causing

orbital wall fractures were associated with road traffic

accidents ( 80%), followed by assault (20%).

Majority of fractures involving orbit were caused by

indirect forces associated with fractures of zygomatico -

maxillary complex with 80% of the study sample being

orbital fracture of impure type and two patients with pure

orbital blow out fractures. Minimum time lapse between

trauma and surgery was 7 days and maximum period was

27 days.

This study showed no cases with infection of the surgical

site.None of cases showed any other complications

associated with the use of alloplastic materials like implant

migration, extrusion of implant or hypersensitivity.

Epiphora was noted in two patients (20%) preoperatively

on fractured side which resolved considerably over the

period of 3 weeks. None of the patients complained of

epiphora upto 8 weeks following surgery.

Enophthalmos was seen in 90% of patients included in

the study preoperatively. Correction of enophthalmos was

seen in 88.9% of our patients, on the 8th week following

surgery only one patient showed signs of enophthalmos.

Though the possibility of late postoperative

enophthalmos is a possible sequale, all our patients were

reviewed after 1 year and did not show any signs of

enophthalmos to date.

This study showed correction of diplopia in 87.5% of

patients. Persistance of double vision was only noted in

one patient in extreme upward gaze, this error in the vision

did not affect the patient’s day to day activities.

Dystopia was present in one patient preoperatively which

corrected after surgery. In this study 40% of the patients

reported numbness over the infraorbital and lateral part

of the nose following trauma. Patients showed

considerable improvement over time and 80% of patients

involved in the study had no complaints of paresthesia

over 8 weeks of surgery.

None of cases showed any obvious entrapment of the

orbital muscles on surgical exposure. Though orbital

connective tissue and fat were noticed to be entrapped in

the fracture site none of the cases showed any obvious

restriction of globe movement.

Fig,-4: Case 1 post operative 3D reconstruction scan Fig.-5: Case 1 post-operative 3 months follow up

Fig.-6: Case 2 preoperative and post-operative profile

view

128 Kazi Lutfor Rahman, Ismat Ara Hayder, Mohammad Ghulam Rasul, Anjal Lal Ghosh, Shibasis Basak


Fig.-7: Case 2 preoperative and post –operative coronal CT scans

Fig.-9 Case 2 post-operative 3D reconstruction scans.

Fig.-8: Case 2 before and after intra operative reconstruction

Fig.-10: Case 2 post-operative 3 months follow up.


VOL. 29, NO. 2, JULY 2014

DISCUSSION

The orbital floor is most vulnerable to fracture because of

thinness of the maxillary roof, existence of the infraorbital

canal and curvature of the floor. Immediately behind the

orbital rim, the floor is concave, whereas further back , it

becomes convex and is called posterior ledge or bulge,

where the bony structure becomes thicker and less

deformed in the orbital floor fracture3.

Reconstruction of this posterior bulge or retrobulbar bulge

by proper contouring of this titanium mesh before insertion

into the defect has to be strictly followed to ensure that

the antero – posterior globe position is maintained after

reconstruction (Fig. 5). Failure to achieve this step during

surgery could result in late postoperative enophthalmos.

There has been extensive debate over the standard of

care of orbital floor and wall fractures. Recommendations

of treatment range from exploration to observation. Clinical

indicators such as enophthalmos, persistent diplopia,

infraorbital nerve paresthesia, muscular entrapment or

incarceration, hypoglobus, potentiation of the

oculocardiac reflex, severe orbital emphysema, as well as

various radiographic criteria have all been proposed as

indications for surgical intervention. Of these, diplopia,

entrapment and hypoglobus, with or without

enophthalmos, seem to be the most common clinical signs

for surgical intervention4.

The ideal material for orbital reconstruction remains

controversial. It should be cheap, biocompatible, readily

available, easy to manipulate and insert in the operating

room and it should allow fixation to the host bone by

screws, wire or sutures.

The more elastic materials are unable to withstand the

dynamic stresses of large defects. Resorbable implants

may be prone to foreign- body reaction, implant exposure

and having only fibrinous connective tissue remains after

resorption. The disadvantages of autogenous bone grafts

include minimal contourability and a donor site defect. In

addition, implant resorption can occur.

High complication rates have been reported in use of some

alloplastic materials5-8.

In the present study showed excellent biocompatibility

with no post surgical infection with the use of titanium

mesh and shows excellent results in correction of post

traumatic orthoptic problems with titanium mesh for orbital

floor fractures. Only one patient showed persistence of

double vision at the end of 8 weeks following

reconstruction in only extreme upward gaze. Some

alloplastic materials like porous polyethylene implants have

shown persistence of diplopia in 25- 30% of patients5-9.

Correction of enophthalmos yielded excellent results with

titanium mesh with 88.9% of the test sample showing

resolution of the symptoms. One patient who showed

persistent enophthalmos presented with extensive injury

(panfacial trauma) to surrounding bony structures with

loss of bony architecture. At the 8 week following surgery

there was significant improvement in globe position and

volume with mild persistent enophthalmos compared to

the uninjured eye. Extensive injury could be postulated to

be the reason for difficulty to correct the globe volume

satisfactorily.

Numbness over the skin in the infraorbital region was

noticed in 40% of the patients which was seen to persist

over a period of 3 weeks following surgery and slowly

resolved over 8 weeks with 80% of patients showing no

symptoms of paresthesia.

CONCLUSION

Titanium mesh has a long track record of reconstruction

of large orbital floor defects and correction of globe

malposition. Care has to be taken in reconstruction of the

retrobulbar bulge with titanium mesh by adequate

contouring of the mesh in this critical area to ensure proper

globe position.

Some advantages of titanium mesh plates are availability,

biocompatibility, easy intraoperative contouring and rigid

fixation. Disadvantages are difficulties with ease of

insertion.Any rough edges on the mesh tend to catch on

prolapsed orbital fat. Removal of the titanium mesh after

the healing period is challenging due to scar tissue that

grows through the mesh perforations.

This study highlights the ability of the alloplastic mesh to

satisfactorily correct post traumatic orbital sequel including

enophthalmos and diplopia.

Titanium mesh can be considered to be the ideal orbital

floor repair material.

REFERENCES

1. Leo FA, CyrusJK (2007) Peri and intraorbital trauma and

orbital reconstruction.In: Booth PW, Schendel SA,

Hausmen JE( ed) Maxillofacial surgery, vol 1, 2nd edn.

Churchil Livingstone, Edinburg, p 205-222

2. Metzger MC, Schon R, Schulze D, Carvalho C, Gutwald

R, Schmelzeisen R (2006) Individual preformed titanium

meshes for orbital fractures. Oral Surg Oral Med Oral

Pathol Oral Radiol Endod 102: 442 – 447

3. Stanley RB (2002) Treatment of orbitozygomatic fractures.

In: Papel ID et al (ed) Facial plastic and reconstructive

surgery, vol 1, 2nd edn. WB Saunders, Philadelphia,p

746-748

130 Kazi Lutfor Rahman, Ismat Ara Hayder, Mohammad Ghulam Rasul, Anjal Lal Ghosh, Shibasis Basak


4. Mazock JB, Schow SR, Triplett RG (2004) Evaluation of

ocular changes secondary to blow- out fractures. J Oral

Maxillofac Surg 62:02-1298.

5. Villarreal PM et al (2007) Porous polyethylene implants

in orbital floor reconstruction. Plast Reconstr Surg 109

:877-885.

6. Baumann A, Burggasser G,Gauss N,Ewers R (2002)

Orbital floor reconstruction with an alloplastic resorbable

polydioxanone sheet. Int J Oral Maxillofac Surg 31: 367-

373.

7. Tuncer S et al (2007) Reconstruction of traumatic orbital

floor fractures with resorbable mesh plate. J Craniofac

Surg 18: 598 – 605.

8. Lee S et al (2005) Porous high- density polyethylene for

orbital reconstruction. Arch Otolaryngol Head Neck Surg

131: 446 – 450.

9. Hidding J, Deitmer T, Hemprich A,Ahrberg W (1991)

Primary correction of orbital fractures using PDS-

foil.Fortschr Kiefer Gesichtschir 36 :195 - 196.


VOL. 29, NO. 2, JULY 2014

Original Article

1. Assistant Professor (Arthroplasty Orthopaedic Surgery), DMCH, Bangladesh

2. Assistant registrar , Orthopaedic Surgery , Dhaka Medical College Hospital. Bangladesh.

3. Assistant Professor (Orthopaedic Surgery), Dhaka Medical College and Hospital, Dhaka, Bangladesh.

4. Assistant registrar , Orthopaedic Surgery, Mymensing Medical College Hospital. Bangladesh.

5. Associate Professor, Department of Orthopaedic Surgery, Dhaka Medical College Hospital, Bangladesh

Correspondense: Dr. Mobarak Hossain. Assistant Professor (Arthroplasty Orthopaedic Surgery), Dhaka Medical College Hospital.

Bangladesh. Tel=+88-01715784628, Email. [email protected]

Evaluation of the Outcome of Proximal

Femoral Locking Compression Plate for

the Treatment of Comminuted

Trochanteric and Subtrochanteric

Femoral Fractures

MM Hossain1, QS Alam2, MFH Qasem3, MTI Noman4, Md. Golam Sarwar5, Md. Golam Mostofa5

ABSTRACT

The Comminuted trochanteric and subtrochanteric femoral fractures are considered as one of the most difficult

fractures to treat in the orthopaedic surgery and they associated with high incidence of nonunion, malunion.

Various implants, both intramedullary and extramedullary, are available for their fixation.

To assess the success rate of proximal femoral locking compression plate osteosynthesis in comminuted

trochanteric and subtrochanteric femoral fracture.

20 consecutive patients with comminuted Trochanteric and subtrochanteric fractures were operated upon with

PF-LCP. Detailed clinical conditions of all patients, duration of operation, technical difficulty with the implant,

hospital stay period were recorded. Patients were visited at 6 weeks interval till union then 3 monthly. The Harris

Hip Score was used to document hip function at final follow-up.

There were fifteen excellent (75%), two good (10%), two fair (10%) and one poor (5%) results according to Harris

hip score. No instance of implant failure was recorded.

Fixation of comminuted trochanteric and subtrochanteric fractures with PF-LCP provides stable fixation with

high union rate and fewer complications.

Keywords: Proximal femoral locking compression plate, Femoral Comminuted trochanteric and subtrochanteric

fracture, plate osteosynthesis

INTRODUCTION

Trochanteric and subtrochanteric femoral fractures

account for 10% to 34% of all hip fractures. They have a

bimodal age distribution and different mechanism of injury.

Older patients typically sustain low-velocity trauma, where

as in younger patients these fractures commonly result

from high-energy trauma and often are associated with

other fractures and injuries. (Lavelle, 2008).

Comminuted Trochanteric and subtrochanteric femoral

fractures are high-energy injuries in adults. In the proximal

part of the femur the medial cortex is subjected to

compressive loads and the lateral cortex to tensile forces

during weight bearing. Comminution of medial cortex may

lead difficulty in anatomic reconstruction of this area. The

blood supply of the comminuted fragments may be

compromised in subtrochanteric region with predominantly

cortical bone which has less healing capacity than

metaphyseal region. Therefore, one should consider the

biomechanics of mechanism of injury and preoperative

plan for stability based on those assumptions. (Kayali, et

al., 2008)


The management of these fractures is challenging for 2

reasons: (1) the inherent instability of the fracture pattern

and (2) the forces of the muscles acting on the proximal

and distal fragments. Fracture patterns at the

subtrochanteric level are typically transverse or run

obliquely in an inferolateral direction from the lesser

trochanter. Thus, the fracture line runs parallel to the

direction of movement of the lag screw in a sliding hip

screw (SHS) implant, rendering this implant ineffective.

Often, the medial calcar is comminuted, giving the fracture

a tendency to collapse into varus. Medial comminution

and the strong pull of the adductor musculature promote

medialization of the shaft. The powerful abductor and

iliopsoas muscles insert on the proximal fragment and force

it into abduction, flexion, and external rotation. This makes

closed reduction of this fracture difficult and pushes the

proximal fragment into a malreduced position. (Kuzyk, et

al., 2009)

Over the last few years, there has been a shift in the

principles of management of these fractures from rigid

anatomic reduction to relative biological fixation which

preserves the vascularity of bone fragments and enhances

their callus-forming abilities. Biological fixation, in

comparison to traditional open plating, has produced good

results for these fractures. (Saini, et al., 2013)

The proposed three requirements for an ideal internal

fixation for pertrochanteric fracture: (1) femoral neck screw

with at least three dimensional structures of the fixed

system; (2) minimal angle between the femoral neck screw

axis and the femoral shaft and thus maximum alignment

between the angle of normal hip joint weight-bearing line

and the femoral graft axis and (3) ability of the implant to

prevent the rotation of the femoral head. Unfortunately,

none of the currently used devices can fully meet these

three criteria. Future studies should be conducted to

determine the optimal implant for the internal fixation of

pertrochanteric fractures that can maximally meet the three

criteria described above. (Zha, et at., 2011).

METHOD:

This is a prospective interventional study (Quasi

experimental type) done From December 2013 to May 2014

at department of Orthopaedic Surgery, DMCH. All patients

with clinical and radiological evidence of comminuted

trochanteric and subtrochanteric fracture admitted in

Hospitals for operation within three weeks of incidence.

Active or latent infection, Pathological fracture other than

osteoporotic fracture, Open fracture, Non-united fracture

were excluded from the study.

Surgery was performed with the patient supine on a fracture

table. Length restoration and fracture reduction was done

either direct or indirect method. In highly comminuted and

unstable fractures that cannot be adequately reduced by

traction on a fracture table, we preferred free draping of

the lower extremity in the supine position on a radiolucent

operating table for open reduction. The operative area

was scrubbed first with hexiscrub and painted with

povidone iodine. Then draping was made. A lateral

approach typically is performed by a straight incision from

the greater trochanter, extending approximately 10 cm

distally. For more complex and comminuted fractures, the

plate can be used as a reduction tool. In this case, the

proximal fragment is first fixed to the plate, and the plate is

then reduced to the femoral shaft. After ensuring perfect

anatomic placement of the plate to the proximal fragment,

a 2.5-mm drill tip guide wire is inserted through a wire

sleeve that is threaded to the most proximal hole at a

predetermined 95° angle. A second guide wire is then

inserted through the drill sleeve of the second hole in a

120° angle. Finally, a third guide wire is inserted through

the sleeve on the third hole above the calcar in a 135°

angle. The plate was then distally fixed with at least 3

bicortical locking head screws. After proper haemostasis

a drain was placed at appropriate site and wound was

closed in layers with vicryl. The skin was closed with skin

stapler.

Fig. 1: The locking compression plate for the proximal

femur is a precontoured, angular stable, with large

fragment screw (7.3/5.0/4.5mm).

Evaluation of the Outcome of Proximal Femoral Locking Compression Plate for the Treatment 133

VOL. 29, NO. 2, JULY 2014

RESULTS

The patients started static quadriceps exercises after 24

hours. Drain tube was removed after 48 hours. Stitches

were removed on 14th postoperative day. Postoperatively

antibiotics were given routinely for 2 weeks. The Patients

was allow moving out of bed using crutch and without

bearing weight on operated limb as pain permits. Knee

bending was allowed as pain permits. The patients was

discharged with the advice to walk on crutch non - weight

bearing on affected side for 6 weeks and then to report to

the outpatient department. Partial weight bearing was

allowed as soon as the patient could tolerate it with

considering the fracture configuration, bone quality and

the stability of the fixation. Full weight bearing was started

when the fracture showed complete union clinically by

absence of limb pain when standing upon the fracture

limb alone and radiologically by the presence of the

abundant callus at least in two views.

Table- I

Distribution of patient according to bony union time .

Evidence of bony union shown on plain radiograph

Time (weeks) Number of Percentage Mean

patients (%) ±SD

12-18 16 80 17.79±2.89

19-24 02 10

25-30 02 10

Among 20 patients mean time to union was 17.79±2.89

weeks. Four cases were of delayed union.

Table-II

Postoperative complication

Postoperative complication No. of Percentage

patient (%)

Infection 1 5

Screw cutout 0 0

Implant failure 0 0

Limb shortening 1cm 2 10

Postoperative complications were minimum.

Table-III

Comparison of ROM and SNA

Outcome Injuried Hip Healthy Hip P-

(Mean±SD) (Mean±SD) value

Range of Motion 139.47±4.04 142.37±2.57 p>.05

Shaft Neck Angle 133.58±1.07 134.32±0.94 p>.05

Table- IV

Distribution of the results according to the final

outcomes (n=20).

Result Number of Percentage

patient

Satisfactory 18 90%

(Excellent & Good)

Unsatisfactory 02 10%

(Fair & Poor)

Total 20 100%

Confidence level of the final outcome:

Range of Motion and Shaft Neck Angle of the hip joint of

the injured and healthy side were measured at the last

follow-up. Paired t- test was done for calculation of test

statistic and there was no significant difference between

them (p>0.05).

Chart-1: Harris Hip Score

Mean Harris Hip Score was 92.05±7.85.

So, among the population we will find almost 70% to 100%

satisfactory result by this procedure. It is quite acceptable

outcome.

134 MM Hossain, QS Alam, MFH Qasem, MTI Noman, Md. Golam Sarwar, Md. Golam Mostofa


Case-1

Pre-operative x-ray on

25/03/2014

Post operative x-ray on

20/04/2014

Post operative x-ray on

20/04/2014

Case-2


12/10/2013Pre-operative x-ray on 12/10/2013 Follow up x-ray on

Case-3


20/05/2014

Follow up x-ray on 07/

06/2014

Follow up x-ray on

19/07/2014

Follow up x-ray on

19/10/2014

Evaluation of the Outcome of Proximal Femoral Locking Compression Plate for the Treatment 135

VOL. 29, NO. 2, JULY 2014

DISCUSSION

Comminuted Trochanteric and subtrochanteric femoral

fractures are considered as one of the most difficult fracture

to treat for the orthopaedic surgeons. It was found that

indirect reduction and biological fixation method with the

dynamic condylar screw and plate is considered as a

valuable cheap fixation method for the management of

comminuted subtrochanteric fractures of femur especially

in the young patient’s populations. (Elzohairy, 2012)

In our study we evaluated the result of proximal femoral

locking compression plate osteosynthesis for the treatment

of comminuted Trochanteric and subtrochanteric fracture

and we did a prospective study. Out of our 20 patients,

age range from 21-70 years with a mean age of 41.35 years.

Among them maximum were between 31-40 years (35%).

Like all trauma cases comminuted Trochanteric and

subtrochanteric fracture is more common in male due to

more activities and traveling. In our study, out of 20

patients, male patients were 17 (85%).

High velocity trauma due to road traffic accidents was the

main cause of these fractures seen in our study. The mean

duration of follow up was 39.70 weeks (24-58 weeks).

Average time to union was 17.35 weeks (14-28 weeks).

Partial weight bearing (15-20kg) was allowed as soon as

the patient could tolerate it and full weight bearing was

started when the fracture showed complete union clinically

by absence of limb pain when standing upon the fracture

limb alone and radiologically by the presence of the

abundant callus at least in two views. Sixteen patients had

union within 18 weeks, 4 patients had delayed union (28

weeks). One centimeter shortening was seen in two

patients. No patient had significant rotational malalignment

as determine by clinical examination. There were no cut-

outs, breakage or pull-out of screws.

Shaft-neck angle and range of motion of hip joint of the

injured and healthy sides were measured at the last follow

up, and there was no significant difference between them

(p>0.05). Harris Hip Score was used for clinical assessment,

as per Harris Hip Score 18 patients (90%) had good or

excellent outcome with two fair result (10%).

CONCLUSION

The present study conclude, with proper patient selection,

good instrumentation, image intensifier and surgical

technique, proximal femoral locking compression plate is

the implant of choice in the management of comminuted

Trochanteric and subtrochanteric fracture.

Large scale studies with longer follow up are essential

requirement for an optimum outcome measurement.

Though the study was small which may not represent the

whole scenario but the results of the study can be utilized

for future large study.

REFERENCES

1. Anglia Ruskin University Library, 2011. Guide to the

Harvard Style of Referencing, 3rd edition, [PDF] London.

Anglia Ruskin University. Available at: <http://

libweb.anglia.ac.uk/referencing/harvard.htm> [Accessed 29

March 2012]

2. Elzohairy, M.M., 2012. Management of Comminuted

Subtrochanteric Femur Fractures by Indirect Reduction

and Biological Fixation with Dynamic Condylar Screw. J

Trauma Treat, 1, pp.1-3

3. Kuzyk, P.R.T., Bhandari, M., McKee, M.D., Russell,

T.A., Schemitsch, E.H., 2009. Intramedullary Versus

Extramedullary Fixation for Subtrochanteric Femur

Fractures. J Orthop Trauma, 23, pp.465–70

4. Kyle, R.F., 1993, Fracture of the hip. In R.B. Gustilo,

R.F. Kyle and D. C. Templeman, eds. 1993. Fractures and

Dislocations, volume 2, St. Louis, Mosby, Ch.23, pp.

783-854.

5. Lavelle, D.G. 2008. Fracture and Dislocation of the Hip.

In: S.T. Canale and Beaty J. H. eds. 2008. Campbell’s

Operative Orthopaedics, Volume III: 11th Ed. Philadelphia,

PA: Mosby, Elsevier, Ch. 52. pp. 3237-309.

6. Saini, P., Kumar, R., Shekhawat, V., Joshi, N., Bansal,

M., Kumar, S., 2013. Biological fixation of comminuted

subtrochanteric fractures with proximal femur locking

compression plate. Injury International Journal of the Care

of the Injured, 44, pp.226–31

7. Zha G.C., Chen Z.L., Qi X.B., Sun J.Y., 2011. Treatment

of pertrochanteric fractures with a proximal femur locking

compression plate. Injury International Journal of the Care

of the Injured, 42, pp.1294 – 99.

136 MM Hossain, QS Alam, MFH Qasem, MTI Noman, Md. Golam Sarwar, Md. Golam Mostofa


Original Article

Result of Arthroscopic Anterior Cruciate

Ligament Reconstruction by

Semitendinosus & Gracillis Tendon

Graft

Md. Harun-Or-Rashid Khan1, Mohammad Serajus Saleheen2 ,M. Muniruzzaman3, Md.Aminul

Haque Pathan 4, Md. Abdus Sabur 5, Md. Iqbal Qavi6

ABSTRACT

This clinical study is the results of ACL injury reconstructed by quadruple semitendinosus & gracillis graft on 10

patients over a period of two years from January 2011 to December 2012 at National Institute of Traumatology and

Orthopaedic Rehabilitation (NITOR) Dhaka. The objective of this study was to evaluate the outcome of ACL

reconstruction. In this study purposive sampling method was followed irrespective of sex. ACL injury which had

persisted at least 3 months and was not improved by conservative treatment and patient with no history of

previous reconstructive surgery of ACL were included in this study. Data were collected by structured questionnaire

which includes all the variables of interest. The test statistics used to analyze the data were descriptive statistics

paired “t” test. Result shows all the patients were male with mean age 26.10 (±6.56 ) years. About half of the

subjects were student & service holder. Right knee was affected in 30% and left knee in 70% patients. Associated

meniscus injury was in 40% cases. Preoperative all patients had positive anterior drawer test. They had either

grade II or grade III positive Lachman test. Pivot shift test was positive in 60% cases. Preoperative Lysholm score

was 55.30 (±5.05). Mean hospital stay after operation was 4.90(±1 .66) days. Post operative subjective outcome

6 months after operation including influence of activity level, knee function, pain, recurrent swelling, and giving

way improved significantly. Post operative objective outcome including Lachman test, Anterior drawer test and

Pivot shift test were improved significantly. Preoperative versus post operative Lysholm score show a significant

improvement (p< 0.001). Final out come of this study shows 80% satisfactory and 20% unsatisfactory result.

1. Jr. Consultant of Orthopaedics (cc), NITOR.

2. Jr. Consultant of Orthopaedics (c.c), NITOR.

3. Jr. Consultant of Orthopaedics, Sadar Hospital, Jhalokathi.

4. Assistant Professor, NITOR, Dhaka

5. Assistant Professor, NITOR, Dhaka

6. Professor of Orthopaedic Surgery, NITOR.

Correspondence to: Dr. Md. Harun- Or- Rashid Khan, MBBS (DU), D ortho, MS (Ortho), Jr. Consultant of Orthopaedics(c.c)., NITOR,

Cell: 01711977642.

INTRODUCTION

The knee is the largest joint in the body. It is also the most

frequently injured joint due to its anatomy, exposure and

the demand placed upon it. Function and stability of the

knee depend upon a complex interrelationship of bony

and soft tissue anatomy 1.

The anterior cruciate ligament is on of the major stabilizing

ligament of the knee. It is a strong rope like structure

located in the centre of the knee running from the femur to

the tibia. It prevents the tibia moving abnormally on the

femur. When this abnormal movement occurs it is referred

to as instability and the patient is aware of this abnormal

movement2. The cruciate ligaments provide both

anteroposterior and rotatory stability; they also help to

resist excessive valgus varus angulations. Injuries of these

ligaments are on, particularly in sporting pursuits but also

in road accidents where they may be associated with

VOL. 29, NO. 2, JULY 2014 137

fractures or dislocations. They vary in severity from a

simple sprain to complete rupture3.

The importance of the anterior cruciate ligament (ACL) in

the maintenance of stability of the knee is well-known.

Active individuals who have a torn anterior cruciate

ligament are frequently troubled by chronic instability and

recurrent episodes of giving-way, which often are

associated with intra-articular injuries4.

The exact incidence of anterior cruciate ligament injuries

is unknown; however, it has been estimated that 100,000

are torn each year, and 50,000 anterior cruciate ligament

reconstructions are done each year in the United States.

The controversy for managing this injury now centers

more on the choice of graft selection for reconstruction

instead of whether surgery is necessary2.

Reconstructions of the anterior cruciate ligament (ACL)

are frequently performed procedures in knee surgery

nowadays. Looking at the history of ACL surgery since

its advent in antiquity, it is amazing to see how long it took

for some diagnostic and management techniques to

establish themselves. However since the early 20th

century, there has been increasing awareness of and

interest in the ligament and its lesions5. Numerous authors

have described successful reconstruction of the ACL with

use of a myriad of donor auto graft Patellar, hamstring or

quadriceps and allograft (Achilles, patellar, hamstring or

tibialis anterior) tendons. A statistical survey was carried

out at NITOR, Dhaka between January 2011 and December

2012 in the patients admitted with anterior cruciate ligament

insufficiency. Effort has been made in this work to extract

certain relevant facts in connection with ACL insufficiency

and the mode of their management and finally to evaluate

the outcome of reconstruction of ACL injury by quadruple

semitendinosus & gracillis tendon graft using arthroscopic

assisted ACL Reconstruction with the hope that it will

impart us a better understanding of further treatment of

this particular trauma in our country.

Reconstruction of ACL by BTB gained popularity but

donor site morbidity, anterior knee pain and stiffness are

major drawback. For this reason semitendinosus & gracillis

graft can be a good alternative for ACL reconstruction.

In this context we are doing ACL reconstruction by

semitendinosus & gracillis using quadruple graft at NITOR

for last few years. But we did not have any study regarding

this technique. So, the purpose of my study is to evaluate

the outcome after reconstruction of ACL injury by

quadruple semitendinosus & gracillis graft.

METHODOLOGY

The study was carried out at National Institute of

Traumatology and Orthopaedic Rehabilitation (NITOR),

Dhaka, Bangladesh from January 2011 to December

2012.The study populations were the patients attending

at the above place for the treatment of torn anterior cruciate

ligament.A total of 10 patients met the following selection

criteria were selected consecutively from the study

population.Inclusion criterias were:Patients with ages

ranging from 15 - 40 years,

ACL injury leading to instability of knee which had

persisted for at least 01 month and failed to respond to

adequate conservative treatment.In doubtful cases

diagnosis confirmed by MRI. Exclusion criterias

were:Patients with a history of previous reconstruction of

the anterior cruciate ligament (ACL),Patients who had a

reconstruction for posterior, posterolateral or lateral

instability of the knee,Osteoarthritis of knee.

OBSERVATIONS AND RESULTS

This prospective study was carried out from January 2011

to December 2012 at NITOR. A total of 10 cases were

selected for the study, all these patients were male and

followed up for 6 months to 12 months. In this present

series the following results were obtained.

Age frequency.

Fig-1: Age distribution of the patients (n-10)

Mean age = 26.10±6.56. Out of the ten patients with ACL

injury the age range was 15-40 years and mean age was

26.10± 6.56 years. Among them 20% were more than 31

years of age and 20% were less than 20 years.

This bar chart describes the distribution of the subjects

by occupation. About one third (30%) subjects were

student, 60% were player, service holder and businessman

(20% each). Only 10% were day labour.

138 Md. Harun-Or-Rashid Khan, Mohammad Serajus Saleheen, M. Muniruzzaman, Md.Aminul Haque Pathan et al


Right side involvement was 30% and left side involvement

was 70%.

Table-I

Associated injury of the subjects.

Associated injury No. of patients Percentage

Lateral collateral ligament 3 30

Medial collateral ligament 3 30

Medial meniscus injury 4 40

Total 10 100

This table describes associated injury along with ACL

injury. 30% were lateral collateral injury, 40% were medial

meniscus injury and another 30% were medial collateral

injury.

Table-II

Duration of suffering from injury to operation

(in months)

Duration of suffering Number of Percentage

thepatients

<5 3 30

5-10 3 30

11-15 2 20

21-25 1 10

25-30 1 10

Total 10 100

Mean-10.4 (±9.53) months.The outcome of ACL

reconstruction greatly depends upon time interval between

injury and operation. So duration of suffering was studied.

Data shows 30% patients have been suffering less than 5

months and 10% patients were suffering for 25-30 months.

Mean duration of suffering was 10.4 (±9.53) months.

Table-III

Hospital stay after operation (in days).

Hospital stay(days) Number of thepatients Percentage

<4 2 20

4-6 6 60

7-9 2 20

Total 10 100

Table shows 20% patient stayed in hospital after operation

less than 4 days. 60% patients stayed 4-6 days and only

20% patients stayed 7-9 days.

Table-IV

Complications of the patients.

Complication Number of thepatients Percentage

Infection 1 10

Endo button slippage 1 10

at femoral site.

Total 2 20

Early post operative period was uneventful in 80% cases.

One patient had infection at tibial screw site and the other

patient had endo button slippage at femoral site.

Tab1e-V

Functional score and result (n-10) Distribution of

patients according to Lysholm score

Case no. Result Functional score

1 Excellent 96

2 Poor 60

3 Good 85

4 Excellent 95

5 Good 85

6 Excellent 96

7 Good 85

8 Excellent 96

9 Fair 67

10 Excellent 97

In the present series excellent result were achieved in 5

patients, good results were achieved in 3 patients and fair

result was achieved in 01 patient, poor result were achieved

01 patient.

Bar Chart-1: Occupational distribution of patient (n-

10)

Result of Arthroscopic Anterior Cruciate Ligament Reconstruction by Semitendinosus & Gracillis Tendon Graft 139

VOL. 29, NO. 2, JULY 2014

Table-VI

Comparison of pre-operative and postoperative

Lysholm knee score.

Number of Mean ±SD p

the patients value

Pre-operative 10 55.30±5.05 0.001*

Postoperative 10 86.20 ±13.08

* Significant

Paired sample ‘t’ test.

Preoperative Lysholm knee score was 55.30 (SD±5.05) and

post operative score was 86.20 (SD± 13.08). Preoperative

versus postoperative Lysholm scores showed significant

improvement (p<0.001).

Outcome of the clinical evaluation after six months:

Preoperative clinical evaluation showed that all patients

had mild to moderate pain. Lachman test was positive in

all patients among them grade II was 70% and grade three

was 30%. All patients had anterior drawer test positive.

80% patient complained of giving way. Pivot shift test

was positive in 40% cases. Mc Murray test was positive

in 30% cases. 60% patients had less than 135° knee flexion

and 40% had 130° flexion preoperatively.

Postoperatively Lachman test improved significantly.

Grade I was in 80% cases and grade II was in 20% cases.

Anterior drawer was positive in 20% cases. Pivot shift

test was positive in only 10% cases. After operation 70%

had 135° knee flexion and 30% had 130° flexion.

Table-VII

Final outcome of the patients.

Final outcome Number of Percentage

thepatients

Satisfactory 8 80

Unsatisfactory 2 20

Total 10 100

This table demonstrates the final outcome of the patients.

Out of 10 patients, 8 (80%) were satisfactory, 2 were

unsatisfactory (20%) result.

DISCUSSION:

The importance of the ACL in the maintenance of the

stability of knee is well known. Active individual who have

a torn ACL are frequently troubled by chronic instability

and recurrent episode of giving way, which often are

associated with intra-articular injuries4.

In the present study, all the subjects were male with mean.

age 26.10 (± 6.56) years and the minimum and maximum

ages were 15 and 40 years respectively.

Eriksson et al6 made study over 164 patients. In his study

age ranges were between 15 and 45 years. (Mean 25.7±

6.9years) which is comparable with present study.

In the present study more two third (70%) of the patients

were Students, service holder and business men. 20%

were player in these group. Only 10% patients were day

labour.

The cause of injury was sporting activity in 70% cases

and 30% was due to accidental fall.

Out of 10 patients right knee involvement was 3 (30%) and

left knee involvement was 7 (70%). In the present study

30% had medial collateral ligament injury, 30% had lateral

collateral injury and 40% had medial meniscus injury. Those

patients who had meniscal injury and underwent partial

menisectomy shows poor results. In my study mean

duration of the suffering from the injury to operation were

10.4 (± 6.56) months ranging from 3 and 30 months.

In this study mean hospital stay after operation was 4.9 (±

1.66) days. Buss et al (1993) investigated 67 ACL

reconstructions and found mean hospital stay was 5 days

(range 3 to 8 days).

Preoperative versus post operative Lysholm knee score

in this series shows significant improvements (p<0.001).

Preoperative and postoperative Lysholm scores were 55.30

(±5.05) and 86.20 (±13.08) respectively.

Wagner et al.7 also showed significant improvement of

the Lysholm score in his study (P<0.001). According to

Williams et al.8 study mean Lysholm score improved from

55 points preoperative to 91 points after 2 year follow-up

over 120 patients. This is comparable with present study.

Regarding final outcome of the patients, present series

shows out of 10 patients 8 (80%) were satisfactory and 2

(20%) were unsatisfactory result. In the 90s, hamstring

reconstruction with double and quadrupled

semitendinosus and gracillis tendons gained popularity

as a result of decreased graft harvesting morbidity and

smaller incisions. It was also shown that biomechanically,

double and quadruple tendons have superior strength

and stiffness compared with bone patellar tendon-bone

grafts and the native ACL5.

140 Md. Harun-Or-Rashid Khan, Mohammad Serajus Saleheen, M. Muniruzzaman, Md.Aminul Haque Pathan et al


CONCLUSION

ACL injury frequently occurs in young adult population,

which reduces activity level and become economic burden.

So, early reconstruction of the ACL is necessary to make

them fit and return to their original activity level.

Graft choice is crucial in reconstruction of ACL injury.

Quadruple semitendinosus& gracillis tendon graft has an

ultimate tensile load to be as high as 4108N.

Quadruple semitendinosus & gracillis graft has got

advantages over other grafts in respect of strength,

stability, less donor site morbidity and anterior knee pain.

The procedure can be done by, where arthroscopic

facilities are available.

REFERENCES

1. Reckling FW, Munns SW 1990, ‘Knee’ in Reckling FW,

Reckling JB, Mohn MP (eds), Orthopaedic Anatomy

and ‘Surgical Approaches, Mosby Year Book, St. Louis,

U.S.A. pp. 357.

2. Miller III RH 2003, ‘Knee injuries’ in Canale ST, Daugherty

K, Jones L, Campbell’s Operative Orthopaedics, 10th ed.

Vol.3, Mosby Yearbook, Philadelphia, USA, pp.2278-80.

3. Solomon L 2001, ‘injuries of the knee and Leg, in Louis

Solomon, David J, Warwick, Selvenduria Nayagum, Apley’s

System of Orthopaedics and Fracture, 8th ed, Arnold,

London, pp. 705.

4. Buss DD, Warren RF, Wickiewicz TL, Galinat BJ,

Panariello R 1993, ‘Arthroscopically Assisted

Reconstruction of the Anterior Cruciate Ligament with

use of Autogenous Patellar-Ligament Graft’, The Journal

of Bone and Joint Surgery, Vol. 75-A, No. 9, pp. 1346.

5. Leong DKH, Lee WP, Low BY 2005, ‘A Historical Review

of ACL Surgery’, The Journal of the Asean Orthopaedic

Association, Vol. 17, No. 1, pp. 9-14.

6. Eriksson k, Anderberg P, Hamberg P, Bredenberg M,

Westman I, Wredmark T 2001, “A comparison of

quadruple semitendinosus and patellar tendon graft in

reconstruction of the Anterior cruciate ligament” , The

Journal of Bone and Joint Surgery, Vol.83B, pp.348-354.

7. Wagner M, Kaab MJ, Schallock J, Haas NP, Weiler A

2005, ‘Hamstring Tendon Versus Patellar Tendon ACL

Reconstruction Using Biodegradable Interference Fit

Fixation,, The American Journal of Sports Medicine, Vol.

33, No. 9, pp. 1327.

8. Williams III RJ, Hyman J, Petrigliano F, Rozental ‘I.

Wickiewicz TL 2004, ‘ACL Reconstruction with a Four-

Strand Hamstring Tendon Auto-graft’, The Journal of

Bone and Joint Surgery, Vol. 86-A, No. 2, pp 225.

Result of Arthroscopic Anterior Cruciate Ligament Reconstruction by Semitendinosus & Gracillis Tendon Graft 141

VOL. 29, NO. 2, JULY 2014

INTRODUCTION

In 1979, Schatzker et al. introduced a clsssification for

tibial plateau fractures that distinguished low –energy split

depression fractures from high energy bicondylar

(Schatzker type V and VI) fractures. Complex tibial plateau

fractures (Schatzker type V and VI) are one of the most

challenging problems in orthopaedic surgery. The Ilizarov

technique solves many of these problems encountered in

the management of such fractures and provides a method

for closed reduction and fixation that does not necessitate

excessive soft tissue stripping3,12.

These fractures involve both medial and lateral condyles

with various amount of articular surface comminution are

often associated with severe soft tissue injury that can

frequently result in compartment syndrome and are

frequently open fractures. Operative management of these

injuries is invariably complicated by the condition of the

soft tissue envelop of the proximal tibia.

Original Article

Management of Complex (Schatzker-

Type V And VI) Tibial Plateau Fractures

by Ilizarov Method

Mir Hamidur Rahman1, Gazi Md. Enamul Kabir2, Monaim Hossen3, Shaymol Deb Nath4, Md.

Mofakhkharul Bari5

ABSTRACT

We studied 46 tibial plateau fractures (Schatzker Type V and VI), managed by Ilizarov fixator in National Institute

of Traumatology & Orthopaedic Rehabilitation (NITOR), Pink unit-II (Ilizarov, Deformity Correction and Reconstruction

Unit), Dhaka, Bangladesh. All fractures were the result of high energy trauma. Duration of study was 6 and a half

years. Using The Knee Society Clinical Rating System, 32 knees were rated as excellent, 13 as good and 1 as fair.

Pin sites inflammation and pin loosening were the commonest complications in our study. This study emphasizes

the clinical success and low morbidity associated with the use of Ilizarov external fixatior.

Key ward: Tibial plateau fracture, Soft tissue injury, External fixator, Functional outcome.

The risk of wound complication following open reduction

and internal fixation is notably high owing to extensive

soft tissue dissection. Alternatively application of Ilizarov

technique minimizes soft tissue dissection and provides

adequate fracture stabilization to allow early movement of

joint and correction of any malalignment. With this

technique soft tissue complication particularly surgical

site infections are expected to be significantly reduced.

The purpose of this study is to evaluate the management

of these complex injuries with the Ilizarov technique,

functional outcome and complications associated with this

treatment method2,6.

The treatment goal for bicondylar tibial plateau fracture

with Ilizarov method is to obtain a stable, aligned, painless

and mobile knee and to minimize the risk of post-traumatic

osteoarthritis. Ring fixator like Ilizarov system, with

tensioned fine wires, utilizes beam loading to creat

uniformed support for the joint and stable fracture

immobilization to achieve fracture union.3,4,5

1. Asst. Professor, OSD, DGHS Attached Abdul Malek Ukil Medical College, Norshidi

2. Junior Consultant, 250 Beded General Hospital, Narayangonj

3. Assistant Professor, Department Orthopaedic Surgery, NITOR, Dhaka

4. Associate Professor, Department Orthopaedic Surgery, NITOR, Dhaka

5. Professor, Department Orthopaedic Surgery, NITOR, Dhaka

Correspondence: Dr. Mir Hamidur Rahman, Asst. Professor, OSD, DGHS Attached Abdul Malek Ukil Medical College, Norshidi


MATERIALS & METHODS

This retrospective study was conducted at Pink Unit –II

(Ilizarov, Deformity Correction & Reconstruction

Unit),NITOR, Dhaka, Bangladesh. Number of total patient

was 46. The duration of study was 6 and half years from

January, 2006 to, July, 2012. All fractures occurred after

high energy trauma including RTI and falls from height of

>2.5 meter. There were 44 male and 2 female with an average

age of 40 years (range 21 to 62 years). 34 were closed

fractures and 12 were open fractures. Soft tissue injury

for the closed fractures was classified according to

Tscherne and Gotzen, and open fracture was classified

according to Gustilo and Anderson. Inclusion criteria were

patients of skeletal maturity with complex tibial plateau

fractures that were treated with Ilizarov external fixator.

Patients were excluded if they had any of the following:

(1) a condition that would impede the rehabilitation process

of the patient – for example, acetabulum fracturs that

would require prolonged immbolization; (2) concomitant

injuries that could alter the functional outcome of the

patient- for example, ipsilateral femoral shaft fractures; (3)

previous major trauma, surgery or deformity of the affected

knee. The preoperative diagnostic approach was to

determine the severity and the extension of the osseous

damage. Plain radiograph were supplemented in all cases

by biplane tomograms. Computed tomography scan was

used in 30 fractures and magnetic resonance imaging was

used in 4 fractures.

Surgical Technique:

The objective was to accurately reduce the condyles in

relation to one another and to reduce and stabilize the

tibial shaft beneath the reduced condyles. Anatomical

reduction of the joint surface was a secondary goal

that was often accomplished percutaneously or

through limited approach. Condylar reduction was

assisted by longitudinal traction on the fracture table

with application of the varus or vulgus forces. Large

pointed reduction forceps applied percutaneously help

to obtain accurate condylar reduction and compression

(Ligamentotaxis).

After reduction of the condyles, counter-opposed olive

wires through the fragments were used to achieve

interfragmentary compression. Three to four wires at least

1.5 cm. from the joint line, with an overall divergence of an

angle at least 60 degree, were introduced for stabilization

of the condylar and metaphyseal fragments. Frequently

we used an olive wire through the fibular head obliquely

into the lateral tibial condyle, taking advantages of the

buttress effect that fibular head offers to the lateral column

of the tibia. A 5/8 ring was attached to allow greater knee

flexion and wire tensioning was performed under C-ARM

guide to directly view the adequacy of the reduction and

avoid over-compression.

Middle construct was made with a full ring two to three

cm. distal to diaphyseal fracture site and distal ring was

placed at a lower level and secured to a transfixation

reference wire positioned parallel to the ankle joint to

ensure mechanical axis of the tibia. Now second and third

ring were joined by four connecting rods, then metaphysio-

diaphyseal alignment was corrected under C-ARM

control. Finally 1st and 2nd ring were joined by four

connecting rods.

Post-Operative Care:

All patients were instructed on fixator care and taught to

do daily pin sites cleansing with rectified sprit and started

on passive range of motion exercise on the 2nd post-

operative day and active motion by 1 week. Ankle equinus

deformity was prevented by meticulous wire placement

technique, active joint mobilization post-operatively and

splinting of the foot in a neutral position. Early range of

movement exercise for the knee and mobilization with

crutches was encouraged in all cases. Partial to full weight-

bearing was increased as tolerated. Patients with marked

articular comminution were kept partial-weight bearing for

6 weeks.

OBSERVATION AND RESULTS

The mean patient’s age at the time of injury was 40 years

(range 22-62 years). Average duration of hospitalization

was 10 days (6 to 14 days).The average follow-up was 14

months (range- 12 to 18 months). All fractures united in

an average time of 14 weeks (ranges 10 to 20 weeks).

Fixators were removed after union of fractures. The

radiographic reduction of fractures was rated as excellent

in 38 and good in 8 according to Rasmussen’s criteria.

Using The Knee Society Clinical Rating system, 34 were

rated as excellent, 11 as good and 1 as fair. The average

total range of knee flexion was 120 degree (range 0 to 140

degree). 34 patients had a normal walking pattern and

were able to climb stairs normally. Five patients had

clinically demonstrable grade 2+ medial-lateral instability.

Only two were symptomatic but had no functional

handicap. 8 had mild or occasional pain. In 4 patients,

walking was limited, and needed walking aids. Pin-tract

infection was mild and common but controlled by

dressing and antibiotics

Management of Complex (Schatzker-Type V And VI) Tibial Plateau Fractures by Ilizarov Method 143

VOL. 29, NO. 2, JULY 2014

Fig.-1: Complex (Schatzker-Type VI) tibial plateau

fractures of a 24 years old boyFig: 2. 2 weeks after application of Ilizarov external

fixator.

Fig.-3: 16 weeks after application of Ilizarov external

fixator.

Fig.-4: After removal of Ilizarov external fixator (at 20

weeks)

144 Mir Hamidur Rahman, Gazi Md. Enamul Kabir, Monaim Hossen, Shaymol Deb Nath, Md. Mofakhkharul Bari


Follow-Up:

After discharge, patients attended the Ilizarov clinic in

NITOR held on every Sunday. During follow-up, the

patients were assessed in term of range of motion, fracture

union clinically and radiologically, any loss of reduction

radiologically, any hardware related complications like wire

breakage, surgical sites infection, complications related

to the surgery like nerve injury from inadvertent pin

placement. Serial standing radiograph of the knee and leg

in antero-posterior and lateral plane were performed at 6th

week, 12th week, 18th week, 24th week and 28th week post-

operatively. The Ilizarov fixator was removed once

radiographic evidence of union was established. Functional

outcome was determined using The Knee Society Clinical

Rating Score.

DISCUSSSION

The goals of operative treatment of these fractures include

anatomic reduction for restoration of articular congruity

and alignment, and stable fixation to allow early motion.

However the classic dual plate osteosynthesis has been

associated with potentially devastating complications such

as fixator failure, malunion, nonunion, joint stiffness,

secondary post-traumatic osteoarthritis, infection, and

most importantly severe soft tissue complications ranging

from 23 to 87.5%2,9,12.

The management of intraarticular fractures in the tibial

plateau is inherently complex. The restoration of articular

congruity is mandatory, and careful treatment of soft tissue

is as important as bone. Over the past few decades, a

number of evolving treatment modalities ranging from

traction to cast immobilization to open reduction and

internal fixation have been used with mixed results. No

treatment modality has been produced consistently good

results, nor has any allowed both stable fixation and

preservation of remaining soft tissues. In an attempt to

achieve both stable fixation and preserving the remaining

soft tissue many surgeons have chosen to use indirect

reduction and external fixation. Ilizarov external fixation

has been introduced and shown to be effective in the

treatment of these difficult fractures3,8,12.

The Ilizarov fixator offers several advantages that include

minimizing further injuries to soft tissue envelop, feasible

surgery even in the presence of badly injured soft tissue,

adequate stability to allow early post-operative

mobilization, and minimizing risk of joint stiffness. The

disadvantages include the need for constant pin site care,

pin sites infection and risk of septic arthritis from incidental

intracapsular pin placement and potential risk of common

peroneal nerve injury from poor pin placement3,9.

Using Rasmussen criteria for radiographic assessment,

excellent to good reduction was achieved in all our cases,

which is superior to all similar series. The mean range of

movement reported by Guadinez et al. was 85 degree and

by Morandi and Pearse was 113 degree (9).All patients

reported by Zecher et al. achieved at least 90 degree.The

average knee range of movement in our study was greater

than comparable studies, despite the presence of 2 cases

of knee stiffness. When applying The Knee Society Rating

System, the average knee score in our study was 80.2 and

average functional score was 83.8, and the average knee

rating was 82.5. Mikulak et al. reported a mean score of

78.5, a mean functional score of 81.9, and an average knee

rating of 80.2 in their 24 patients8. Kumar and Whittle

reported a mean score of 83 and a mean functional score

of 69 (79%) in 45 patients6.

Several published studies have shown decreased

complication with treating bicondylar tibial plateau

fractures with the fine-wire external fixator. Kataria et al.

reported on a series of 38 patients treated with small wire

external fixator and had no incidences of non-union or

septic arthritis. In series by Dendrinos 24 patients were

treated with Ilizarov circular external fixator, and there was

no incidence of non-union, osteomyelitis or septic arthritis.

Chin et al. reported similar results of 18 patients, none of

whom developed wound dehiscence, infection,

osteomyelitis or septic arthritis1. The current series is

comparable to these studies in that no cases of wound

dehiscence, infection, osteomyelitis or septic arthritis were

encountered.

Pin tract infection was the main drawback when using an

external fixator to treat fractures. In meta-analysis of 10

studies with a total of 381 patients, Hutson et al.

encountered 38 cases superficial pin tract infection (10%),

5 septic arthritis (1%), and 13 deep infection (4%).

Limitations of this study include the small number of cases

and the retrospective nature of the review. Also, the

exclusion of patients with certain concomitant injuries

could lead to a selection bias, possibly omiting patients

with more severe injuries.

CONCLUSION

Complex tibial plateau fractures fixation by Ilizarov

technique has become increasingly popular over the past

decade. The degree of soft tissue injury associated with

these fractures is an important determinant for both the

choice of treatment modality and prediction of treatment

outcome. Ilizarov method is a safe and effective option for

the treatment of difficult Schatzker type V & VI tibial

Management of Complex (Schatzker-Type V And VI) Tibial Plateau Fractures by Ilizarov Method 145

VOL. 29, NO. 2, JULY 2014

plateau fractures. This method minimizes soft tissue

complication and favours bony union with an acceptable

return of function. Complications are mainly related to pin

tract sepsis. We feel that the technique merits a place in

the armamentarium for managing.

REFERENCES

1. Chin TYP, Bardana D, Bailey M, Williamson OD, Miller

R, Edward ER, Esser MP. Functional outcome of tibial

plateau fractures treated with the fine-wire fixator. Injury

Int. J. Care Injured 2005;36:1467-75.

2. Dendrinos GK, Kontos S, Katsenis D ,Dalas A. Treatment

of High energy tibial plateau fractures by the Ilizarov

Circular fixator. J Bone Joint Surg 1996;78-B:710-17.

3. El Barbary H, Abdel Gani H, Misbah H, Salem K. Complex

tibial plateau fractures treated with Ilizarov external fixator

with or without minimal internal fixation. International

Orthopaedics (SICOT) 2005;29:182-185.

4. Ilizarov G.A. The treatment of fractures, theoretical

considerations, experimental studies and clinical

application of the apparatus. In: Ilizarov G. A., Green

SA, eds. Transosseous osteosynthesis: theoretical and

clinical aspects of the regeneration and growth of tissues.

Berlin: Springer-Verlog 1992:369-452.

5. Katsenis D, Dendrinos G, Kouris A, Savas N,

Schoinochoritis N, Pogiatzis K. Combination of fine wire

fixation and limited internal fixation for high energy tibial

plateau fractures: functional results at minimum 5-year

follow-up.J Orthop Trauma 2009; 23: 493-501.

6. Kumar A, Whittle AP. Treatment of complex (Schatzker

type-VI) fractures of tibial plateau with circular wire

external fixator: retrospective case review. J Orthop Trauma

2000;14(5):339-44.

7. Marsh JL, Smith ST, Do TT. External fixation and limited

internal fixation for complex fractures of the tibial plateau.

J Bone Joint Surg Am 1995;77:661-173.

8. Mikulak SA, Gold SM, Zinar DM. Small wire external

fixation with high-energy tibial plateau fractures. Clin

Orthop Relat Res 1998;365:230-238.

9. Morandi MM, Pearse MF. Management of complex tibial

plateau fractures with the Ilizarov external fixator. Thec

Orthop. 1996; 11:125-131.

10. Rasmussen PS.Tibial condylar fractures: Impairment of

knee joint stability as indication for surgical treatment. J

Bone Joint Surg. 1975;55(A):1331-1350.

11. Rationale of The Knee Society Clinical Rating System.

Clin Orthop. 1989;248:13-14.

12. Young MJ, Barrack RL. Complications of internal fixation

of tibial plateau fractures. Orthop Trauma 2005;19:

241-48.

146 Mir Hamidur Rahman, Gazi Md. Enamul Kabir, Monaim Hossen, Shaymol Deb Nath, Md. Mofakhkharul Bari


Original Article

A diabetic foot is a foot that exhibits any pathology

resulting directly from diabetes mellitus. Presence of

several characteristic diabetic foot pathologies is called

diabetic foot syndrome.

The most serious foot complications in diabetes are:

• Diabetic foot ulceration. It occurs in 15% of all patients

with diabetes and precedes 85% of all diabetes-related

lower leg amputations.

• Diabetic foot infections

• Neuropathic osteoarthropathy of the foot

Wound healing assessment of diabetic ulcers:

• Damage to blood vessels and impairment of the

immune system from diabetes makes it difficult to heal

diabetic ulcers. Bacterial infection of the skin,

connective tissues, muscles and bones then occur.

These infections can develop into gangrene.The only

treatment for this isamputation of the foot or leg. If

the infection spreads to the bloodstream, this process

can be life-threatening.

• People with diabetes must be fully aware ofhow to

prevent foot problems before they occur, to recognize

problems early, and to seek the right treatment when

problems do occur. Although treatment for diabetic

foot problems has improved, prevention - including

good control of blood sugar level - remains the best

way to prevent diabetic complications.

Causes of Diabetic Foot:Several risk factors causing

diabetic foot are -

• Footwear: Poorly fitting shoes are a common cause

of diabetic foot problems.

- If the patient hasred spots, blisters, corns,

calluses, or consistent pain associated with

wearing shoes, new properly fitting footwear

must be obtained as soon as possible.

Management of Diabetic Foot

Noor Mohammad1, Md. Golam Sarwar2, Anjon Lal Ghosh3, MA Sabur4, Shibasis Basak5, Mollah

Eshadul Haq6, Shahidul Haq7

1. Associate Professor, BIHS General Hospital, 125/A, Darus Salam Road, Mirpur-1,Dhaka-1216

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

3. Assistant Professor, Department of Orthopaedic Surgery, NITOR, Dhaka

4. Assistant Professor, Department of Orthopaedic Surgery, ZH Sikder Women’s Medical College Hospital

5. Registrar, DMCH, Dhaka

6. Assistant Professor, Department of Orthopaedic Surgery, SSMCH, Dhaka

7. Asst. Professor, Department of Surgery, Cox’s Bazar Medical College, Chittagong

Correspondence: Dr. Noor Mohammad, Associate Professor, BIHS General Hospital, 125/A, Darus Salam Road, Mirpur-1,Dhaka-1216,Mobile: +8801710562467, E-mail: [email protected]

- If the patient has common foot abnormalities such

as flat feet,bunions, or hammertoes etc. prescription

shoes or shoe inserts may be necessary.

• Nerve damage: People with long-standing or poorly

controlled diabetes are at risk for having damage to

the nerves in their feet (peripheral neuropathy).

• Because of the nerve damage, the patient is unable to

feel their feet normally. Also, they may be unable to

sense the position of their feet and toes while walking

and balancing.

• A person with diabetes may not properly sense minor

injuries (such ascuts, scrapes, blisters), signs of

abnormal wear and tear (that turn into calluses and

corns), and foot strain.

• Poor circulation: When poorly controlled, diabetes

can lead to atherosclerosis causing poor blood flow to

injured tissues.Thus healing does not occur properly.

• Trauma to the foot: Any trauma can increase the risk

for a more serious problem to develop.

• Infections Athlete’s foot, a fungal infection of the

skin or toenails, can lead to more serious bacterial

infections. Ingrown toenails should be treated by an

appropriate doctor.

• Smoking: Smoking causes damage to smallblood

vessels in the feet and legs. This damage can disrupt

the healing process and can be a major risk factor for

infections and amputations.

Symptoms of Diabetic Foot:

• Persistent pain is a symptom ofsprain, strain, bruise,

improperly fitting shoes, infection etc.

• Redness can be a sign of infection, especially when

surrounding a wound.

VOL. 29, NO. 2, JULY 2014 147

• Swelling of the feet or legs can be a sign of underlying

inflammation or infection or poor venous circulation.

Other signs of poor circulation include:

- Pain in legs or buttocks that increases with

walking but improves with rest (claudication).

- Hair no longer growing on the lower legs and feet

- Hard shiny skin on the legs

• Localized warmth can be a sign of infection or

inflammation.

• Any break in the skin canresult from abnormal wear

and tear, injury, or infection. Calluses,corns may be a

sign of chronic trauma.

• Drainage of pus from a wound is usually a sign of

infection.

• A limp can be sign of joint problems, serious infection,

or improperly fitting shoes.

• Fever or chills in association with an wound can be a

sign of a limb-threatening infection.

• Redness spreading out from a wound is a sign of a

progressively worsening infection.

• New or lasting numbness in the feet or legs can be a

sign of nerve damage from diabetes.

Exams and Tests:

Medical evaluation should include a thorough history and

physical examination and may also include laboratory tests,

x-ray studies of circulation in the legs, and consultation

with specialists.

• History and physical examination:Detailed personal

family and clinical history is very important for

diagnosis. The examination should include the

patient’s vital signs, examination of the sensation in

the feet and legs, an examination of the circulation in

the feet and legs.

• Laboratory tests include :

1. Complete blood cell count which will assist in

determining the presence and severity of infection. A

very high or very low white blood cell count suggests

serious infection.

2. Random blood sugar,FBS with 2 hrs. PP either by

fingerstick or by a laboratory test. Depending on the

severity of the problem, the doctor may also order.

3. Kidney function tests.

4. Blood chemistry studies (electrolytes)

5. Liver enzyme tests.

6. Heart enzyme tests to assess whether other body

systems are working properly in the face of serious

infection.

• X-rays of the leg and footto assess the condition of

bones andjoints, damage from infection, foreign

bodies in the soft tissues. Gas in the soft tissues

indicates gangrene - a very serious, potentially life-

threatening or limb-threatening infection.

• Ultrasound: Doppler ultrasound to see the blood flow

through the arteries and veins.

• Consultation:The vascular surgeon and/or an

orthopedic surgeon may be asked for consultation.

• Angiogram: If the vascular surgeon determines that

the patient has poor circulation in the lower

extremities, an angiogram may be performed in

preparation for surgery to improve circulation.

DIABETIC FOOT CARE AND TREATMENT:

Self-Care at Home:

A person with diabetes should do the following:

• Foot examination:The patient should examine his foot

daily after any trauma, no matter how minor the trauma

is. A water-based moisturizer should be used every

day to prevent dry skin and cracking. He should wear

cotton or wool socks and avoid elastic socks,

• Eliminate obstacles: Remove any objects he islikely

to trip over or bump his feet on. Keep the sharp objects

on the floor picked up. Light the pathways used at

night - indoors and outdoors.

• Toenail trimming should be done with a safety

clipper leaving plenty of room out from the nail

bed.Help from a family member can be sought.

• Footwear: Wear sturdy, comfortable shoes whenever

feasible to protect your feet. If you have flat feet,

bunions, or hammertoes, you may need prescription

shoes or shoe inserts.

• Exercise: Regular exercise will improve bone and joint

health in your feet and legs, improve circulation to

your legs, and will also help to stabilize your blood

sugar levels.

• Smoking: Smoking accelerates damage to blood

vessels, especially small blood vessels leading to poor

circulation, which is a major risk factor for foot

infections and ultimately amputations.

• Diabetes control: Following a reasonable diet, taking

medications, checking blood sugar regularly and

maintaining good communication with your physician

are essential in keeping your diabetes under control.

Consistent long-term blood sugar control to near

normal levels can greatly lower the risk of damage to

your nerves, kidneys, eyes, and blood vessels.

MEDICAL TREATMENT:

• Antibiotics: If the doctor determines that a wound or

ulcer on the patient’s feet or legs is infected, antibiotics

will be prescribed to treat the infection or the potential

infection. It is very important that the patient take the

148 Noor Mohammad, Md. Golam Sarwar, Anjon Lal Ghosh, MA Sabur, Shibasis Basak, Mollah Eshadul Haq, Shahidul Haq


entire course of antibiotics as prescribed. For limb-

threatening or life-threatening infections, the patient

will be admitted to the hospital and given IV

antibiotics. Less serious infections may be treated

with pills as an outpatient. The doctor may give a

single dose of antibiotics as a shot or IV dose prior to

starting pills in the clinic or emergency department.

• Referral to wound care center: Many of the larger

community hospitals now have wound care centers

specializing in the treatment of diabetic lower extremity

wounds and ulcers. In these multidi ciplinary centers,

professionals of many specialties work as members

of a team in developing a treatment plan for the wound.

Treatment plans may include surgical debridement of

the wound, improvement of circulation through

surgery or therapy, special dressings, and antibiotics.

The plan may include a combination of treatments.

Referral to podiatrist or orthopedic surgeon: If the patient

has bone-related problems, toenail problems, corns and

calluses, hammertoes, bunions, flat feet, heel spurs,

arthritis, or have difficulty with finding shoes that fit, a

physician may refer you to one of these specialties.

Care of the Diabetic Foot:

Diabetic foot problems are a major health concern and are

a common cause of hospitalization.Most foot problems

that people with diabetes face arise from two serious

complications of the disease: nerve damage and poor

circulation. The lack of feeling and poor blood flow can

allow a small blister to progress to a serious infection in a

matter of days. Chronic nerve damage (neuropathy) can

cause dry and cracked skin, which provides an opportunity

for bacteria to enter and cause infection. The

consequences can range from hospitalization for

antibiotics to amputation of a toe or foot. For people with

diabetes, careful daily inspection of the feet is essential to

prevent damaging foot problems.

General Care of the Diabetic Foot:

• Never walk barefoot. Thus decrease the chances of

injuries leading to infection.

• Wash your feet every day with mild soap and warm

water. Test the water temperature with your hand first.

Dry the feet & toes with a clean towel.

• Use lotion to keep the skin soft and moist. This

prevents cracks & decreases the risk of infection.

• Trim toe nails carefully & avoid cutting corners. If

you find an ingrown toenail, seek advice.

• Do not use antiseptic solutions orheating pads.

• Do not put your feet on radiators or in front of the

fireplace.

• Keep your feet warm. Do not wet your feet in snow or

rain. Wear socks & shoes in winter.

• Do not smoke. Smoking damages blood vessels and

decreases theavailability of oxygen to the feet. In

combination with diabetes, it significantly increases

the risk of amputation.

Inspection:

• Inspect your feet every day.

• Look for puncture wounds, bruises, pressure areas,

redness, warmth, blisters, ulcers, scratches, cuts, and

nail problems.

• Get someone to help you or use a mirror. You may not

feel that damage has occurred to the skin.

• Look at and feel each foot for swelling. Swelling in

one of the feet and not the other is an early sign that

you may be experiencing early stages of Charcot foot.

This can occur in people with nerve damage. It can

destroy the bones and joints.

• Examine the bottoms of your feet and toes.

A few typical diabetic lesions in feet:

Management of Diabetic Foot 149

VOL. 29, NO. 2, JULY 2014

150 Noor Mohammad, Md. Golam Sarwar, Anjon Lal Ghosh, MA Sabur, Shibasis Basak, Mollah Eshadul Haq, Shahidul Haq


Shoe wear: Choose & wear the proper shoes. Poor fitting

shoes cause ulcers leadingto infection.

• Buy new shoes late in the day when your feet are

larger. Buy shoes that are comfortable without a

“breaking in” period.

• Check how your shoe fits in width, length, back,

bottom of heel, and sole. Have your feet measured

every time you buy new shoes. Your foot will change

shape over the years and you may not be the same

shoe size you were 5 years ago.

• Avoid pointed-toe styles and high heels. Try to get

shoes made with leather upper materias.l

• Wear new shoes for only 2 hours or less at a time. Do

not wear the same pair every day.

• Inspect the inside of each shoe before putting it on.

Do not lace your shoes too tightly or loosely.

• Avoid long walks without taking a break, removing

your shoes and socks and checking for signs of

pressure (redness) or ulcers.

ORTHOTICS

An accommodative orthotic made from a soft material called

plastizote is commonly prescribed. The orthotics should

not be hard, as this will increase the risk of a pressure

ulcer. The orthotic can be transferred from shoe to shoe

and should be used at all times when standing or walking.

REFERENCES:

1. Reiber, G.E., Boyko, E.J., and Smith, D.G. 1995. Lower

extremity foot ulcers and amputations in diabetes.In

Diabetes in America.M.I. Harris and M.P. Stern, editors.

U.S. Government Printing Office. Bethesda, Maryland,

USA. 409–428.

2. Falanga V. Wound healing and its impairment in the diabetic

foot. Lancet.2005;366:1736–1743.

3. Boulton A.J., Vileikyte L., Ragnarson-Tennvall G.,

Apelqvist J. The global burden of diabetic foot

disease.Lancet.2005;366:1719–1724.

4. Ramsey SD, Newton K, Blough D, et al. Incidence,

outcomes, and cost of foot ulcers in patients with diabetes.

Diabetes Care 1999;22:382–387.

5. Bartus CL, Margolis DJ. Reducing the incidence of foot

ulceration and amputation in diabetes.CurrDiab Rep

2004;4:413–418.

6. Apelqvist J, Bakker K, van Houtum WH, Nabuurs-

Franssen MH, Schaper NC, International Working Group

on the Diabetic Foot International consensus and practical

guidelines on the management and the prevention of the

diabetic foot. Diabetes Metab Res Rev 2000;16(Suppl.

1):S84–S92.

7. Singh N, Armstrong DG, Lipsky BA. Preventing foot

ulcers in patients with diabetes.JAMA 2005;293:217–

228.

INTRODUCTION

The management of chronic osteomyelitis continues to

pose a major challenge for orthopaedic surgeons. Chronic

Osteomyelitis of child is most commonly of

haematogenous origin but in adult it is commonly occur

after trauma in relation with either open # or to internal

fixation.

Because of the avascular nature of sequestrum,

osteomyelitis is difficult to treat and can be associated

with high morbidity and possible mortality for the patient.

Treatment is aimed at resolution of infection and

maximization of patient function.

The treatment of chronic osteomyelitis significantly

advanced with the use of muscle flaps and vascularized

bone transfer to manage large open defect after

debridement.

Further advancement have included –

1. Antibiotic beads to manage dead space in staged

reconstruction.

2. The use of ext. fixator in the illizarov technique of SK

reconstruction.

Original Article

We studied prospectively a consecutive series of 16 patients with chronic osteomyelitis. All patients had a

surgical intervention before coming to the hospital. All patients had open wound. After doing culture & sensitivity

and antibiotics accordingly patient didnot improved satisfactorily but after removal of dead and infected bone

patient improved dramatically and only one patient developed recurrence. There is always controversy about the

removal of sequestrum. We preferred to remove the dead and infected bone when there is line of demarcation

between living and dead bone.

Removal of Dead and Infected Bone in

Chronic Osteomyelitis is the Prime

factor to Control Infection – Early

Removal Decreases Morbidity

AHM Rezaul Haque,1 Debashis Biswas2, Shakeel Akter3, Takbirul Islam4, Debashis Ghosh5

Abstract

1. Assistant Professor, Dept. of Orthopaedics, Uttara Adhunik Medical College, Uttara, Dhaka.

2. Associate Professor, Dept. of Orthopaedics, Uttara Adhunik Medical College, Uttara, Dhaka.

3. Associate Professor, Dept. of Orthopaedics, Uttara Adhunik Medical College, Uttara, Dhaka.

4. Assistant Registrar, Dept. of Orthopaedics, Uttara Adhunik Medical College, Uttara, Dhaka.

5. Assistant Registrar, Dept. of Orthopaedics, Uttara Adhunik Medical College, Uttara, Dhaka.

Correspondence: Dr. A.H.M Rezaul Haque, Assistant Professor, Department of Orthopaedics, Uttara Adhunik Medical College,

Uttara, Dhaka.

3. There advancement has led to increased success in

the management of Chronic Osteomyelitis with success

rates > 90% in the literature2.

Principle of treatment is eradication of infection by

thorough debridement and appropriate antibioticcoverage.The main part of debridement is sequestrectomy.There is debate about the timing of sequestrectomy.Herewe have removed the sequestrum when there is line ofdemarcation between living and dead bone. The extent ofbone removal was decided during operation. We followpaprika technique. Early sequestrectomy causesimprovement of local wound, control of infection andgeneral condition of patient.

Patient & Method:

There were 10 men and 6 women with a mean age at

presentation of 20 (2- 52) years. The diagnosis of chronic

osteomyelitis was made on the basis of clinical presentation

and imaging. The aetiology of chronic osteomyelitis was

post traumatic in 6 patients, post traumatic post-operative

in 1 patient and haematogenous in 4 patients.

Depending on the anatomical location of disease the extent

of osteomyelitis, the patients’ age and comorbidity and

their preference of treatment option a decision was made

about surgical intervention.

VOL. 29, NO. 2, JULY 2014 151

Radiographs were done before operation for determining

the line of demarcation. The actual extent of bone resection

was determined at the time of surgery.

Debridement is aimed at removing all infected or necrotic

bone and soft tissues. All sinus tracts, scar tissues and

wound edges were excised and the adjacent soft tissues

were resected back to the tissue the bleed briskly. In

general, scalpel was used.

Bone was exposed to in extra periosteal. Periosteal

stripping avoided. Involucrum was kept in situ. Precise

bone debridement was performed until the paprika sign.

For endosteal infection debrided with curate and reamer.

In some situations, debridement of intramedullary canal

done by means of a trough in the bone.

In patient with extensive or circumferential involvement

of cortical bone, extensive resection of the involved area

was done. Infected perioseum was removed. In these

situations, stabilization done.

Tissue obtained at the time of debridement was sent for

culture and pathology. In some cases serial debridement

is done. After closing the wound, closed irrigation and

suction system, temporary antibiotic laden polymethyl

methacrylate beads, given in some cases. Bony defect

can be corrected by fibula graft and illizarov external

fixator.

After surgery, broad spectrum antibiotics were

administered I/V to all patients, this was modified after the

result C/S.

All patients were followed up regularly, with a mean length

of follow up of 20 months. Recurrence of infection was

diagnosed by local signs and symptom of infection, sinus

formation or drainage, a raised level of C reactive protein

or E S R or of systemic symptom such as fever for which

no other cause could be found.

RESULTS:

The clinical details and the outcome of treatment for all

patients are given in table. Despite accurate

microbiological diagnosis from intralesional biopsy and

of antibiotic therapy all patients had a recurrence of

infection.There were only one case of recurrence in

patients after removal of infected bone after one year.

In some patients, 2/3 times operations had to be

performed.

Mean age at first surgical intervention was 20 yrs (2 – 52),

75% (12) of the patients with chronic osteomyelitis came

from the rural community while 25% (4) came from urban

or common. Other bones involved are humerous and ulna.

The duration of osteomyelitis was determined as the time

from the first onset of symptom to the time of surgical

intervention.

Other determinant factor which might affect the likelihood

of recurrence of infection are aetiology, site of infection,

host comorbidity, duration of infection and causative

organism.

It is showing that most of the chronic osteomyelitis of

femur is of post traumatic. After accident, proper

surgical toileting is not done in remote area. First

surgical toileting and wound care is the most important

factor to prevent development of chronic osteomyelitis

after open fracture.

Fig.-1: Preoperative x-ray Fig.-2: Post operative x-ray Fig.-3: Bones to be removed during operation

152 AHM Rezaul Haque, Debashis Biswas, Shakeel Akter, Takbirul Islam, Debashis Ghosh


Table 1

Pt/ Sl Age Aetiology Site Duration Stabilisation Follow up Recurrence Complication

1 20 PT & PO femur 6months Nail, Ext. fixator, illizarov* 4years No Knee stiffness

2 2 H tibia 3months LLBS 1year No Fibula Migration

3 24 PT femur 1year Illizarov 1year No Limb Shortening

4 12 H tibia 6months LLBS 1year No Nil

5 40 PT & PO tibia 8months Illizarov* 1year No Skin

6 10 PT & PO femur 3years Nail 1year No Ugly scar

7 12 PT Ulna 4years Graft and nail 6months No Nil

8 40 PT Humerous 1year Ext. Fixator 1year No Nil

9 3 H Tibia 6months LLBS 1year No Fibula migration

10 18 PT & PO Femur 10months Ext. Fixator 2years Once Nil

11 25 PT Tibia 1year Illizarov 3years No Nil

12 9 H Humerous 6months LABS 2years No Nil

13 19 PT Tibia 1year ORIF* 2year No Nil

14 52 PT Femur 2year ORIF* 1year No Nil

15 24 PT & PO R&U 6months Nail/Ext. 1year No Nil

16 16 PO Femur 2year IM Nail* 1year No Nil

PT- Post traumatic; PO- Post Operative; H- Haematogenous

*Final Fixation

Fig.-4: Segmental Bones remove Fig.-5: X Ray film before removal

DISCUSSION

It is essential to remove all necrotic and infected bone

when treating osteomyelitis. Many techniques have been

used to determine whether bone is alive or dead. The

technique most commonly used is the presence of bone

at the time of surgery and the presence of punctuate

bleeding. We used this technique to assess whether or

not the bone was viable.

In post -traumatic osteomyelitis where repeated surgical

clearance done chance of involucrum formation is

negligible. Repeated surgical clearance causes increased

local tissue scarring, decreased local vascularity, decreases

chance of neovascularisation so there by healing and union.

Waiting for separation of sequestrum makes the surgery

late.

Prolonged use of antibiotic causes antibiotic causes

antibiotic resistance, renal impairment, increases morbidity

and increased financial loss.

The duration of the infective process also adversely

affected the prognosis. It has been suggested that

Removal of Dead and Infected Bone in Chronic Osteomyelitis is the Prime factor to Control Infection 153

VOL. 29, NO. 2, JULY 2014

prolonged infection causes increased sclerosis and

scarring of the soft tissue envelope, making the infection

more resistant to treatment6.

The local or systemic immune response of some patient

may be suboptimal which may lead to higher recurrence

ratio7. It is very difficult to remove all dead and necrotic

material in a single sitting. After removing the main bulk of

infective foci body’s immune system can remove small

infective foci. This was seen in haematogenous

osteomyelitis.

It is showing that most of the chronic osteomyelitis of

femur is of post traumatic. After accident, proper surgical

toileting is not done in remote area. First surgical toileting

and wound care is the most important factor to prevent

development of chronic osteomyelitis.

CONCLUSION

Chronic osteomyelitis is a condition associated with

potentially high morbidity and has historically been very

difficult to cure. Treatment is geared toward resolution of

infection, while maintaining optimal function of the

patients’ extremity.

Although a variety of treatment options are available, no

set guideline or algorithm is available for treating patients

with chronic osteomyelitis. The main factor to control of

infection is removal of dead infected bone. As early as the

dead and infected bone can be removed as early as

infection can be controlled, so the morbidity decreases

and gives near normal function of extremity.

Ciernyand others stress that treatment should be

individualized to the patient. Management should take

into account the anatomic aspects of the patients’

infection, morbid medical condition and patients perception

of the expected outcome. This will allow the optimum

outcome in the management of these patients.

REFERENCES

1. Mathes SJ, Alpert BS, Chang N. Use of muscle flap in

chronic osteomyelitis: experimental and clinical correlation.

Plast Reconstr. Surg. 1982;69: 815-829.

2. Patazakis MJ, Mazur K, Wilkins J, Sherman R, Holtom

P. Septopal beads and autogenous bone grafting for bone

defects in patients with chronic osteomyelitis. Clin

Orthop 1993; 295: 112-118.

3. Cierny G, Mader JT, Penninck JJ. A clinical staging system

for adult osteomyelitis. Contemp Orthop 1985; 10:

17-37.

4. Mader JT, Cripps MW, Calhoun JH. Adult post-traumatic

osteomyelitis of the tibia. Clin Orthop 1999; 360: 14-21.

5. Daoud A, Saighi- Bouaouina A. treatment of sequestra,

pseudarthroses, and defects in the long bones of children

who have chronic hematogenous osteomyelitis. J Bone

Joint Surg. [AM] 1989; 71: 1448-1468.

6. West WF, Kelly PJ, Martin WJ. Chronic osteomyelitis:

factors affecting the results of treatment in 186 patients.

JAMA 1970; 213: 1837-42.

7. Kelly PJ. Infected non-union of the femur and tibia. Clin

Orthop North Am 1985; 15:1481-90.

154 AHM Rezaul Haque, Debashis Biswas, Shakeel Akter, Takbirul Islam, Debashis Ghosh


Original Article

INTRODUCTION

Achilles tendon (AT) injuries may occur due to sports

injuries and about 10% to 25% of the complete AT ruptures

are not diagnosed1; accidental cuts by sharp household

tools, penetrating injuries, road traffic accidents, slipping

of the foot in toilet pans and spontaneous rupture; local

corticosteroid injection causes rupture after minimal

trauma2,3. Acute AT injury may be managed either

operatively or non-operatively. However, generally 6 weeks

following an injury of AT (old/neglected) a direct repair

opposing the tendon ends becomes increasingly difficult.

Through this time scar tissue forms, disuse leg muscles

atrophy and the tendon ends weaken4. The old AT injury is

debilitating; their optimal management is surgical3,4,5. The

purpose of this series was to evaluate clinical result of old AT

injury reconstruction by FHL tendon.

MATERIAL AND METHODS

This prospective study was conducted in the department

of orthopaedic surgery in Sylhet MAG Osmani Medical

College, Sylhet Women’s Medical College Hospital and

other private hospital in Sylhet, science January 2007 to

June 2014. Each patient had an old AT injury, whereby all

Achilles tendons tear were presented and/or treated more

than 6 weeks after the index lesion (Fig-1). We have

performed 10 cases of old AT injury. All age and sex, patient

Old Achilles Tendon Injury

Reconstruction with Flexor Hallucis

Longus Tendon-a Prospective Study

Md. Abdul Gani Ahsan1, Kazi Md Salim2, Ishtiaque-Ul-Fattah3, AKM Zahir Uddin4

Abstract

The optimal management of old Achilles tendon (AT) injury is surgical reconstruction. In case of wide gap between

tendon’s ends of old AT injury, need long tendon for reconstruction. Flexor hallucis longus (FHL) tendon can serve

this type of reconstruction. We describe 10 cases of Achilles tendon reconstruction by FHL tendon with satisfactory

outcome. This technique allows reconstruction of the old AT injury with any length of gap using FHL.

Key wards: Achilles tendon, flexor hallucis longus, reconstruction.

1. Associate Professor, Department of Orthopaedics, Sylhet Women’s Medical College, Sylhet.

2. Professor and Head, Department of Orthopaedics, Sylhet Women’s Medical College, Sylhet.

3. Associate Professor, Department of Orthopaedics, Sylhet MAG Osmani Medical College, Sylhet.

4. Associate Professor, Department of Orthopaedics, NITOR, Dhaka

Correspondence: Dr. Md Abdul Gani Ahsan, Associate Professor, Department of Orthopaedics, Sylhet Women’s Medical College, Sylhet.

with old (neglected) AT injury, re-rupture after primary

repair of AT injury were included in this study. Fallow-up

time was 6 to 12 months.

Surgical procedure: Surgery was performed under spinal

anaesthesia, in prone lateral position. A tourniquet was

applied to the thigh. After usual antiseptic preparation,

the limb was draped in a sterile field. A longitudinal skin

incision was given in between Achilles tendon (AT) and

posterior border of medial malleolus and tibia (Fig-2).The

paratenon was incised, tenolysis performed and the AT

was inspected. Debridement of tendon fibrosis was

performed with conservation of a distal and a proximal

tendon stump. The average AT defect after fibrosis

debridement was 6.2 cm (range, 4–10). After incision of

the deep fascia of the leg and having located and retracted

the posterior tibial bundle, the FHL muscle belly and

tendon were identified and isolated. To harvest the distal

portion of the FHL, a second short medial arch incision

was performed (Fig.-2,3). The flexor digitorum longus

(FDL) tendons were identified and connections between

FHL and FDL were freed. FHL tendon was divided distally

and pulled out through the proximal approach (Fig-3).

Reconstruction techniques include passing the tendon

(FHL) through tenotomy in the distal and the proximal

tendon stumps 3, 6 or through a tunnel drilled through the

posterior calcaneal cortex and a tenotomy in the proximal

VOL. 29, NO. 2, JULY 2014 155

Achilles tendon stump7 (Fig- 4). Next the FHL tendon was

tenodesed to itself with a tension fixed at 40° of plantar

flexion (Fig- 4). Wound closure was performed carefully

to avoid subsequent skin necrosis. A well padded cotton

bandage with a short anterior plaster slab was applied

with the ankle in maximum plantar flexion for 6 weeks. Post

operatively, patients are allowed to toe touch walking with

the help of elbow crutches. After 6 weeks, the plaster slab

is removed and physiotherapy is commenced focusing on

proprioception, plantar and dorsi flexion of the ankle,

inversion and eversion for reduce further muscle atrophy.

During this period of rehabilitation the patient is permitted

to weight bear as comfort allows. Athletic activities were

restricted for six months after surgery (Fig-5).

RESULTS

A series of 10 patients (eight men, two women) with age

distribution was 32.3 years (18 to 52) in our study. All 10

patients presented with a limp, inability to run and AT

gap, among them 6 had a scar overlying skin. Causes of

AT injury were Indian type broken toilet pan 3 (30%),

spontaneous rupture 2(20%), local corticosteroid injection

2(20%), motor vehicle accident 2 (20%) and 1(10%) with

an Achilles tendon (AT) re-rupture. The AT defect after

fibrosis debridement averaged 5.4 cm (range, 3.5–8).

All patients were inadequately treated previously and

lastly present minimum after 6 weeks for reconstructive

surgery. Left sided AT injury is predominant (70%) in our

study. The mean follow-up was minimum 6 months (range,

6–18). All the patients were evaluated according to Nada

criteria 8. Functional outcome was satisfactory (excellent

and good). Average delay of work and sports recovery

was 6 months (range, 5–8). All patients returned to a sports

activity within minor limitations. No re-rupture has been

described. No major complication was observed

particularly on wound healing. Two patients developed a

small skin necrosis and a mild discharging sinus. Both

were healed spontaneous after 2-3 weeks. All patients

presented with a loss of active flexion of great toe without

subsequent hyperextension. However, no patient

presented with functional weakness of the great toe during

athletic or daily life activities.

Fig- 1 Old AT injury (left); before operation Fig-2 Incision site Fig- 3 Delivery of FHL (left)

Fig-4 Complete TA reconstruction Fig- 5 Eight months later of AT reconstruction

156 Md. Abdul Gani Ahsan, Kazi Md Salim, Ishtiaque-Ul-Fattah, AKM Zahir Ueddin


DISCUSSION

In 1993 Wapner et al. 9 first described the use of FHL as a

graft for reconstruction of AT. Many procedures have

been described in the literature for old AT injury

reconstruction with different local autologous material

such as the gastrocnemius soleus complex with V-Y

myotendinous advancement 10 or a “turn-down” of

proximal AT tissue11. Other surgical techniques used

tendon transfer of peroneus brevis (PB) 3, 6, 7, flexor

digitorum longus (FDL) 12 or flexor hallucis longus (FHL)9, 13 tendons.

Compared to PB or FDL, the FHL is a stronger plantar

flexor, its axis of contractile force more closely reproduces

that of the AT, it fires in phase with the gastrocnemius-

soleus complex and its anatomical proximity avoids the

neurovascular bundle. Another benefit of FHL transfer is

the plantar flexion strength reinforcement which is almost

always compromised with fascial advancement alone 15.

With regards to vascularisation of AT, the FHL muscle

belly extends distally into the avascular zone of AT and

allows recruitment of an increased blood supply to the

repaired AT. Furthermore, FHL transfer maintains the

normal muscle balance of the ankle by transferring a muscle

with the same function. In a recent study using MRI

evaluation, Hahn et al. showed a complete integration of

the FHL tendon in 60% of the patients 16. The FHL was

free of degeneration in all patients and more than 15%

hypertrophy of the FHL was observed in 80% of the

patients which suggests functional incorporation into

plantar flexion after the transfer of FHL16.

Excision of degenerative part of the AT due to chronic

rupture was complete to improve pain relief 9. Some

authors proposed preservation of fibrous scar tissue at

the stumps of the ruptured AT to keep its original length,

make length adjustment easier and to use it as a scaffold

for the FHL transfer 15, 16, 18. In our series, fibrous scar

tissue of AT stumps was not preserved. Another authors

describe FHL transfer alone was insufficient for

reconstruction of defects greater than 5 cm; a V-Y

myotendinous advancement or a fascial turn-down flap

was required 14,15,17. The main morbidity of FHL harvesting

is the loss of active interphalangeal plantar flexion strength

of great toe. According to our results and those of other

studies, FHL transfer morbidity is clinically insignificant,

even for good push-off or balance in running sports 9, 14,

19. Therefore, alternatives to FHL such as FDL or PB appear

less advantageous in these respects. In our study and

other previous series, when using FHL tendon transfer

for AT rupture reconstruction, no case of re-rupture has

been reported at latest follow-up 9, 14. However, account

all other surgical procedures, the incidence of AT re-rupture

following acute or chronic rupture reconstruction has been

reported to be 1.4–3.7% 20. In our study no re-rupture of

Achilles tendon after reconstruction. The main limitation

of our series is the small number of patient’s included.

CONCLUSION

For old Achilles tendon injury with a wide gap, surgical

reconstruction by FHL tendon transfer achieved excellent

outcome with a neglected drawback.

Table-I

Clinical characteristics of the patients

Patient no. Age/Sex/Side Cause of AT Injury to operation AT defect after Complication Outcome

involved injury AT duration fibrosis

(Weeks) debridement(cm)

1 25/M/L TP 12 4 None Excellent

2 18/F/L TP 10 3.5 None Excellent

3 20/M/R MVA 16 6 None Excellent

4 52/M/L SR 24 7.5 None Excellent

5 24/M/L RR 13 4.5 None Excellent

6 35/M/L TP 14 5 Skin necrosis Good

7 45/F/R LSI 18 6.5 None Excellent

8 25/M/R MVA 15 5 None Excellent

9 32/M/L LSI 12 4 None Excellent

10 47/M/L SR 20 8 Discharging sinus Good

Abbreviations: M-Male; L- Left; R-Right; TP-Toilet pan; MVA- Motor vehicle accident; LSI- Local steroid injection;

SR- Spontaneous rupture; RR-Re rupture.

Old Achilles Tendon Injury Reconstruction with Flexor Hallucis Longus Tendon-a Prospective Study 157

VOL. 29, NO. 2, JULY 2014

REFERENCES

1. Thermann H, Hufner T, Tscherne H. Achilles tendon

rupture. Orthopade. 2000; 29: 235-50.

2. Chatterjee SS, Sarkar A, Misra A. Management of acute

open tendo-Achilles injuries in Indian lavatory pans. Indian

J Plast Surg 2006; 39(1):29-33.

3. Ahsan MAG, Fattah IU, Hasan SM, Salim KM. Evaluation

of result of peroneus brevis tendon transfer in the

management of neglected tendo Achilles Injury. Osmani

Medical Teachers Association Journal 2011; 10(2):98-101.

4. Carmont M, Maffulli N: Less invasive Achilles tendon

reconstruction. BMC Musculoskelet Disord. 2007, 8: 100.

5. Leslie HD, Edwards WH: Neglected ruptures of the Achilles

tendon. Foot Ankle Clin 2005, 10(2):357-70.

6. Turco VJ, Spinella AJ: Achilles tendon ruptures-peroneus

brevis transfer. Foot Ankle 1987, 7(4):253-59.

7. Pérez Teuffer A: Traumatic rupture of the Achilles Tendon.

Reconstruction by transplant and graft using the lateral

peroneus brevis. Orthop Clin North Am 1974, 5(1):89-

93.

8. Nada A. Rupture of calcaneus tendon treatment by external

fixator. J Bone Joint Surg (Br) 1985; 67(3):449-53.

9. Wapner KL, Pavlock GS, Hecht PJ, Naselli F, Walther R:

Repair of chronic Achilles tendon rupture with flexor

hallucis longus. Foot Ankle 1993, 14(8):443-49.

10. Abraham E, Pankovich AM . Neglected rupture of the

Achilles tendon by V-Y tendinous flap. J Bone Joint Surg

(Am) 1975; 57: 253–56.

11. Bosworth DM. Repair of defects in the Tendo Achilles. J

Bone Joint Surg (Am) 1956; 38:111–14.

12. FDL Mann RA, Holmes GB, Seale KS, Collins DM.

Chronic rupture of the Achilles tendon: a new technique

of repair. J Bone Joint Surg (Am)1991; 73-A:214–19.

13. Wilcox DK, Bohay DR, Anderson JG: Treatment of

chronic Achilles tendon disorders with flexor hallucis

longus tendon transfer/augmentation. Foot Ankle Int 2000,

21(12):1004-10.

14. Kann JN, Myerson MS. Surgical management of chronic

ruptures of the Achilles tendon. Foot Ankle Clin

.1997;2:535-45.

15. Hartog BD. Surgical strategies: delayed diagnosis or

neglected Achilles tendon ruptures. Foot Ankle Int. 2008;

29: 456-63.

16. Meyer P, Maiwald C, Zannetti M, Vienne P. Treatment

of chronic Achilles tendinopathy and ruptures with flexor

hallucis longus tendon transfer: Clinical outcome and MRI

findings. Foot Ankle.2008; 794-802.

17. Kissel CG, Blacklidge DK,Crowley DL. Repair of

neglected Achilles tendon rupture: procedure and functional

results. J Foot Ankle Surg. 1994; 33:46-52.

18. Park YH, Yoon TR, Chung JY. Reconstruction of neglected

Achilles tendon rupture using the flexor hallucis longus

tendon.Knee Surg Traumatol Arthrosc. 2008; 17:316-20.

19. Coull R, Flavin R, Stephens MM. Flexor hallucis longus

tendon transfer: evaluating of postoperative morbidity;

24: 931-34.

20. Linden-vander Zwang HMJ, Nelissen RGHH, Sintenie

JB. Results of surgical versus non-surgical treatment of

Achilles tendon rupture. Int Orthop.2004; 28:370-73.

158 Md. Abdul Gani Ahsan, Kazi Md Salim, Ishtiaque-Ul-Fattah, AKM Zahir Ueddin


Original Article

Anterolateral Chest Wall Flap as a

salvage for composite wound coverage

of the elbow, forearm and hand

A.B.M. Golam Faruque1, A.H.M. Tanvir Hasan Siddiquee2, Uttam Kumar Saha3, A K M Zohiruddain4,

Md. Mohabbatullah5, Md Zahid Ahmed6

ABSTRACT

Anterolateral chest wall flap has a significant effect on the patient’s aesthetic and functional outcome, especially

in the cases of the soft tissue defects in the elbow, forearm and hand. The surgical procedure must be tailored to

the needs of the wound and the patient.

This prospective study was carried out on 10 patients with post traumatic soft tissue defects over the elbow,

forearm and hand. The duration of this study was 2 years. Average age of the patients was 28.5 years, ranging

from 6 to 60 years. 6 were males and 4 were females, with a male female ratio of 3:2. 6 patients had soft tissue

loss over forearm with exposed bone; 3 had exposed bones and tendons at the elbow and 1 had lost skin and soft

tissue over the dorsum of the hand with exposed, infected 2nd & 3rd metacarpals. All patients were treated with

inferiorly based anterolateral chest wall flap. 1 case developed marginal necrosis, which was overcome by

debridement and dressings. A follow up ranging from 2 to 24 months (mean 12 months) showed that patients

achieved a good aesthetic and functional outcome.

Key words : Anterolateral chest wall flap, reconstruction, soft tissue defect.

1. Associate Professor, Orthopaedic Surgery, National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR), Dhaka

2. Junior Consultant, Orthopaedic Surgery, Govt. Emplyees Hospital, Dhaka.

3. Junior consultant, Orthopaedic Surgery ,Louhajonj UHC, Munsighonj

4. Associate Professor, Orthopaedic Surgery, National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR), Dhaka

5. Assistant Professor, Orthopaedic Surgery, National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR), Dhaka.

6. Junior Consultant, Orthopaedic Surgery, National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR), Dhaka

Correspondence: Dr. A.B.M. Golam Faruque, Associate Professor, Orthopaedic Surgery, National Institute of Traumatology &

Orthopaedic Rehabilitation (NITOR), Dhaka

INTRODUCTION

Flap surgery is a technique in plastic and reconstructive

surgery where any type of tissue is lifted from a donor site

and moved to a recipient site with an intact blood supply.

Soft tissue reconstruction in the upper limb is a common

challenge following trauma, burns, tumour resection and

infection. The quality of the reconstruction has a significant

effect on the patient’s aesthetic and functional outcome.

The options for soft tissue reconstruction in the upper

extremity include skin grafting, local flaps, regional flaps

and free flaps. The preferred approach is the simplest

method which can provide the most stable coverage. The

mechanism, time, location and extent of soft tissue injury,

severity of contamination, nature of the structure exposed

and expected outcomes of spontaneous healing of the

defect will dictate the soft tissue reconstruction options

used in the upper limb.1 Successful soft tissue coverage

requires removal of all necrotic tissue, control of

contamination and confirmation of a good blood supply.2,3

Soft tissue restoration will take place as early as possible

to prevent wound infection and allow earlier patient

recovery and rehabilitation.4,5,6

Several factors, including the patient’s age, sex,

occupation, and general health status before injury or an

operation, should be considered before choosing the

method of wound closure. The surgical procedure must

be tailored to the needs of the wound and the patient.7

Anterolateral chest wall flap gets blood supply from the

intercostals and the thoraco-epigastric vessels. The skin

in this area has great mobility. This skin is more pliable,

sub cutaneous tissue is thinner and the surrounding skin

VOL. 29, NO. 2, JULY 2014 159

is more elastic, thinner tissue provides accurate fitting of

the flap, minimizing the need for secondary defatting,

scanty hair on the skin is an additional benefit. The donor

site usually is bounded superiorly by the nipple line,

inferiorly the umbilicus and laterally by the mid-axillary

line. The inferiorly based flap is the preferred orientation,

because it minimizes venous congestion and edema

formation in the flap by permiting dependent drainage.

This transversely oriented flap should not extend across

the ventral midline, since the collateral blood supply of

the skin across the midline is poor. The approximate length

to width ratio should be 1.5:1, not exceeding 7-8 cm in

width and 10-12 cm in length.8

Anterolateral chest wall flaps may be contralateral or

ipsilateral. Contralaterl anterolateral chest wall flaps are

ideal source for application to the digits, palm, dorsum of

the hands and occasionally to the wrist. Ipsilateral

anterolateral chest wall flaps are best suited for coverage

about the elbow, forearm and proximal wrist.8

MATERIALS AND METHODS

This prospective study was carried out at NITOR and

some other private hospitals from May 2013 to May 2015.

10 patients with post traumatic soft tissue injury of the

elbow, forearm and hand were included in this study. 6

patients had soft tissue loss over forearm with exposed

bone; Among them, 2 were with degloving injury of forearm

with open fracture of radius & ulna, 2 with fractured radius;

1 open & 1 closed, with compartment syndrome, being

treated initially by a traditional bone setter; 1 with fractured

ulna with dislocated elbow and 1 without fracture. 3 patients

were with exposed elbow and 1 patient with wound at the

dorsum of the hand, with lost skin, muscle & tendon over

infected 2nd & 3rd metacarpals. Fractured bones were were

internally fixed by Rush nail and K wire, although 1 was

treated initially by external fixator, which was later fixed by

rush nail. All patients were treated with inferiorly based

anterolateral chest wall flap for wound coverage.

OPERATIVE TECHNIQUE

Under general anesthesia, the patient was placed supine.

After sterile drapping, a marking line was drawn on the

upper border of the flap on the donor site, above the

umbillicus. A fasciocutaneous flap of appropriate size was

then elevated. Meticulous hemostasis was ensured.

Wound gap on the donor site was minimized by skin

mobilization and direct closure. Then the recipient site

was prepared and wound coverage was done without

undue tension over the flap. The vascularity of the flap

was checked. After application of sterile dressing, The

arm was held flush with the trunk.

Early in the postoprative period, the operated extremity was

immobilized by dressing and elastic bandages. A light plaster

covering was added over the bandages in 4 cases, especially

in the children, to ensure more secure mobilization.

In all cases, the flaps were divided 3 weeks after application.

The donor site was then covered by direct closure of the

pedicle, or by split thickness skin grafting.

Thereafter dynamic splintage and physiotherapy was

instituted.

The patients were followed up regularly at every month

for the first 3 months, then at every 3 months at the

outpatient department.

RESULTS

The duration of this study was 2 years; from May 2013 to

2015. Total 10 cases of soft tissue injury over the elbow,

forearm and the hand were included. Average age of the

patients was 28.5 years, ranging from 6 to 60 years. Among

the 10 cases, 6 were males and the rest 4 were females,

with a male female ratio of 3:2. All patients were treated

with inferiorly based anterolateral chest flap.

Adequate functional restoration was achieved in all 10

cases. A follow up ranging from 2 to 24 months (mean 12

months) showed that patients achieved a good aesthetic

outcome, satisfactory elbow and wrist movement,along

with good thumb-index pinch, chuck pinch, hook and

grasp. The donor area is concealed and there has been no

hypertrophic scarring or spreading of the scar.

Regarding complication, 1 case with open fracture radius

& ulna, developed marginal necrosis, which was overcome

by debridement and dressings.

Fig 1 : Dosum of the hand defect with exposed 2nd and 3rd metacarpals; before & after surgery

160 Anterolateral Chest Wall Flap as a salvage for composite wound coverage of the elbow, forearm and hand


DISCUSSION

Trauma to extremities often results in complex bony and

soft tissue injuries, that require free flap reconstruction.9,10,11,12 But, free flaps are prone to vascular thrombosis

at the recipient area in cases of traumatic injury.13 In

cases of trauma, the status of recipient vessels is directly

related to the magnitude of the injury. 14 Although

microsurgical techniques are well developed and can be

used in one stage operations to provide good contour,

the distant pedicle flap is still the method of choice for

reconstruction of upper extremity defects. Pedicled flaps

are good to cover the forearm and elbow defects, as free

flaps may fail due to trauma induced thrombosis.15

The advantages of this flap are :

- The blood supply is reliable and the elevation of the

flap is easy and quick.

- Major arteries are not sacrificed.

- Easy identification of the perforator vessel using

Dopplar ultrasound.

- The perforator vessel need not to be exposed.

- Adequate vascular network for covering large soft

tissue defects.

- Can cover forearm and elbow defects without

tension.

The disadvantages are :

- Inevitable ugly scar,

- Bulkiness of flap in overweight patients,

- Needs a second procedure for pedicle separatiion.16

A study on 8 patients of post burn contracture affecting

dorsum of the hand, treated by contralateral anterolateral

chest wall flap showed satisfactory outcome in all 8

patients, and all the patients could return to their previous

vocation within a follow up period of 5 to 12 months.17

Similarly, in this study on 10 patients with post traumatic

elbow, forearm and hand defects, which were treated by

inferiorly based anterolateral chest wall flaps, adequate

functional restoration was achieved in all 10 cases within

a follow up period of 2 to 24 months.

CONCLUSION

Anterolateral chest wall flap is useful for covering severe

crush injury defects of the forearm, elbow and even hands

that have a high risk of free flap necrosis because of

inadequate recipient vessels. The flap procedure is easily

performed and the site of the flap can be raised safely .

The chest flap can be used as salvage flap to cover the

forearm and elbow defects, where free flap surgery is not

possible because of a poor armamentarium.

REFERENCES

1. Levin LS, Erdmann DE. Primary and secondary

microvascular reconstruction of the upper extremity. Hand

Clinics. 2001;17: 447–55.

2. Lister G, Scheker L. Emergency free flaps to the upper

extremity. J Hand Surg Am. 1988; 13: 22–8.

3. Godina M. Early microsurgical reconstruction of complex

trauma of the extremities. Plast Reconstr Surg. 1986; 78:

285–92.

4. Chen S, Tsai YC, Wei FC , et al. Emergency free flaps to

the type IIIC tibial fracture. Ann Plast Surg. 1990; 25:

223–9.

5. Chen SHT, Wei FC, Chen HC , et al. Emergency free flap

transfer for reconstruction of acute complex extremity

wounds. Plast Reconstr Surg. 1992; 89: 882–8.

6. Chen ZW, Yan W. The study and clinical application of

the osteocutaneous flap of the fibula. Microsurgery. 1983;

4: 11–6.

7. Russell RC, Zamboni WA. Soft tissue reconstruction.

Coverage of the elbow and forearm. Orthop Clin North

Am. 1993 Jul; 24(3): 425-34.

8. Griffin M, Hindocha S, Malahias M, Saleh M, Juma A.

Flap Decisions and Options in Soft Tissue Coverage of

the Upper Limb. Open Orthop J. 2014; 8: 409–14.

(A)

Fig.-2 : Degloving injury with fractured radius and ulna with dislocated right elbow; A. Initial appearance, B. After

debridement, C. After wound coverage, D. Final appearance

(B) (C) (D)

A.B.M. Golam Faruque, A.H.M. Tanvir Hasan Siddiquee, Uttam Kumar Saha, A K M Zohiruddain, Md. Mohabbatullah et al 161

VOL. 29, NO. 2, JULY 2014

9. Howard TW, James WF, Detlev E, Scott L. Use of the

anterolateral thigh free flap for upper extremity

reconstruction. J Hand Surg . 2005; 30: 859-64.

10. Chen SL, Chen TM, Wang HJ. Free thoracodorsal artery

perforator flap in extremity reconstruction: 12 cases. Br J

Plast Surg. 2004; 57: 525-30.

11. Schenck RR. Rectus femoris muscle and composite skin

transplantation by microneurovascular anastomosis for

avulsion of forearm muscles: a case report. J Hand Surg .

1973; 3: 60-9.

12. Wei CY, Chuang DC, Chen HC, Lin CH, Wong SS, Wei

FC. The versatility of free rectus femoris muscle flap: an

alternative flap. Microsurgery . 1995; 16: 698-703.

13. Yunchuan P, Jiaqin X, Sihuan C, Zunhong L . Use of the

lateral intercostal perforator-based pedicled abdominal flap

for upper limb wounds from severe electrical injury. Ann

Plast Surg. 2006; 56: 116-21.

14. Khouri RK, Shaw WW. Reconstructionof the lower

extremity with microvascular free flap : a 10- year

experience with 304 consecutive patients. J Traum. 1989;

29: 1086-94

15. Acland RD. Refinement in lower extremity free flap. Clin

Plast Surg. 1990; 17: 733-44

16. Tzeng Y, Yu C, Dai N, Chen T, Chen S. The Abdomino-

hypogastric flap as a salvage flap for composite wound

coverage of the forearm and elbow. J Med Sci. 2007; 27(4):

185-8

17. Bhattacharya S, Pandey SD, Chandra R, Bhatnagar SK.

Lateral chest wall fasciocutaneous flaps in the management

of burn contractures on the dorsum of the hand. Eur J

Plast Surg . 1988; 11: 8-11.

162 Anterolateral Chest Wall Flap as a salvage for composite wound coverage of the elbow, forearm and hand


Original Article

Minimally invasive plate osteosynthesis

(MIPO) for fracture of distal tibia in 18

patients at BIRDEM Hospital

Anwar Ahmed1, Ahmed Suparno Bahar Moni2, MKI Quayyum Choudhury3, M Golam Sarwar4,

Anjan Lal Ghosh5

ABSTRACT

The treatment of distal tibia fracture by minimally invasive locking plate osteosynthesis (MIPO) was a prospective

study carriedout at BIRDEM Hospital in Dhaka, Bangladesh, between August 2008 to July 2014.Total 18 patient

were included in the study. Among them 14 cases were male, four were female. The age range of patients was 18

to 75 year. Mean age is 28.5 years. Majority of the patient was in the age group of 30 -55 years (50%). 14 patient

were injured from road traffic accident, four cases due to fall. The mean time of union was 18 weeks. Very few

complications were observed, among which ankle stiffness was common. Satisfactory results (Excellent and

good) were in 83.33% cases and unsatisfactory results in 16.67%.

1. Associate Professor of Orthopaedics, BIRDEM General Hospital and Ibrahim Medical College.

2. Assistant Professor (Orthopaedics), BIRDEM General Hospital and Ibrahim Medical College.

3. Professor of Orthopaedics, BIRDEM General Hospital and Ibrahim Medical College.

4. Associate Professor of Orthopaedic Surgery, DMCH, Dhaka

5. Assistant Professor of Orthopaedic Surgery, ZH Sikder Medical College

Correspondence: Dr. Anwar Ahmed, D.Ortho, MS (Ortho), MchOrth, Associate Professor of Orthopaedics, BIRDEM Hospital and

Ibrahim Medical College, E-mail: [email protected]

INTRODUCTION

Distal tibial fractures show some characteristics as:

hardship regarding reduction and stabilization, an

increased local complication rate following classic

osteosynthesis by metallic plates (nonunions, infections,

tegumentary necrosis) and also consecutively to

intramedullary osteosynthesis (malalignment) or to external

fixation (healing delay).

Poor soft tissue coverage and blood supply act as a

deterrent to quick healing of fracture. Alternative for

management of distal third tibial fracture are diverse and

modalities of treatment is influenced by its integrity of the

soft tissue, open fracture, presence or absence of infection.

Conservative treatment of these fracture often results in a

number of complications including malunion, non-union

and ankle stiffness1,2. Intramedullary nailing is not suitable

for all distal tibial fracture3,4. External fixation can be used

as either a temporary or definitive method of

treatment.Open plating of the medial aspect of the distal

tibia causes greater disruption of the extraosseous blood

supply leading to higher incidence of non-union, infection,

skin necrosis and implant failure

On one side, MIPO shows the advantage of periosteal

circulation preservation with positive effect on bone

healing5,6, and on the other side, it provides a good

stability for the fracture site.

It is with these background, treatment of distal tibial

fracture by minimally invasive locking plate osteosynthesis

has been evaluated in this study from August 2008 to

July2014.

MATERIALS AND METHOD

This was a prospective study carried out at BIRDEM

hospital in Dhaka, Bangladesh.during the period from

August 2008 to July 2014. A total number of 18 patient

were selected.

This study comprising 18 cases for follow-up for a period

of 6 to 24 months. Patient with open fracture were excluded

from study. Among these 18 cases, 14 cases were male, 4

cases were female. 14 patientwere injured after road traffic

accident and 4 patient had a fall. The average age of the

patient was 38 years (range 18 to 75 years). The fracture

were classified according to the Muller’s AO classification

system. There were type A (5 in A1,6inA2,4 inA3)

VOL. 29, NO. 2, JULY 2014 163

andtypeB(2in B1,linB2). Surgery was performed as soon

as the swelling subsided. When indicated, the fibula was

fixed initially by using standard AO technique. Through a

small curve incision behind the medial malleolus an

extraperiosteal or subcutaneous tunnel was created along

the medial aspect of tibia by blunt dissection, using

periosteal elevator. The distal tibial medial

anatomicallocking plate was then inserted extraperiosteally.

Initially fixation was carried out with a distal screw under

the guidance of image intensifier. And the fracture was

indirectly reduced on to the plate. Axial traction on the

foot or application of the reduction forceps was used to

obtain acceptable reduction. Once the sagital, coronal and

rotational alignment appeared to be satisfactory, the

proximal screws were passed percutaneously under image

intensifier.

RESULT

All the 18patients were reviewed clinically and

radiologicaly at regular interval: 6 week interval for 6 month,

12 week interval onward. Follow up period was between 6-

24 month (average 14.6 month). Evaluation of results of the

study was done on the basis of criteria followed by Tucker

et.al (1992) (7) Patient were graded into excellent, good, fair

and poor depending onunion, pain, shortening, angulation,

range of ankle and knee movement. Any angulation of more

than 5 degrre of varus valgus and 10 degree of anterior-

posterior angulation and over 1cm. of shortening were

considered to be radiologically fair to poor result. Mean

time of union was 18 weeks.

Table-I

Post operative complications

Case Ankle Knee Flexion Deficit varus valgus Antro- Rotation Shortening

no pain on pain deficit knee Ankale posterior In degre

weight ROM Angulation

1. + - - - - - - - -

2. - - - l0® - - - 5® -

3. - - - 8® - - 8® 5® -

4. - - - 5® - - - - -

5. - - - - - - - - -

6. - - - 5® - - - - -

7. - - — 4® - — 8® — —

8. + - - 5® - - - - -

9. + - - - - - - - -

10. + - - S® - - - - -

11. + - - 8® - - - - -

12. - - - 5® - - - - 1.5 cm

13. - - - 5® - - - - -

14. - - - - - - - - -

15. - - - l0® - - - - -

16. - - - 5® - - - - -

17. + - - 10® - - 4® - -

18. - - - - - - - - -

Table-II

Results according to tucker criteria

Grading Number of Percentage

Patient

Satisfactory Excellent 7 38.89

Good 8 44.44

Unsatisfactory Fair 2 11.11

Poor 1 5.56 Fig.-1: Insertion of LCP

164 Anwar Ahmed, Ahmed Suparno Bahar Moni, MKI Quayyum Choudhury, M Golam Sarwar, Anjan Lal Ghosh


DISCUSSION

MIPO shows the advantage of periosteal circulation

preservation with positive effect on bone healing5,6, and

on the other side, it provides a good stability for the fracture

site.

According to Helfet8, the standard protocol that precedes

MIPO procedure includes: a. tibial fracture alignment with

external triangular temporary fixation, extended from

heelbone to tibia; b. reduction of the fibular fracture and

plate fixation by a precontoured one third tubular plate or

by a small DCP. MIPO by medial approach is recommended

at 5-7 days from accident.It is more advantageous over

IM nailing or by open reduction and internal fixation using

plates in respect of non-union, skin problems, local septic

complications and stiffness of adjacent joints9,4.

In our study 18 patients were treated by this method.All

fractures healed, within a mean time of 18 weeks. No bone

grafting is required. No incidence of nonunion but 2 cases

of delayed union was observed.There wereno infections.

In several series of minimally invassive plate

osteosynthesisno infection was reported 10,4. Jensen

et.al.11 reported 9% superficial infection treated by open

method.

In our study, there were wound necrosis in 2 cases. But it

is common in medial plating by open method (12.5%)

because open plating of the medial aspect of distal tibia

caused massive disruption of the extraosseous blood

supply of the metaphysical region.12

All patients had a satisfactory knee and ankle range of

motion.There were no implant failures

CONCLUSION

MIPO is a safe and effective procedure to preserve bone

biology and minimise surgical soft tissue trauma.It is a

demanding technique in cases of lower tibia fracture,

which requirescautious intraoperative clinical and

fluoroscopic control in order to reestablish limb axis,

rotation and length.

REFERENCES

1. Digby JM, Holloway GM, Webb JK. A study offunction

after tibia! cast bracing. Injury.1983;14(5):432439. doi:

10.1016/0020-1383(83)90094-3. [RefMed] [Cross Ref]

2. Oh OW, Kyung HS, Park lH, Kim PT, lhn JC. Distal

tibialmetaphyseal fractures treated by percutaneous plate

osteosynthesis. C/in Orthop Re/at Res. 2003;408:286291.

Doi: 10.1097/00003086-200303000-00038. [RefMed]

[Cross Ref]

Fig.-2: Insertion of distal and proximal screws

Fig.-3: Preoperative x - ray

Fig.-4: Post operative x - ray (after 4 months)

Minimally invasive plate osteosynthesis (MIPO) for fracture of distal tibia in 18 patients at BIRDEM Hospital 165

VOL. 29, NO. 2, JULY 2014

3. Dickson KF, Montgomery S, Field J. High energyplafond

fractures treated by a spanning external fixator initially

and followed by a second stage open reduction internal

fixation of the articularsurface preliminary report. Injury.

2001 ;32(Suppl4):5D925D98. [PubMed]

4. Krackhardt T, Dilger J, Flesch I, Höntzsch D, Eingartner

C, Weise K. Fractures of the distal tibia treated with closed

reduction and minimally invasive plating. Arch Orthop

Trauma Surg. 2005; 1 25(2):8794. doi: 10.1 007/s00402-

004- O778-y[RefMed] [Cross Ref].

5. Baumgartel, F.; Buhl, M. &Rahn, B.A. (1998). Fracture

healing in biological plate osteosynthesis. Injury, Vol.29,

Suppl.3, pp. C3-6, ISSN 0020-1383

6. Farouk, O.; Krettek, C.; Miclau, T.; Schandelmaier, P.;

Guy, P. &Tscherne, H. (1997). Minimally invasive plate

osteosynthesis and vascularity: preliminary results of a

cadaver infection study. Injury, Vol.28, Suppl.1, pp. 7-12,

ISSN 0020-1383

7. Tucker HL and Kendra JC(1992),management of unstable

open and closed tibial fractures using llizarov method. C/

in Orthop 280:125

8. Helfet, D.L.; Shonnard P.Y.; Levine, D. &Borrelli, J. (1997).

Minimally invasive plate osteosynthesis of distal fractures

of the tibia. Injury, Vol.28, Suppl.1, pp. 42-48, ISSN 0020-

1383.

9. Fisher WD, Hamblen DL. Problems and pitfalls of

compression fixation of long bone fractures: a review of

results and complications. Injury1978;10(2):99107. dol:

10.1016/S0020- 1383(79)80069-8. [RefMed] [Cross Ref]

10. Collinge C, Kuper M, Larson K, Protzman R.Minimally

invasive plating of high-energymetaphyseal distal tibia

fractures. J OrthopTrauma. 2007;21(6):355361. doi: 10.1

097/BOT. 0b013e3180ca83c7. [PubMed][Cross Ref].

11. JensenJS,HansenFW,JohansenJ.Tibialshaftfractures.A

comparison of conservative treatment and internal fixation

with conventional plates or A0 compression plates.

ActraOrthopScandd. 1977 48(2):204-21 2.

12. Hasenboehler E, RikIl D, Babst R. Locking compression

plate with minimally invasive plate osteosynthesis in

diaphyseal and distal tibial fracture: a retrospective study

of 32 patients. Injury. 2007;38(3):365370. Doi: 10.1 016/

j.injury. 2006. 10.024. [RefMed] [Cross Ref]

166 Anwar Ahmed, Ahmed Suparno Bahar Moni, MKI Quayyum Choudhury, M Golam Sarwar, Anjan Lal Ghosh


Original Article

Functional Outcome of Minimally

Invasive Percutaneous Plate

Osteosynthesis Using Locking Condylar

Plates In Distal Femoral Fractures

Md. Saidul Islam1, Md. Golam Mostafa2, Shah Jawaher Jahan Kabir3, Shahidul Haq4

ABSTRACT

Minimally Invasive Percutaneous Plate Oseosynthesis for distal femoral fractures is a type of Biological

osteosynthesis which preserve biological environment at the fracture site and vascularity of fracture fragment

and thus improved fracture healing.Distal femoral fractures are associated with high energy trauma and

osteoporotic bone . Metaphyseal comminution and osteoporotic bone is a challenge to conventional plate

fixation.The present study was carried out for evaluation and analysis of the role of Minimall invasive percutaneous

plate osteosynthesis with locking condylar plate for distal femoral fractures.Total 20 cases ,aged more than 18

years were included in this study. .According to AO/OTA classification,the fractures were classified as types

A1(n=7 )A2 (n=6) A3(n= 3),C1(n=3),C2(n=1).All the fracture were closed.The result in all the 20 cases ,17 cases

had acceptable result (i.eExcellent and good) and 3 cases had poor result. MIPPO with Locking condylar

plate(LCP) achieves favorable biological fixation for distal femoral fractures for early fracture union and less

complications especially when fracture is comminuted and osteoporotic.

Key words: Distal femoral fractures,Indirect reduction, Minimally Invasive technique.

1. Associate Professor, Department of Orthopaedic Surgery , Dhaka Medical Collge,Dhaka.

2. Associate Professor, Department of Orthopaedic Surgery , Dhaka Dhaka Medical Collge,Dhaka.

3. Assistant Professor, NITOR,Dhaka

4. Assistant Professor, Department of Surgery, Cox’s Bazar Medical College, Chittagong

Correspondense to: Dr. Md. Saidul Islam, Associate Professor, Department of Orthopaedic Surgery, Dhaka Medical College, Dhaka

E-mail: [email protected]

INTRODUCTION

Distal femoral fractures are associated with high energy

trauma in young adults and osteoporotic bone in elderly1.

and are frequently comminuted and intra-articular.

Metaphysial comminuttion is a challenge to conventional

plate fixation.The locking condylar plate (LCP) forms a fixed

angle construct and enables placement of the plate without

any contact to the bone2,3. It can therefore be used in

metaphysical comminution. The pull-out strength of the

locking screw is substantially higher than that of

conventional screws and it is difficult for one screw to pull-

out or fail unless all adjacent screw do so4. This enables a

better hold in osteoporotic bones.LCP is anatomocally

precontoured ,so it reduces soft tissue problem and act as

internal external fixator5. LCP is suitable for minimal invasive

percutaneous plate osteosynthesis (MIPPO) for distal

femoral fracture. MIPPO is a type of biological plate

osteosynthesis, is important to preserve bone

vascularization, to improve consolidation, to decrease

infection rate, and bone grafting.

Our goal of this study was to assess the functional

outcome of MIPPO technique using Locking condylar

plate for distal femoral fractures.

MATERIAL AND METHOD

This was a prospective study which was carried out at

Orthopaedic department of Dhaka Medical college and

different private clinic in Dhaka,Bangladesh during the

period from July 2o12 to June 2014. Our study comprising

20 patient of either sex with distal femoral fractures

underwent minimally invasive percutaneous plate

osteosynthesis using LCP . Age range of the patient was

18 to 65 years, mean age was 48 year. 16 patient were

male , 4 patient were female.The causes of injury were

vehicular accidents(n=18),falls(n=2).According to AO/

OTA classification,the fractures were classified as types

VOL. 29, NO. 2, JULY 2014 167

A1(n=7 )A2 (n=6) A3(n=3 ),C1(n=3),C2(n=1) (Table -1).All

the fractures were closed.Two patient had contralateral

femer fractures ,one patient had ipsilateral middle tthird

fracture of tibial and fibular shaft which were treated with

intramedullary interlocking nailing. 13patient were rihgtt

side 7 were left sided .

The method used for fracture fixation was minimally

invasive percutaneous plate osteosynthesis (MIPPO)

with locking condylar plate . ( Fig I and 2)

Inclusion Criteria

1. Those patients who were above the age of 18 yrs of

either sex.

2. Type A, Type C1,C2 according to AO/OTA classification

system ,both closed and Gustillo type -1.

3. Patient willing for treatment and given informed written

consent.

Exclusion criteria

1. Patient aged below 18.

2. Fractures more than 3 wks old.

3. Gustillo type II and III fractures,pathological fracture

other than osteoporotic fractures and fractiure types

B and C3 of AO/OTA classification were excluded.

RESULTS

The mean operating time was 80 (range 60-110 )

minutes.The mean length of hospital stay was 14(8- 21 )

days. The mean follow-up period was 14 months (range 4-

24 monthes).

Partial weight bearing was usually achieved at 8 wks

and full weight bearing was started around 18 weeks

according to signs of union on follow-up.Follow-up was

given for 2 years with evaluation at 2 weeks , 4 weeks , 6

weeks ,12 weeks and then every 6 weeks interval upto 6

months and thereafter 3 monthly interval onward. (Fig.-

3 and 4)

The average time to union was 18.5 weeks. The mean

flexion was 105egrees. (range 85-140)The extensor lag

ranged from 0 degree to 10 degree with an average of 4

degree. Out of 20 patient 2 had leg length discrepancy.

One patient had shortening of <1 cm and another patient

had shortening 1.5 cm.Two patient had 05degree varus

and one patient had 06 degree valgus malalignment. One

patient had superficial infection.

Functional outcome was assessed using Schatzker et al.(7)

scoring system. Excellent in 5 patients(25%),good in 12

patients (60%), fair in 3 patients (15%) (Table-I).

Table –I

Functional outcome and fracture type

Type of Excellent Good Fair Failure Total

fracture

A1 4 3 0 0 7

A2 1 5 0 0 6

A3 0 2 1 0 3

C1 0 2 1 0 3

C2 0 0 1 0 1

Total 5 12 3 0 20

Table-II

Radiological union

Union (Weeks) No. of cases Percentage

< 16 1 5%

16-18 14 70%

19-20 3 15%

21-22 2 10%

Non-union Nil Nil

Table-III

Knee flexion

Knee Flexion (Degrees) No. of cases Percentage

>90 02 10

91-109 06 30

11o and more 12 60

Fig.-1: (a) Distal and proximal incision, (b) Pre-operative x-ray, (c) X-rray at 12 Wks (d) X-ray at 18 wks

(a) (b) (c) (d)

168 Functional Outcome of Minimally Invasive Percutaneous Plate Osteosynthesis Using Locking Condylar Plates


DISCUSSION

There are different modalities of treatment for distal femoral

fractures.They include direct reduction and internal fixation

with condylar buttress plates, retrograde nailing,dynamic

condylar screws , external fixators, open minimal invasive

approaches,Indirect reduction and plate osteosynthesis

using a locking condylar plate by MIPPO technique or by

less invasive stabilization system (LISS). (6).Good fixation

outcomes depends on bone quality,fracture complexity

and surgical techniques.

Conventional screw-plate systems (condylar buttress

plates and dynamic condylar screws) depends on the bone

–plate interface for stability1,7,8. When screw are

tightened,the plate compresses against the cortex and

maintain stability.The stability of the standard screw

depends on bone quality. So in metaphysical

comminution,in osteoporotic bone ,the holding power of

the screw is compromised leading to failure of screw –

plate system.More over fixation with DCS requires at least

4 cm of uncomminuted bone in the femoral condyles above

the intercondylar notch9. This limits its use in more distal

extr-articular fractures.Soft tissue striping during

conventional plating adds a biological insults to the poor

bone quality as in metaphyseal comminution and

osteoporotic bones.These may lead to poor outcomes such

as non-union,implant failure,malunion and infection10.

Retrograde intramedullary nailing involves joint opening

and is associated with joint stiffness,protrusion of nail in

the joint,patellofemoral problems and knee sepsis9.

Locking plate system such as the LCP have been

extensively used for distal femoral fractures.It has a lower

risk of early implant loosening than DCS and promote

early mobilistion and rapid healing without bone grafts

.The LCP differ from LISS in that the LCP has combination

holes (6) and does not have a jig.

LCP acts on the internal fixator principle 9 and enables

percutaneous plating.The LCP is compatible with MIPPO.

Many studies combining the LCP and MIPPO/MIPO have

shown improved results.

In our study all the 20 fractures were treated by indirect

reduction and internal fixation by LCP . The size of the

plate was selected based on the type of fracture. Of 20

patient 14 patient (70%) showed radiological union within

18 weeks. Sk Venkatesh et al. showed 73% radiological

union within 18 weeks, J.P.S et al(11). showed 100% mean

time of radiological union 16.2 weeks. Normal knee flexion

is 140 degrees.Thus ,acceptable knee flexion compatible

with daily activity would be 110 degree.Average flexion in

this study was 105 degree with 60% patient having range

of knee flexion more than 110 degrees. Sk Venkatesh et al.

showed 50 % patient with more than 110 degreeknee flexion

and J.P.S et al showed 36 % patient with more than 110

degree knee flexion. This difference may be due to we had

given early knee movement, no post operative back slub

given.

In this study , overall results were tabulated in four groups

i.e Excellent, good ,fair and failure according to the criteria

Schatzker et al.(7 ) scoring system.Out of 20 cases 17

cases had acceptable result (i.eExcellent and good) and 3

cases had poor result. Ravi Nayak et al. (12). obtained

excellent and good outcomes in 29 out of 31 cases.19

CONCLUSION

MIPPO with Locking condylar plate achieves favorable

biological fixation for distal femoral fractures for early

fracture union and less complications especially when

fracture is comminuted and osteoporotic.

REFERENCES

1. T.F Higgins. Distal femoral fracture. The Journal of Knee

Surgery, Vol 20,No 1 p 56-66,2007.

2. Mast J,Jakob R, Genz R.Planing and reduction technique

in fracture surgery.Springer- Verlage,New yourk 1989.

3. Brunner CF,Weber BG.Antiglide plate ,In:mBrunner

CF,Weber BG;eds Osteosynthesis technique,Berlin:

Springer 1982.

4. Scultz M,Sudkamp NP; Revolution in plate

osteosynthesis: New internal fixator system. J. Orthop

Sci. 2003; 8:252-8.

5. Close reduction by manipulation and minimally invasive

percutaneous plate osteosynthesis for the treatment of

supracondylar femer fracture .Orthopaedic Hospital of

Sichuan, Chengdu 610041,Sichuan China,2011.

6. Hontzsch D. Distal femoral fracture - technical

possibilities(In German),Kongressbd Dtsch Ges Chir

Kongr 2001;118:371-4.

7. Schatzker J,Tile M. The rationale of operative fracture

care.Berlin: Springer Verlage;1987.

8. Klaue K.Principles of plate and screw osteosynthesis.In

Bulstrode C, Buckwalter J, Carr A, editor. Oxford textbook

of orthopaedics and trauma. Oxford: oxford University

press; 2002:1697-710.

9. Whittle AP, Wood II GW.Fracture of the lower

extremity.In: canale ST,editor. Campbell’s operative

orthopaedics. Vol 3, Philadelphia:Mosby; 2003;2725.

10. Grewiwer RM.Archdeacon MT.Locking plate technology:

current concepts. J knee surg 2007; 20; 50-5.

11. J.P.S et al. Minimally Invasive Plate Osteosynthesis for Distal

femoral Fractures.JIMSA Oct-Dec.2014 Vol. 27 No 4.

12. Ravi Nayak, MR Koichade,Alok N. Minimally Invasive

Plate Osteosynthesis for Distal femoral Fractures. J Orthop

Surg 2011;19 (2): 185-90.

Md. Saidul Islam, Md. Golam Mostafa, Shah Jawaher Jahan Kabir, Shahidul Haq 169

VOL. 29, NO. 2, JULY 2014

Original Article

Posterior Long Segment Transpedicular

Screw Fixation for Unstable

Thoracolumbar Fractures with

Incomplete Spinal Cord Injury

Syed Shahidul Islam1, M R Karim2, Purnendu3, Meraj 4, Azad5, Swapan 6, Rahman7,

Rayhan Hamid8, Susmita9

ABSTRACT

Prospective study. To evaluate the outcome after long segment pedicle instrumentation in unstable fractures of

the thoracolumbar spine with incomplete neurological deficits.

We reviewed the outcome in 40 patients (32 males and 8 females) of unstable thoracolumbar fractures with

incomplete neurological deficits who underwent long segment pedicle screws & rod fixation and fusion from

January 2009 to January 2013 at National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR),

Dhaka, Bangladesh. Mean age was 33.3years (range 14-55 years). Leading cause of fracture was motor vehicle

accident. Involvement of T12, LI & L2 was noted, respectively in 12, 17 and 11 patients. According to the ASIA

impairment scale 5 patients had B, 25 patients had C, 9 patients had D and 1 patients had E scale. The mean

follow-up was 13.2 months (Range 10-42 months).

According to Modified Macnab criteria functional result were excellent in 22 patients (55%) good in 14 patients

(35%). fair in 3 patients (7.5%) & poor in 1 patients (2.5%). Neurological recovery of one or more ASIA Impairment

Scale was seen in all patients. There is no implant failure, correction loss and complication.

Long segment pedicle screw fixation for unstable thoracolumbar fracture with incomplete neurological deficit

achieves adequate fixation without implant failure and correction loss and gives satisfactory results.

Keywords: Thoracolumbar fracture, Unstable, incomplete neurological deficits, long segment instrumentation.

1. Associate Professor, National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR), Dhaka, Bangladesh.

2. Asst. Professor, National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR), Dhaka, Bangladesh.


4. Registrar,, National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR), Dhaka, Bangladesh.

5. Asst. Registrar, National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR), Dhaka, Bangladesh.


7. Medical Officer, National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR), Dhaka, Bangladesh.

8. Registrar, National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR), Dhaka, Bangladesh.

9. Lecture, Physiotherapy. National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR), Dhaka, Bangladesh.

Correspondence: Dr. Syed Shahidul Islam, Associate Professor, National Institute of Traumatology & Orthopaedic Rehabilitation

(NITOR), Dhaka, Bangladesh.

INTRODUCTION

Thoracolumbar junction is the mechanical transition zone

between rigid thoracic and more mobile lumbar spine which

predispose to failure. Injury to the cord or cauda equina

associated with 14 to 38% .25

The treatment of thoracolumbar fractures remains

controversial15,22. Although most authors believe that

surgical treatment is needed for unstable fractures, the choice

for operative approaches remains disputed2,5,22. Common

opinion is to obtain the most stable fixation by fixating as few

vertebrae as possible and neural canal decompression1,2.

Short-segment posterior instrumentation (SSPI) is the most

common and simple treatment, offering the advantage of

incorporating fewer motion segments in the fusion18. A


review of the literature showed that SSPI alone led to a 9-

54% incidence of implant failure and re-kyphosis in the

long-term, and 50% of the patients with implant failure

had moderate-to-severe pain2: To prevent this, several

techniques have been developed to augment the anterior

column in burst fractures, such as transpedicular bone

grafting2, 18, 19, placement of body augmenter5,

polymethylmethacrylate (PMMA) injection6, anterior

instrumentation and strut grafting17, or long-segment

posterior fixation (LSPF)1,6.

There are few controlled studies explaining the reasons

for implant failure and re-kyphosis for thoracolumbar

fractures2. In the current study, only patients with

thoracolumbar junction (T12-L2), fractures were included.

The aim of the present study was to determine the proper

treatment choice for thoracolumbar junction fracture.

MATERIAL AND METHODS

Between January 2009 and January 2013, 40 patients with

acute, traumatic fractures of the thoracolumbar junction

were treated with long-segment transpedicular screw

fixation.

In LSP screw fixation we applied eight screws: two levels

above and below the fracture. All the operations were

performed by us without any discriminations according

to the fixation type. The authors had decided to apply

long-segment posterior instrumentation during the

operation, till January 2013.

Screws were 40 or 45 mm long, depending on the level and

size of the vertebra. At the tenth and eleventh thoracic

levels, 5.5 or 6.5-mm-diameter multiaxial screws and at the

twelfth thoracic level and caudally 6.5-mm-diameter

multiaxial screws were used. The instrumentation was

applied by laterally and cross-links were used to augment

torsional rigidity. Reduction of the fracture was

accomplished by the rod contouring and extension and

compression-distraction forces before tightening the

screws. Patients were a thoracolubar brace for two months.

Complete clinical and radiologic examinations were done on

admission. Clinical and radiographic follow-up was at 1, 3, 6,

and 12 months and every year thereafter. Data were collected

concerning age, sex, localization, presence of neurological

deficits, pain and work status, mobility complications and

radiologic parameters. Correction loss was defined as an

increase of more than 10R” SI in the latest follow-up

radiographs compared with the measurement on the initial

post-operative radiographs. Neurologic assessment was

done using ASIA Impairment scale. Modified Macnab Criteria

is used for categorizing the outcome of surgery.

RESULTS

Postoperatively, kyphosis was corrected by more than

10° in 33 (82.05%). Last follow-up values showed a

correction of more than 10° in 26 patients (26%) Correction

loss more than 10° was found 4 (10%). All patients with

incomplete neurologic injuries improved. In ASIA Impairment

scale two grade of improvement in 23 (57.5%) patients and

one grade of improvement in 17 (42.5%) patients.

Male, Age 30 yrs, L1 Fracture with incomplete SCI Preoperative X-ray and MRI

Immediate post operative X-ray and follow up X-ray after 1 year

Posterior Long Segment Transpedicular Screw Fixation for Unstable Thoracolumbar Fractures 171

VOL. 29, NO. 2, JULY 2014

corrective force over multiple levels and the reduction of

the likelihood of implant failure.

Serin et al.23 reported that four level posterior fixation is

superior to two level posterior fixation. Tezeren et al[25

demonstrated that final outcome regarding sagital index

and anterior body compression is better in the long

segment instrumentation group than short segment

instrumentation group.

In this surgical method we need the statistical analysis of

cobb angle, Kyphotic deformity anterior body compression.

The thoracolembar junction contributes the transitions

zone between the rigid thoraces and mobile lumbar spine.

Vertebral fracture in this area are usually extremely unstable

and Kyphotic deformity is often significant degree

therefore inserting the screw only one level above and

below the fractured segment might not have provided

adequate stability Gurr et al[14 found that two level above

and below the injured level in an unstable calf spine model

provided more stiffness than the intact spine. Carl et al4

reported that segmental pedicular fixation two level above

the kyphosis should be used at the thoracolumbar junction,

where compression force act more antereorly.

Post operative correction loss after posterior

instrumentation has been reported by many authors. The

mean correction loss ranged from 0.3º to 15.4º has been

reported in may authors. In our study mean correction

loss is 3.2º. In our study no there were no instrument

failure.

Selection of the surgical method in the treatment of

thoracolumbar fractures remains a matter of

discussion2,5,6,8. Multiple parameters have to be

considered, such as the type and stability of the fracture,

degree of CC, and neurological status26. SSPF is frequently

regarded as the procedure of choice because it offers

advantages such as incorporating fewer motion segments

in the fusion, shorter operative time and fewer blood

transfusions. But without body reconstruction, many

authors believe that transpedicular bone grafts have not

prevented early implant failure and correction loss, and

may lead to low anterior inter body fusion rates in the long

term2,18,21. Recently, PMMA was reported to strengthen

the fractured body and prevent instrument failure, but the

long-term result is unknown6. Injection of PMMA into a

fractured vertebral body may lead to cement extrusion

into the spinal canal, particularly if the posterior

longitudinal ligament is torn. Anterior instrumentation and

strut grafting have proven to be effective17, but require a

more invasive approach, prolonged operation may cause

blood loss and morbidity.

Table-I

Neurological recovery after surgery

ASIA Scale Preoperative Latest Follow-up

A B C D E

B 5 - - 2 3 -

C 25 - - - 5 20

D 9 - - - - 9

E 1 - - - - 1

*Two grade of improvement in 23 (57.5%) patients*One grade

of improvement in 17 (42.5%) patients.

Table-II

Surgical outcome with modified Macnab criteria

Excellent 22 patients (55%)

Good 14 patients (35%)

Fair 3 patients (7.5%)

Poor 1 patients (2.5%)

In the last follow-up visit, all 40 patients there were no

implant failures, including no screw breakage, or loosening.

According to Modified Macnab criteria functional result

were excellent in 22 patients (55%) good in 14 patients

(35%). fair in 3 patients (7.5%) & poor in 1 patients (2.5%).

Neurological recovery of one or more ASIA Impairment

Scale was seen in all patients. There is no implant failure,

correction loss and complication.

DISCUSSION

It is widely accepted that thoracolumbar frature should be

addressed surgically2. The goals of treatment of

thoracolumbar fracture regardless of the selected method

are the restoration of the stability of the vertebral column,

prevention and correction of collaps and deformity, the

decompression of the spinal canal, protection of intact or

incompletely injured neural element leading to earlier

mobilization of the patient. Short segment pedicle

instrumentation is popular since Dick et al10 have

developed the SS stabilization. However there is a

controversy as far as the result of this instrumentation are

concerned. There are studies that report high rate of failure

because of proximal screw pullout, screw breakage and

loss of correction even if material failure does not always

affect the clinical outcome21.

The advantage of long segment instrumentation that used

in this study is the immediate mobilization of the patient

with less depending of bracing, the distribution of

172 Syed Shahidul Islam, M R Karim, Purnendu, Meraj, Azad5, Swapan, Rahman, Rayhan Hamid, Susmita


CONCLUSION

The recent literature does not provide a gold standard for

the treatment of thoracolumbar fractures. Therefore, the

choice of therapy should be made individually, considering

the type and severity of fracture, the neurological status

and the patient’s condition as well as the skill of the

surgeon. LSPS fixation of unstable thoracolumbar spine

fracture can provide more secure fixation & better

correction of deformity and avoiding correction loss with

patients’ satisfaction. Long-term follow-up needed for

clear evaluation.

REFERENCES

1. Akbarnia BA, Crandall DO, Burkus K et al (1994) Use of

long rods and a short arthrodesis for burst fractures of

thethoracolumbar spine. A long-term follow-up study. J

Bone Joint Surg Am 76(11):1629-1635

2. Alanay A, Acarolu E, Yazici M et al (2001) Short-segment

pedicle instrumentation of thoracolumbar burst fractures:

does transpedicular intracorporeal grafting prevent early

failure. Spine 26(2):213-217

3. Boerger TO, Dickson RA (2000) Does canal clearance

affect neurological outcome after thoracolumbar burst

fractures? J Bone Joint Surg Br 82(5):629-635

4. Carl AL, Tromanhauser SG, Roger DJ (1992) Pedicle screw

instrumentation for thoracolumbar burst fractures and

fracture-dislocations. A calf spine model. Spine 17:317-

324

5. Chen HH, Wang WK, Li KC et al (2004) Biomechanical

effects of the body augmenter for reconstruction of the

vertebral body. Spine 29(18):382-387

6. Cho DY, Lee WY, Sheu PC (2003) Treatment of thoraco

lumbar burst fractures with polymethyl methacrylate

vertebroplasty and short-segment pedicle screw

fixation. Neurosurgery 53(6):1354-1360

7. Dall BE, Stauffer ES (1988) Neurologic injury and recovery

patterns in burst fractures at the T12 or LI motion segment.

Clin Orthop 233:171-176

8. De Peretti F, Howorka I, Cambas PM et al (1996) Short

device fixation and early mobilization for burst fractures

of the thoracolumbar junction. Eur Spine J 5:112-120

9. Denis F, Armstrong GWD, Searls K et al (1984) Acute

thoracolumbar burst fractures in the absence of neurologic

deficit: a comparison between operative and nonoperative

treatment. Clin Orthop 189: 142-149

10. Dick W, Kluger P, Magerl F, Woersdorfer O, Zach G. A

new device for internal ‘fixation interne’. Paraplegia 1985:

23(4): 225-32.

11. Farcy JP, Weidenbaum M, Classman SD (1990) Sagittal

index in management of thoracolumbar burst fractures.

Spine 15(9):958-965

12. Frankel HL, Hancock DO, Hyslop G et al (1969) The

value of postural reduction in the initial management of

closed injuries of the spine with paraplegia and tetraplegia.

Para plegia 7:179-192

13. Gertzbein SD, Court-Brown CM, Marks P et al (1988)

The neurologic outcome following surgery for spinal

fractures.Spine 13:641-644

14. Gurr KR, McAfee PC (1988) Cotrel-Dubousset instrumen

tation in adults. A preliminary report. Spine 13:510-520

15. Kaneda K, Taneichi H, Abumi K et al (1997) Anterior

decompression and stabilization with the Kaneda device

for thoracolumbar burst fractures associated with

neurological deficits. J Bone Joint Surg Am 79(l):69-83

16. Katonis PG, Kontakis GM, Loupasis GA et al

(1999) Treatment of unstable thoracolumbar and lumbar

spine injuries using Cotrel-Dubousset instrumentation.

Spine 24(22):2352-2357

17. Kim NH, Lee HM, Chun IM (1999) Neurologic injury

and recovery in patients with burst fracture of the

thoracolumbar spine. Spine 24:290-293

18. Knop C, Bastian L, Lange U et al (2002) Complications in

surgical treatment of thoracolumbar injuries. Eur Spine J

ll(3):214-226

19. Knop C, Fabian HF, Bastian L et al (2002) Fate of the

transpedicular intervertebral bone graft after posterior

stabilisation of thoracolumbar fractures. Eur Spine J

11(3):251-257

20. Knop C, Fabian HF, Bastian L et al (2001) late results of

thoracolumbar fractures after posterior instrumentation

and transpedicular bone grafting. Spine 26(l):88-99It)

spring.

21. Kramer DL, Rodgers WB, Mansfield FL. Transpedicular

instrumentation and short-segment fusion of

thoracolumbar fractures: A prospective study using a single

instrumentation system, J Orthop Trauma 1995; 9(6):

499-506.

22. McLain RF, Sparling E, Benson DR. Early failure of short

segment pedicle instrumentation for thoracolumbar burst

fractures. A preliminary report, J Bone Joint Surg Am

1993; 75(2): 162-7.

23. Serin E, Karakurt L, Yilmaz E, Belhan O, Varol T, Effectys

of two- levels, four-levels, and four-levels plus offset-

hook posterior fixation techniques on protecging the

surgical correction of unstable thoracolumbar vertebral

fractures: a clinical study. Eur J Orthop Surg Traumatol

2004; 14 (I): 1-6.

24. Saboe, Limda; Reid, David; Davis; Lylea Warrer, Sharon,

Grace. Spine Trauma and Associate injuries. Journal of

Trauma & Acute care surgery, January 1991.

25. Tezeren G, Kuru I. Posterior fixation of thoracolumbar

burst fracture: Short-segment pedicle fixation versus long-

segment instrumentation. J Spinal Disord Tech 2005;

18(6): 485-8.

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Posterior Long Segment Transpedicular Screw Fixation for Unstable Thoracolumbar Fractures 173

VOL. 29, NO. 2, JULY 2014

Original Article

Management of Open Gustilo IIIB Tibia-

Fibula Fractures By Soleus Muscle Flap

and Locally Made AO External Fixator

Abdullah Al-Mahmood Bilal1, Mir Hamidur Rahman2 , Mohammed Abdus Sobhan3 Milon Krishna

Sarker4, Md.Wahidur Rahman5 M Monaim Hossen6

ABSTRACT

This prospective study of ‘‘ Management of open Gustilo IIIB tibial fractures by soleus muscle flap and locally

made AO external fixator produce good success rate’’ was carried out with 26 patients of Gustilo, type IIIB open

fracture of the tibia-fibula during the period of July 2000 to June 2002 at NITOR. Out of 26 patients, 4 patients were

lost from the follow up. So ultimately the final result based on the results of 22 patients. In this study patients were

randomly selected irrespective of age and sex. Open fracture type IIIB (middle 1/3rd) were selected only. Polytrauma

patients were excluded from the study. Most common age group in this series were 26-35 years (41%) age group.

Lowest age was 16 years and highest age was 52 years with mean age 30 years. Male were more commonly

affected than female with a ratio of 9:2. Most common fracture were comminuted (63%). Right side involvements

were more (55%). Soleus muscle flap coverage with external fixator was done in all cases. Partial flap failure in

8 cases (36%) which were managed by cross leg fasciocutaneous flap in 6 cases and split thickness skin graft

in 2 cases. Various complications were observed. Commonest one was infection. Out of these bone infection

55%, soft tissue infection 36%, pin tract infection 10%. Non union was observed in 12 cases (55%). Out of these 8

were managed by BMP, 3 cases by bone graft and 1 by Illizarov external fixator. Leg length discrepancy in 7 cases

(32%) of which 5 was acceptable managed by heel raised shoe and other two by Illizarov external fixator. Varus

angulation of about100 in 1 case (4%),50 in 1 case (4%) and 100 valgus in 1 case (4%) was observed. None of the

cases developed compartment syndrome. Stiffness of ankle were observed in 6 cases (27%).According to

criteria of Tucker et al. (1992) final results of treatment were analyzed. Acceptable results were in 72.73% of

cases ( Excellent 22.73% and good 50%), 27.27% cases were not acceptable (Fair 9.09% and poor 18.18%)

1. Assistant Professor (C,C) OSD, DGHS, attached Abdul Malek

Ukil Medical College, Noakhali

2. Assistant Professor, OSD, DGHS, attached Abdul Malek Ukil

Medical College, Noakhali

3. Senior Consultant, 250 bedded General Hospital Noakhali,



5. Associate Professor, NITOR, Dhaka


Correspondence: Dr. Abdullah Al-Mahmood Bilal, Assistant

Professor (C,C) OSD, DGHS, attached Abdul Malek Ukil Medical

College, Noakhali

INTRODUCTION

An open tibia-fibula fracture has been the most challenging

problem of all long bone injuries (Gustilo, 1993). Gustilo

(1993) Developed the historiocal and world wide accepted

classification system of open fractures of Tibia-Fibula that

is relevant to both treatment and outcome. The problem is

challenging because high incidence if sepsis and other

complications like chronic osteomyelitis, malunion,

nonunion and amputation. Among the trauma patients

open fracture of the tibia fibula comprises a substantial

group who requires careful attention to prevent mortality

as well morbidity. Because one third of its surface is

subcutaneous throughout most of its length, open

fractures are more common in the tibia than in any other

major long bones. Furthermore the blood supply to the

tibia is more precarious than that of bones enclosed by

muscles. The emergency department of National of

Traumatology and Orthopaedic Rehabilitation (NITOR) is

to manage huge number of open tibia-fibula fracture of

different types each and everyday. It is also a common but

sorrow picture to have a good number of patients occupying

the hospital beds for long duration. Their broken pieces of

bones smiling at the surgeons are surrounded by hundreds

of thousands of bacteria along with devitalizing tissues

resulting from open fracture tibia-fibula.


The goal of treatment of an open fracture are prevention

of infection, healing of the fracture and restoration of

function of the extremity.

Gustilo type IIIB open fractures are characterized by:

(1) Extensive soft tissue loss.

(2) Extensive periosteal stripping with a large fragment

of bone exposed.

(3) Massive contamination.

(4) Severe fracture Comminution

The essential criterion is that after adequate debridement

and irrigation, a segment of bone exposed that requires

flap coverage . Regarding the timing of wound closure,

there is no place primary closure in open fractures

irrespective of any because of increased sepsis and the

risk of gas gangrene(Gustilo,1993) suggested wound

closure in type lllB fractures within three to five days.

Adequate debridement and early assessment of the soft

tissue defect are necessary so that appropriate soft tissue

coverage can be provided within first one to two weeks

(Fisher et.al.,1991).In present study the badly

contanminated wounds were covered, when judged to

be clinically & bacteriologically fit for ,between 5 th to 21st

trauma. According to the just mentioned study early

muscle-flap coverage has been termed when done within

ten days after injury. It usually took at least 3-5 days to

stabilize both the wound and the patient. Why muscle-

flaps has been selected ? The advantages of muscle flaps

are:

(1) Muscle have a rich blood supply with distinct vascular

pedicle which enhance fracture union

(2) The vascular pedicle is often located outside the

surgical defect owing to the are of rotation and the

length of the muscle

(3) The muscle provides bulk for deep , extensive defects

and protective padding for exposed vital structures

(4) Muscle can be mainpulated to prouduce a desired

shape or volume

(5) well-vascularized muscle is resistant to bacterial

inoculation and infection

(6) Reconstruction using muscle is often a one stage

procedure

(7) The reliability and availability of soleus muscle make

them an excellent alternative means of reconstruction

when the method of choice for a particular defect is

unavailable or inadequate

(8) Negligible morbidity of donor site (Mc Carthy, 1990).

AIMS AND OBJECTIVES OF THE STUDY

Aims:

To find out the bitter method of management of open

Gustilo IIIB fracture of the tibia in context of our socio-

economic condition

Objectives :

1. Union of open Gustilo IIIB fracture of fibula after solues flap.

2. To evaluate the success rate of soleus muscle flap

transposition for coverage.

3. Soft tissue healing

Functional assessment of the survived limb with or without

complications

Patients and methods

Type of the Study

This prospective study was carried out to evaluate the

results of management of open Gustilo IIIB tibia-fibula

fractures by soleus muscle flap coverage and locally made

AO external fixator.

Place and period of study

This study was carried out at National Institute of Trauma

and Orthopaedic Rehabilitation, Dhaka; during the period

of July 2000 to June 2002.

Sample Size

A sample size of 26 patients were taken. Out of 26 cases

four cases were dropped out from the follow-up. Hence,

this study comprises 22 cases.

Sampling Technique

Sampling was purposive as guided by some inclusion and

exclusion criteria.

Criteria for selection of patients

Inclusion Criteria

These were as follows :

1. Cases were randomly selected between 16-50 years

2. facture of any side of tibia and fibula.

3. Only open fracture shaft of the tibia and fibula (Middle

1/3 rd )

4. Only open fracture-Gustilo type IIIB irrespective of

fracture configuration viz oblique, transverse, spiral

segmental, comminuted or with loss of bone.

5. Open fracture on same day of injury.

EXCLUSION CRITERIA

1. Polytrauma patients

2. Diabetic patients

3 Patients of peripheral vascular disease

4. Any open fracture except type IIIB (Middle 1/3 rd )

5. General condition of patient not fit for general or spinal

anaesthesia

Management of Open Gustilo IIIB Tibia-Fibula Fractures By Soleus Muscle Flap and Locally Made AO External Fixator 175

VOL. 29, NO. 2, JULY 2014

Data Collection Protocol

A questionnaire and checklist was designed consisting of

variables related to patients , treatment timing, soft tissue

management fracture management. Data protocol includes

history, physical examination, clinical examination,

radiological assessment, wound care and management.

Data Analysis

Once data collection was completed, data were complied

manually according to the key variable .All statistical

analysis of different variable were analyzed according to

standard statistical method and calculation done by using

scientific Calculator.

Observation and Result

In the present series, the following observations were noted:

Age Incidence : in this study there were 22 patients with

age range 16-52 years . Mean age 30 years. Maximum

incidence was in 26-35 years age group.

Table-I

Showing different age group in the present series.

(Age in year) Number of patients Percentage (%)

16-25 07 31.82%

26-35 09 40.90%

36-45 05 22.73%

46-60 01 4.55%

N=22

Sex Distribution: In the present series, 18 were male and 4

female. Male female ratio 9:2

Table-II

Showing sex distribution of patients in present series.

Sex Number of patients Percentage (%)

Male 18 81.82%

Female 04 18.18%

N=22

Side Involved:

In the present series, right side involvement were in 12

cases and left side involvement ni 10 cases.

Table-III

Showing side of the injury in this series.

Side Number of patients Percentage (%)

Right 12 54.55%

Lift 10 45.45%

N = 22

Location of fracture: in this series all 22 (100%) cases of

open gustilo IIIB fracture were in the middle 1/3 rd of the

shaft of tibia.

Gusstilo Type of feacture: in this series all 22 (100%)

cases were type iiiB:

Causes of injury : in this series, motor vehicle accident

were found in 17 cases, assault in 2 cases, machinery

injury in 3 cases.

Table-IV

Showing causes of injury in this series.

Causes of Injury Number of patients Percentage (%)

Motor Vehicle Accident 17 77.27%

Assault 2 9.09%

Occupational 3 13.64%

N = 22

Configuration of Fracture:

In the present series, fractures configuration were comminuted

in 14, oblique in 5, transverse 1 and segmental in 2.

Table-V

Showing configuration of fracture in this series.

Fracture Configuration No. of patients Percentage

Comminuted 14 63.64%

Oblique 5 22.72%

Segmental 2 9.09%

Transverse 1 4.55%

N=22

Occupation of Patients:

People of different occupations were patients of open

fractures tibia- fibula found in this study.

Table-VI

Showing occupation of patients in this series.

Occupations Number of patients Percentage (%)

Farmer 3 13.64%

Labour 7 31.82%

Businessman 2 9.09%

House wife 4 18.18%

Student 2 9.09%

Govt. Service 2 9.09%

Technician 2 9.09%

N = 22

176 Abdullah Al-Mahmood Bilal, Mir Hamidur Rahman, Mohammed Abdus Sobhan, Milon Krishna Sarker, Md.Wahidur Rahman et al


Soft tissue and fracture healing :

Table- XI

Showing incidence of Soft Tissue and fracture healing .

Healing Procedure employed Number of patient Percentage (%)

A. Soft Tissue Soleus Flap only 14 63.64%

Soleus Flap (>25%-50% failure) followed by cross leg flap 6 27.28%

Soleus flap (25% failure) followed by split thickness skin graft 2 9.08%

B. Fracture Primary healing Nil 0%

Secondary healing 10 (without bone graft/BMP) 45%

8 BMP 36.87%

3 (Bone graft) 13.63%

1 Ilizarov 4.54%

Incidence of Complications :

Table-XII

Showing incidence of complications in the present series

Complication Number of patient Percentage (%)

Infection

Soft tissue 8 36.37%

Pin-tract 2 9.09%

Bone 12 54.54%

Delayed union 8 36.37%

None Union 4 18.19%

Restriction of knee 6 27.28%

and ankle movement

Angulations 3 13.63%

Leg length discrepancy 7 31.82%

RESULTS

To choose an unique parameter for analysis of results is a

difficult task in open tibia fibula shaft fractures. These

injuries are associated with moderate to severe

complications because soft tissue, bone and adjacent joint

movements, all contributes to the final out come of the

result.Bony unions take much longer time than any

other bones body (Edward, 1988). Most difficult part of

the evaluation was the limited time of follow up for this

type of study. Gustilo et al. (1993) used following criteria

to define a satisfactory result:-

i) Fracture healing without sepsis.

ii) No mal alignment or angulatory deformity in excess of

valgus angulation 10 degrees, varus angulation 5

degrees, Anteroposterior angulation of 10 degrees

and shortening lcm.

iii) Near or near-normal joint motion of both knee and

ankle. Main disadvantage of this parameter is, they

did not graded their results. so, statistical analysis

and comparison of results of treatment is not possible.

Karlstrom et sl. (1975) used following parameters for

evaluation of their results of severe open fractures of tibia.

They graded the result as A, B, and C . (Table No. XIII)

Preoperative X-ray after injury Application of external fixator in open Gustillo IIIB fracture

tibia-fibula


VOL. 29, NO. 2, JULY 2014

DISCUSSION

This study was carried out in order to find out an easy,

appropriate and well accepted technique for solving

prolonged suffering and complication of patients with

Gustilo type IIIB open tibia-fibula fractures involving

middle 1/3 rd . As a tertiary hospital like NITOR the

incidents of open fracture shaft of tibia-fibula are not

negligible encountered in daily practice in the casualty

department.

Out of 22 cases, all were type IIIB involving middle 1/3 rd

of shaft of the tibia-fibule. In this type cast immobilization

is very troublesome and difficult to maintain. Cast does

not allow access for serial debridement and dressing. It

soaks readily and needs frequent change which is quite

costly, time consuming and hampers maintenance of

fracture reduction. More over cast immobilization for

prolonged time leads to joint stiffness, muscle atrophy

and diffuse osteoporosis.

Most of our patients reported to hospital after golden

hours (>8 hours). Internal fixation in this situation by intra

medullary nailing or plating carries consequences of high

risk of bone infection (Edward, 1988) and in this cases

external fixation is this treatment of choice (Seligson, 1990;

Gustilo, 1993) for early wound care, sequential debridement

and early wound coverage.

In this study wound could not be covered within three

days, Possible causes were : a) All the cases were badly

Soleus muscle flap separation with

external fixation.

Check X-ray after external fixation

3 weeks after soleus muscle flap surgery Patient with partial

weight bearing at 8 weeks



contaminated and potentially infected b) Exact nature and

velocity of injury could not be ascertained c) correct

evaluation of local circulation of deep soft tissues is

unpredictable d) lack of sufficient operation theatre (O.T)

available which is overburdened with disproportionately

huge number of patients.

Definitely there is relationship between early wound

coverage and better results. In this study 10 cases (45%)

were covered at 5-10 days after injury and 12 cases (55%)

after 10 days of injury/. Flap success rate is 80% in early

covered cases and success rate dropped to 50% in late

covered cases. Out of 10 cases done within 5 to 10 days

extent of flap

Among the complications out of 22 cases, 12 developed

bone infection, 8 cases soft tissue infection, 2 pin tract

infection and 7 developed limb length discrepancy. No

specific infection (Gas gangrene, tetanus) were noted.

Wound swab yields growth of mixed bacteria (staph. aureus,

E.coli, Pseudomonas) which were resistant to almost all

usual antibiotics. They are very sensitive to Ciprofloxacin,

ceftriaxone, netilmycin.

Of the 12 cases of chronic osteomyelitis, sequestrectomy

done in all cases. After 6-8 weeks of sequestrectomy 11

cases developed aseptic nonunion and one infected

nonunion. Out of 11 aseptic nonunion cases 8 were treated

by BMP and 3 cases by autogenous bone graft. One

infected nonunion case was treated by Ilizarov extetnal

fixator.

Pin tract infection was managed by daily cleaning with

povidone iodine scrub and dressed with povidone iodine

ointment. Antibiotics were given according to culture and

sensitivity report. In one case external fixator was removed.

Soft tissue infection were managed by daily flushing with

normal saline followed by povidone iodine dressing.

Antibiotic was given according to culture and sensitivity

report till infection controlled.

After control of infection bony procedures (Bone graft,

BMPP) were done. necrosis was 25% occurred in 2 cases

(20%) and out of 12 eases done after 10 days extent of flap

necrosis was > 25%-50% occurred in 6 cases (50%).

Out of 10 soleus muscle flaps done earlier( within 10 days),

3 casses (30%) (case no.4,6,16) developed chronic

osteomyelities. so 70% open fractura can be protected

from infection. Out of 12 soleus muscle flaps done after 10

days, 9 cases (75%) developed chronic osteomyelities.

only 30% open fracture can be protected from infection in

late wound covered cases. In the study of fishier et al.(1991)

82% in early covered cases .(within 10 days) can be

protected from deep bone infection. After 10 days

protection rate dropped to 25%. so fisher et al. (1991) study

is nearly similar to this study.

Fracture union occurred unevently in 10 cases (45%). Bony

procedures (BMP/ bone graft) were done in rest of the 12

cases(55%). These results are comparable with Eshaque

et al. (2001) study.

In this series time of fracture healing was 5.5 to 12 months

with a mean of 7.5 months which is nearly similar to

Eshaque et al. (1991) study where time of fracture healing

is 5 to 10 months.

None of the patient developed neurovascular or

compartment injury during the study of this series. In this

series locally made AO external fixator was applied in 22

cases for stabilization of fracture on the same day of injury.

AO/ASIF External fixator, Hoffmann fixator, Ilizarov ring

fixators are costly and most of our patient can not afford

to purchase such set. So AO external fixator can be made

locally and cost is cheap which our patient can afford. So,

in other word cost benefit ratio is higher with locally made

AO external fixator than standard external fixators.

At the end of discussion I would like to express my overall

impression that early the wound was covered with muscle

flap and stabilization of fracture, the better was the

prognosis.

CONCLUSION

Open fracture in leg in mid third with exposed tibia, Gustilo

type IIIB can be better managed by immediate reduction

of fracture and immobilization by AO external fixator after

surgical toileting and application of soleus flap over the

exposed bone in due time. Post-operative care is very

important for soft and hard tissue healing.

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orthop, vol. 206,n.1, pp.151-61.

13. Caudle R. J. and Stern P. J. Severe open fractures of the

tibia. J. Bone and joint Surg. July 1987, 69-A : 801 807.

14. Chapman M. W. The role of intramedullary fexation in

open fractures,clin Orthop 1986; 212 : 26-34.

15. Charnley J. The Closed treatment of Common Fractures

(3rd ed), Livingstone, Edinburgh, 1961, P: 105.

16. Cierny, George HI, Byrd H. S. and Jones R. E. Primary

versus delayed soft tissue coverage for severe open

tibialfractures. A comparison of result. Clin. Orthop. 1983,

178 : 54-63.

17. De Bastiani G, Aldegheri R, Brivio LR. The treatment of

fractures with a dynamic axial fixator. J Bone joint Surg

(Br) 1984; 66-45.

18. Eggers G. W. N. Internal Contact Splint, Journal of Bone

and Joint Surgery 1948, 30-A : 40.

19. Grosse A, Kempf I Lafforgue D. Treatment of femoral

fractures with interlocking intramedullary nails. Rev. Clir

Orthop 1978, 64 (Suppl 2) : 33-5.

20. Gustilo R.B. Fractures of Tibua and Fibula. In -. Gustilo

RB, Kyle R.F, Tempeman D.C editors. Fracture and

Dislocation. St. Louis, Mosby, Year Book Inc, 1993 :

901-941 Open fractures p. 169-195

21. Haq. Z. Evaluation of Treatment of Open Tibial Shaft

Fracture by llizarov Technique. MS. thesis 1996;

University of Dhaka, Bangladesh.

22. Islam R. Result of Management of Open Tibial Shaft

Fracutres with External Skeletal Fixation in Adults. MS.

thesis 11989; University of Dhaka., Bangladesh.

23. Karlstrom G . and Olernd S. Percutaneous Piu Fixation of

Open Tibial Fractures J Bone Joint Surg. 1975, 57: 91 5-

923.

24. Heating J. F, O’Brien P. L,Blacuhut P . A , Meak R. N,

Brockhuyse H. M. Reamed interlocking intramedullary

nailing of open fracture of the tibia. Clin orthop 1997

May, 338: 182-91.

25. Klein M. P. M, Rahn B. A, Frigg R, Kessler S, Perren

S.M, Reaming versus non-reaming in medullary nailing :

Interference with cortical circulation of the canine tibia.

Arch Orthop Traumat. Surg 1990, 109: 314-316.

26. Krehek C, Gluer S, Schandelmaier P, Tscherne H,

Intramedullaty nailing of open fractures, orthopadics 1996,

25 (3).

27. Lottes J. O. Closed reduction, plate fixation and medullary

nailing of fracture of both bones of the leg. J Bone Joint

Surg (A) 1952, 34A:861 Medullary nailing of the tibia

with the triflange nail. Clin Orthop 1974, 105 : 253.

28. Holbrook J. L, swiontkowski M. F, Sander S. R. Treatment

of open fractures of the tibial shaft: Endcr nailing versus

external fixation. A randomized prospective comparison,

J Bone joint surg [Am|1989, 71 (A):1231-1238.

29. Thunold J, Varhaug Je, Bjerkeset T. Tibial shaft fractures

treated by rigid internal fixation: the early results in a 4-

year series. Injury 1975-76,:125-133.



Original Article

Watson Jones.Chamley (1961).Sarmiento (1967), and Nicoll (1974). The cast through dose not provide great

stability and there is a chance of shortening and malunion. Moreover incases of open fractures soft tissue care

is difficult.Application of a plate and screws provides right internal fixation and has shown comparatively less

incidence of non-union. But the high rate of infection has left much to be desired.

ABSTRACT

This prospective study of” Evaluation of outcome of open intramedullary interlocking nailing in tibial shaft

fracture in adults” carried out at CMCH between January 2007 to July 2008, involving 40 patients with

fractures of shaft of tibia. The aim of this study was to compare the outcome of treatment of closed tibial

fractures by interlocking nail. There were 23 patients with closed tibial shaft fractures and 17 patients

with open tibial shift fractures . 6 patients with closed fractures and 2 patients with open fractures were

lost at subsequent follow up so ultimately there were 32 cases ; 17 with closed fractures and 15 with open

fractures. In this study purposive sampling method was followed irrespective of sex .In open fracture

cases only types I, II and IIIA were selected .Two cases amongst the closed tibial fractures group had

associated ipsilateral femoral fractures and one had an ipsilateral fracture of the radius. Most common

age group in this series was 18-25 years (43.75%). The mean age of occurrence was 31.16 years for

closed fracture and 29.85 years for open fracture. Right side involvement was more (59.37%), while the

middle third of the shaft (59.4%) was the commonest site of fracture followed by the distal third (28.1%). In

cases with open fracture, the wound in 7 (46.66%)cases were closed by delayed primary suture, 5(33.3%)

healed up by granulation ,2 (13.3%) were managed by secondary suture and 1 (6.6%)case was managed by

slit thickness skin graft Mean time of union was 16.5 weeks incase of closed fracture and 26.5 weeks in

case of open fracture various complication were noticed such as, infection (12.54%),leg length discrepancy

(6.27%), knee pain (18.75%), knee and ankle stiffness. There were two cases of delayed union (table

XVIII).The final outcome of treatment was analyzed according to the criteria set by Tucker et al. 1992.

Acceptable results in close fracture were 82.3%while in case of open fracture79.9%were found acceptable

.17.6% of results were graded unsatisfactory in close fracture while 19.9% were unacceptable in open

fracture. So Intramedullary interlocking nailing is a modern, safe and appropriate technique regarding the

management of close and open tibial shaft fracture in adults.

Evaluation of Outcome of Open

Intramedullary Interlocking Nailing In

Tibial Shaft Fracture In Adults

Mohammed Abdus Sobhan1, Mir Hamidur Rahman2, Abdullah Al-Mahmood Bilal3, Milon Krishna

Sarker4, Md.Wahidur Rahman5 , M Monaim Hossen6

1. Senior Consultant, 250 bedded General Hospital Noakhali,



3. Assistant Professor (C,C) OSD, DGHS, attached Abdul Malek

Ukil Medical College, Noakhali





Correspondence: Dr. Mohammed Abdus Sobhan, Senior

Consultant, 250 bedded General Hospital Noakhali, Dhaka

INTRODUCTION

Fractures of the Shaft of tibia constitute the commonest

diaphyseal fractures amonogst all long bones. By this

very location , the tibia is exposed to frequent injury and

because 1/3rd of its surface is subcutaneous throughout

most of its length. Open fracture are more common in the

tibia than in any other bone.

Treatment of tibial fracture continues to pose a challenge

to orthopedic surgeons. Poor soft tissue coverage and

VOL. 29, NO. 2, JULY 2014 181

blood supply act as a deterrent to quick recovery.

Moreover, neuro-vascular injury, compartment syndrome

and infection (more so in open fractures) might add to the

burden. Later, delayed union nonunion and malunion may

complicate a tibial fracture.

The indication for operative and conservative treatment

of tibial shaft fracture has not been well defined. Early

workers advocated conservative management with close

reduction and piaster cast immobilization. Most prominent

amongst these were

Currently for open tibial fractures (Gustilo type II and

Gustilo type III) external fixator seen to be widely accepted.

It provides a right fixation with a relatively low rate of

deep infection, although the problems of pin tract infections

and malunions coupled with a low acceptability to patients,

remain. Over the last couple of decades intrameculiary

nailing of both closed and open fractures of tibial shaft

have come to gain acceptance and popularity.Herzog (1951)

was the first to modify the strainght Knail to accommodate

the eccentric proximal pole. Since then various authores

have reported their work on intramedullary nailing of tibial

fracture. Lottes (1974). Sedlin and Zitner, and d’ Aubigne

et al. (1974) reported encouraging results in the treatment

of both closed and open tibtal fractures.

The management of tibial fracture, both closed and open

by SIGN nailis still in its early stages in Bangladesh. The

study is based on the intrameduilary fixation of closed

and open tibial shaft fractures by IM interlocking nail

PATIENTS AND METHODS

Type of the study :

this was is prospective randomized analysis on the

outcome of intramedullary interlocking nailing in closed

and open tibial shaft fractures in adults.

Place of Study :

Orthopedic units of Chittagong Medical College Hospital

and deferent clicnics in Chittagnog Metropolitan Area,

Chittagong.

Study Duration:

January 2007 to July 2008 ( Year)

Study Population

All the patents above 18 years of age with closed and

open fracture ( upto Gustillo IIIB) of the Shaft of tibia

admitted in the different units of Chittagong Medical

College Hospital Chittagong and deferent clinics in

Chittagong Metropolitan Area, Chittagong.

Inclusion criteria :

· Age – above 18 years of age

· Sex _ patients were selected irrespective of sex

· Site _ diaphyseal (fractures of the tibia ) Shaft,4” below

the knee and 3” above the ankle joint

· Type of fractures

· Closed displaced fractures of the tibia Shaft either

fresh, or those in which initial conservation

management was unsatisfactory ( eg.-lost reduction in

a cast)

· Open fractures, Gustilo typel to type IIIB irrespective

of fracture configuration viz oblique, transverse, spiral,

segmentai and corn minuted. open fractures treated

within 7 days of injury and without any infection will

be included in this study.

· Associated injuries-

Other long bone injuries like fracture of femur, or of the

Humerus, radius and ulna.

Exclusion Criteria :

· Fractures in children

· Gustilo type IIIC

· Active or latent infection

Observation

During the period extending form January’ 07 to June 2008

a total of 32 patients wear studied. Seventeen patients

had close fractures and fifteen suffered open fractures of

tibia.

Occupation of the patients:

people from various walks of life were victims of tibial

fracture..

Age incidence :

in the study age range was form 18 to 55 yes. Maximum

incidence was found in 18 to 25 yrs age group.

Sex distribution:

In this series, 27 cases (84.37%) were, ales and 5 cases

(15.62%) were females.

Causes of injury:In this study motor vehicle accident (

MVA) accounted for 21 cases (65.62%) fall form height for

7 cases (21.8%) and 4 cases (21.5%) were due to assault.

Side involved:

In this study right side involvement was seen in 19 cases

( 59.37%) and left side in 13 cases (40.6%)

182 Mohammed Abdus Sobhan, Mir Hamidur Rahman, Abdullah Al-Mahmood Bilal, Milon Krishna Sarker, et al


Both or single bone involvement:

Both bones were involved in 29 cases (90.6%) 3 cases

(9.3%) had only tibial fractures.

With associated other long bone fractures (other than

fibula):

2 cases (6.2%) had ipsilateral femoral fractures and one

case (6.26%) had a radial fracture.

All associated fractures occurred in cases with closed

tibial fractures only .

Level of fractures :

In this series there were 17 cases (53.1%) involving the

middle i/3. followed by 11 cases (33.3%) in the lower 1/3

and 4 cases (12.5%) in proximal 1/3 of the tibial shaft.

Pattern of fracture (fracture configuration):

In this series, fracture pattern was comminuted in 14 cases

(43.7%), oblique in 9 cases (28.1%), transverse in 7 cases

(21.8%) and segmental in 2 cases (6.25%)

Static or Dynamic nailing of tibial shaft fracture:

In the series 12 closed fracture cases and 12 open fracture

cases were managed by static nailing, 5 closed fracture

cases and 3 open fracture cases were managed by dynamic

locking.

Types of open fractures (Gustilo):

In this study the open fracture types were as follow: 8

were type 1.5 were type II and 2 were type III A.

Soft tissue management (with reqard to wound closure)

in case of open fractures:

In this series, delayed primary suture was applied in 7

patients, in 5 patients wound was left to heal by secondary

intention, secondary sutures were applied in 2 cases and

in 1 case skin graft was applied.

Duration of hospital stay:

Maximum and minimum hospital stay in this series was 7

and 15 days respectively for closed fractures and 10 and

25 days respectively for open fractures.

Time taken for union:

In this series, the minimum time for union in closed fracture

was 14 weeks and maximum was 27 weeks with a mean of 16.5

weeks. In case of open fractures, the minimum time for union

17 weeks and maximum was 35 weeks with a mean of 26.

Time taken for union as per fracture site:

In this series, for the closed group fractures in the distal 1/3

of tibial shaft took the longest to union with a mean of 18.5

weeks while. for the proximal 1/3 fractures had a mean union

time of 15.5 weeks. In case of open fractures distal 1/3 fractures

had a mean union time 29.2 weeks while the proximal 1/3

fractures showed the earliest mean union rate of 20.5 weeks.

Fracture union as per fracture pattern (in weeks):

In this study. In the closed fracture group, comminuted

fracture took the longest to union with a mean of 17.7

weeks, while oblique fracture were the earliest to unite

with a mean of 15.6 weeks. In the open grope, comminuted

fractures had a mean union of 26.57 weeks while. oblique

fracture had a mean of 21.7 weeks

Incidence of complication:

In this series 2 cases had post-operative superficial in

both groups. There was knee stiffness in 3 cases in both

groups. Delayed union was seen in 1 case in each group.

Shortening was observed in 1 case in each group. Other

complication were knee and ankle pain.

Table XVIII. Showing incidence of complications.

Incidence of Infection in the post operative period and

the causative organism:

Post- operative wound infection showed staphylococcal

and pseudomonal infections

Evaluation of Outcome of Open Intramedullary Interlocking Nailing In Tibial Shaft Fracture In Adults 183

VOL. 29, NO. 2, JULY 2014

X-ray after 20 WeeksPost Operative X-ray Preoperative X-ray

RESULTS

Analysis of results of tibial fractures is difficult task.

Besides the fracture itself ,soft tissue healing and

adjacent joint movements, greatly affect the final

outcome.The number of different grading systems is a

proof of lack of one single universally accepted grading

criterion .On this back drop, this study has attempted to

draw a comparative analysis on the outcome of closed

and open tibial fractures when treated by IM interlocking

nail.All the 32 patients in the study were followed up for

at least 6 months and upto a maximum of 12 months. In

fact the most worrisome part of the evaluation was the

time constraint for this type of study.The final result of

the study was analyzed by observng the outcome of

treatment of 32patients,which were included in this study.

For evaluation of results, Tuckers criteria was considered

for both closed and open fractures. A single grading

system for both types of fractures was used to have

uniformity while comparing the outcome of treatment in

bothclosed and open fractures. Moreover this system

included infection as one of the parameters for

assessment of outcome. Excellent and good results were

accepted as satisfactory, while fair and poor results were

regarded as being unsatisfactory. In this series ,for closed

fractures there were satisfactory results in

14cases(82.35%)and unsatisfactory in 3cases (17.64%).

For open fractures there were 12 cases(80%) as

satisfactory and 3(20%)unsatisfactory. Analysis was

done by applying the Chi-square test to compare the

outcome of the results of closed and open groups. There

was no significant difference in the results between the

two groups.

Table XX a.

Results of closed fractures (n=17)

Grading of result No. of patients %

Excellent 8 47.05

Good 6 35.29

Fair 1 5.88

Poor 2 11.76

Satisfactory result (Excellent + Good )= 82.35% Unsatisfactory

result (Fair + Poor) = 17.64%.

Table XX b

For Results of open fractures (n=15)

Grading of result No. of patients %

Excellent 5 33.33

Good 7 46.66

Fair 2 13.33

Poor 1 6.66

Satisfactory result (Excellent + Good )= 80% Unsatisfactory

result (Fair + Poor) = 20%

DISCUSSION

The fractures of the tibial shaft constitute the commonest

diaphyseal fractures amongst all long bones. But in spite

of the vast experience gained over the last 50 years, the

treatment of tibial fractures still can’t be governed by a

given set of rules. A number of treatment methods have

been well documented. The advocates of plaster cast

application have been well (1958) , Nicoll (1964) and

Sarmiento (1967). The main drawback of plaster cast

treatment has been shortening and malunioin. It would

probably be better indicated in cases with stable fractures

with minimal soft tissue injury.Interest in internal fixation

has centered round the use of the AO dynamic

compression plate and this has been well documented

(Thunold et al; 1975). The relatively hih rate of infection

makes the use of a plate an unattractive treatment

option.External fixator provides a rigid fixation with a

relatively low rate of deep infection, but prolonged

application, unsightly appearance and inconvenience to

the patient has limited its use for the treatment of severe

compound fractures, although its use has been

documented in the management of closed and minor

compound fractures of shaft of the tibia (De Bastiani et al.

1984; Court-Brown and Hughes, 1985; Evans. 1988)

Intramedullary devices have been used to stabilize tibial



Final Outcome

fractures for many years. Kuntscher (1958) was the first to

document the treatment of tibial fractures with IM nailing.

Since then a lot of authors have come up with their

observations.Most used the Lottes nail. Aubigne et at.

(1988), Lottes (1974) and Velasco et al. (1997), showed

commendable results in treating tibial fractures with Lottes

nail. The major drawback of simple IM nailing has been

malunion, as demonstrated by Swansonetal.

(1990).Interlocking IM nailing solver the problem of

malunion because it provides the ability to control length,

angulation and rotation. IM nailing of closed tibial fractures

has been an accepted treatment modality for sometime

now. Its use in open tibial fractures has been a more recent

innovation.Ekeland et al. (1987), Court-Brown et al. (1990),

and more recently Keating et al. (1997), have documented

good results in the treatment of open tibial fractures with

interlocking nail. Grosse-Kempf interlocking tibial nail was

used by these workers.While reamed nailing has gained

acceptance in closed tibial fractures, its use in open

fractures is still not considered favourable, due to an

increased incidence of complications.At NITOR the

treatment of tibial fractures with IM interlocking nail has

gradually come to gain acceptance over the last couples

of years. Alam 2002, and Chowdhury 2002, both showed

acceptable results in their study of treating closed and

open tibial fractures respectively with SIGN nail.The

present study has been undertaken in CNCH, Chittagong

to do a comparative analysis on the outcome of treatment

of both closed and open fractures by IM interlocking nail.

In this study, most victims fell under the 18-25 years group

(41.17% for closed fractures and 46.66% for open

fractures), while the next common age group being 26-35

years group (35.29% and 33.33% respectively for closed

and open fractures). The mean age of incidence was 31.16

years for closed fractures and 29.85 for open fractures.

These figures compare favorably with those shown by

other workers. The high incidence of young adult age

group points to the higher rate of mobility as well as social

violence in this age group. Male population in this study

constituted 84.81% of cases, while the females made up

the remaining 15.62%. Bone and Johnson (1986), observed

a male predominance of 81.81%, while Court-Brown et al.

(1990), showed males to make up 81.30% of the cases in

his study. Males being the major working force of a society

and are thus more consistently exposed to the external

environment, which probably accounts for this

discrepancy.Motor vehicle accidents were found to be

the most common causative factor of the injury in this

study (75%).Bone and Johnson (1986),-90%, and Court-

Brown et al. (1991), - 66.6%, both observed motor vehicle

accidents as the major reason for tibial fractures . Gustilo

1993,described road traffic accident as the commonest

cause of open tibial fractures. In this study, motor vehicle

accidents made up a slight higher percentage of victims in

case of open fractures (86.66) as compared to close

fractures (64.70).Most Fractures occurred in the middle

third of the shaft of tibia (53.12), f0llowed by distal third

(34.37) in this series. the incidence of facture level was

more or less similar in both closed and open fractures. this

is consistent with the observations of Bone and Johnson

(1946), Smet et al. (2000), and choudhury (2002).court –

Brown et al. (1990). found a greater incidence of fracture at

the distal third (51%). At its middle third the tibia is slender,

with a subcutaneous anterior-medial surface and lacks

muscle coverage, with a subcutaneous anterior-medial

surface and lacks muscle coverage. which exposes it to

injury. in this series most factures were comminuted (44%).

High velocity trauma results in comminution of bone

(Apley and Solomon 1993). In the study of Blachut et al.

(1997, 71% of fractures were comminuted.The tiba of the

right side fractured in 19 (59.37%)was injured in 13 (40.62)

cases. Both tibia and fibula were fractured in 29 (90.62)

cases of while the tibia alone was fractured in only 3 (9.37%)

cases. in two cases of closed tibial fractures, an ipsilateral

femoral fracture (closed) which was managed by

conservatively.

CONCLUSION

As can be seen from the study, interlocking IM nailing of

tibial fractures is a safe technique with a commendable

performance regarding soft tissue management as well as

fracture healing.After comparing the results of closed and

open tibial shaft fractures when treated with intramedullary

interlocking nail, it can be recommended to be used safely

for both closed and open (type l, ll and lllA) fractures.

REFERENCES

1. Gustilo R. B, Mendoa R. M and Williams D. N Problems

in the management of type 111 (severe) open fractures : A

new classification of type 111 open fractures. J Trauma

1984,24:742-746.

2. Ellis H. The speed of healing after fracture of the tibial

shaft.J Bone Joint Sueg (Br) 1958, 40-B : 42-6

3. Nicoll E. A. Fracture of the tibial shaft a survey of 705

cases. J Bone Joint Surg (Br) 1964,46-8:373-87.

4. Sarmiento A. A functional below-the –knee brace for tibial

fractures Bone Joint Surg (Am)\97Q; 52A: 295-311.

5. Court-Brown C. M, Christie J, Mcqueen M. M. Closed

intramedullary tibial nailing, J Bone Joint Surg (Br) 1990;

72^B: 605-11.

Evaluation of Outcome of Open Intramedullary Interlocking Nailing In Tibial Shaft Fracture In Adults 185

VOL. 29, NO. 2, JULY 2014

6. Allen. w, Piotrowsky G, Burnstein A, Frankel V.

Biomechanical principles of intramedullary fixation. Clin

Orthop. 1968; 60:13-20.

7. Brown P. W, Urban J. G, Early weight-bearing treatmrnt

of open fractures of the tibia : An end-result study of

sixty-three cases. J Bone Joint Surg. 1969, 51A, 59-75.

8. Wenger H. l. Shaft Fracture Immobilizstion with plaster,

American Journal of Surgery 1944, 66, 382.

9. Edwards C. C, Simmon S. C, Browner J. d, Weigel M. C.

Severe Open Tibial Fractures; Result Treating 202 Injuries

withy External Fixation. Clin. Orthop 1988, 230: 98.

10. Lottes J. O. Closed reduction, plate fixation and medullary

nailing of fracture of both bones of the leg. J Bone Joint

Surg (A) 1952, 34A:861 Medullary nailing of the tibia

with the triflange nail. Clin Orthop 1974, 105 : 253.

11 Holbrook J. L, swiontkowski M. F, Sander S. R. Treatment

of open fractures of the tibial shaft: Endcr nailing versus

external fixation. A randomized prospective comparison,

J Bone joint surg [Am|1989, 71 (A):1231-1238.

12. Thunold J, Varhaug Je, Bjerkeset T. Tibial shaft fractures

treated by rigid internal fixation: the early results in a 4-

year series. Injury 1975-76,:125-133.

13. Christensen J, Greiff J, Rosendahl S. Fractures of the

shaft of the tibia treated with AO-compression

osteosynthesis./n/ury 1982 ; 13:307-14.

14. Allo A, Molster A, Thoresen BO, Gjerdej NR, Ekeland

A, Polleras G, etal. Effect of rotational stability of

intramedullary nailing on bone healing. Acta Orthop Scand

1991;62:573-6.

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16. Appley A. G. and Solomon L. Apleys System of

Orthopaedics and Fractures 7th ed. Butterworth-

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D, PopmanD. The treatment of open and or unstable tibial

fractures with an unreamed double locked tibial nail. In :

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tibia, Clin orthop 1997, juni; (339):58-64.



Review Article

Upper Cervical Spinal Injuries : A

Review

Ghosh JC1, Mollah Ershadul Haq2, Dulal Datta3, Monaim Hossen4, Noor Mhammad5, Lokman Hossain6

Abstract:

This study was done to review the management of upper cervical spinal injuries, so that the recent management

trends along with pitfall in management can be utilized for better patient management. Methods: This is a review

study done by searching the literature through pubmed using the key words; injury , upper cervical spine and

management. Correct diagnosis and classification of a lesion is the first step for determining the most appropriate

form of treatment. The emergent evaluation of patient who are at risk of cervical spinal injury relies on standardized

clinical and radiographic protocol to identify and classify injury and predict instability. Upper cervical spinal

injuries are frequently missed and the most common reason is in inadequate radiological examination.

Ligamentous injuries usually require surgical intervention although bony injuries can mostly be managed

conservatively. The indication for operative treatment or significant injuries to cervical spine is basically determined

by instability and dislocation and urgency of operative treatment in based on neurological status. Upper cervical

spinal injuries are commonly associated with trauma and which require significant force to produce. Significant

upper cervical spinal injuries are potentially life threatening injuries that may cause immediate death as a

consequences of complete respiratory arrest due to brain stem compression.

Key word: Upper cervical, Spinal injury, Management.

1. Associate professor (ortho -surgery), Gopalgonj Medical College, Gopalgonj

2. Assistant Professor of Orthopaedic Surgery, Shiheed Suhrawardy Medical College Hospital, Dhaka

3. Assistant Professor of Orthopaedic Surgery, NITOR, Dhaka

4. Associate Professor of Orthopaedic Surgery, NITOR, Dhaka

5. Associate Professor, BIHS General Hospital, Mirpur, Dhaka

6. Assistant Professor, Department of Orthopaedics, NITOR, Dhaka

Correspondence: Dr. Jagodish Chandra Ghosh, Associate Professor (ortho -surgery), Gopalgonj Medical College, Gopalgonj, Email:

[email protected]

INTRODUCTION

Cervical spine trauma is a common problem with wide range

of severity from minor ligamentous injury to frank osteo-

ligamentous instability with spinal cord injury.12

Approximately 5-10% of patient who are unconscious and

present on emergency basis as a result of motor vehicle

accident or fall have major injury to the cervical spine. The

cervical spine is conventionally divided into upper and lower

cervical spine . The upper cervical spine extend from occipital

to 2nd cervical vertebrae and lower cervical spine from C3-C7

vertebrae. The anatomy of upper cervical spine is unique in

its structural design This distinctive anatomy the upper

cervical spine leads injuries to occur in a predictable pattern.4

Most of the upper cervical spinal injuries are due to high

energy trauma and among all the cervical spinal injuries about

one third occurs at the level C2. Common injuries of upper

cervical spine include occipital condylar fracture, atlanto

occipital dislocation fracture of the ring of C1, ligamentous

injuries, odontoid fracture and C2 body fracture.4 The

integrity of upper cervical spine is essential for survival and

function because of the neurovascular structure contained

within its bony elements.1 The skull base with its bony and

ligamentous elements surrounding the foramina magnumplays an integral part in maintenance of normal functionalalignment of these two cervical vertebrae. Bony injuries canbe treated either by conservative or surgical interventiondepending on the fracture stability but significantligamentous injury needs surgery. Atlanta-occipitaldislocation is uncommon injuries and usually fatal injuriesbut there are reports of survival of such patient with urgentand appropriate management.

RESULTSDislocation of atlanta-occipital joint:Atlanta-occipital dislocation are uncommon injury. Thisinjury is rarely seen even in a level1 trauma centre and it isassociated with high morbidity and mortality. It may beeither anterior or posterior but usually fatal. Bone fracturemay accompany atlatooccipital dislocation . Althoughmost of the patient die immediately of complete respiratoryarrest caused by brainstem compression but, there arereports in the literatures in of patient who survived thisinjury..6 Survival in atlantooccipital dislocation is possible

in patient with minimum neurological deficit and if

VOL. 29, NO. 2, JULY 2014 187

diagnosed quickly and treated appropriately. Treatment

of this injury consist of reduction of dislocation and

stabilization of the atlanto occipital joint. Rapid diagnosis

by CT scan is so called gold standard and treatment

initiation using occipitocervical stabilization if possible or

temporary application of a halo fixator is crucial because it

is possible for adults to survive this injury.7Cervical

traction is contraindicated because instability. Immediate

application of a halo vestis recommended to stabilize the

joint. Patient’s respiratory and neurological status must

be carefully monitored. Occipital condylar fracture:

Occipital condylar fractures are rare.19 This injury

infrequently missed on initial evaluation. The first

description of occipital condylar fracture inliterature was

provided by Bell in 1817.18 These injuries usually results

from axial loading andlateral bending during which force

is applied to the head and neck .Stable occipital

condylerfracture can be treated in a rigid cervical orthoses

or halo vest. Potentially unstableinjury needs

immobilization in a halo vest for 12 weeks. After an

adequate period of immobilization in a halo vest if

instability is indicated by flexion and extension imaging

film then occipital C2 fusion may be necessary. If atlanto-

occipital dislocation has been diagnosed in addition to

fracture then it require surgical stabilization independent

of occipital condylar fracture andit is a significant predictor

for outcome. 24 Atlas fracture: Atlas fracture represent 2%

of all vertebral spine fracture and occur when an axial

compression of the skull on the atlas forces it into the axis

resulting in a fracture at the weakest point. Most fracture

in the atlas can be treated with immobilization in a rigid

cervical orthosis or in halo vest. Isolated posterior arch

fracture are stable injuries that can be treated in a cervical

collar for 8-12 weeks. Levine and Edward found that53%

of patient with atlas fracture had additional cervical spinal

injuries in their series. Non displaced or minimally displaced

fracture of the lateral mass and Jefferson fracture can be

treated by collar immobilization to prevent displacement

and allow fracture healing. Fracture in which the lateral

mass of atlas is displaced laterally more than 7mm beyond

the articular surface of the axis should be reduced with

halo traction .Halo traction should be maintained for 3-

6weeks before application of a halo vest if the lateral mass

is severely displaced, since displacement may recur if a

halo vest is applied immediately after reduction. Rupture

of transverse ligament: This is a purely Ligament us injury

and different from other injuries involving C1-C2 complex.

It is most commonly results from a fall with blow to the

back of the head. The transverse ligament may be avulsed

with a bony fragement from the lateral mass on either side

or it may rupture in its midsubstances. Because rupture of

the transverse ligament is primarily a ligamentous injury ,

nonoperative treatment is ineffective in obtaining stability.

Surgical stabilization of the C1 complex is the treatment of

choice. Axis fracture: The mechanism of axis fracture is

hyperextension injury. Among the axis fracture odontoid

fracture most often result from trauma.tic flexion In young

patient these injury require a good deal of forces such as

motorvehicle collision, skiing or fall from a height.

Immediate death from medullary injury may occur. Fracture

through the base of the dens neck are the most common

type of dens injury and are usually unstable injury. ,fracture

displaced beyond 6mm in old or that are unstable even in

halo vest require surgery. Fracture through the body of

the axis may be displaced or undisplaced. Undisplaced

fracture are stable injuries that heal with 8-12 weeks of

immobilization in either a halo vest or cervical collar.

Displaced fracture may have multiple combination of

angulations and translation although most of these fracture

could be reduced with halo traction, continuous traction

with extension is required to maintain reduction. Traumatic

spondylolisthesis of axis (Hangman fracture) : Hangman

fracture was originally described as those neck injuries

that incurred during hanging of criminals. Their most

common cause now a days are motor vehicle accident

with hyperextension of the head on neck. The occiput is

forced down against the posterior arch of the atlas which

in turn is forced against the pedicle of C2. Minimally

displaced and stable Hangman fracture usually heal within

12 weeks of immobilization in a rigid cervical orthosis.

Hangman fracture with more than 3mm of anterior

translation and significant angulations require application

of skull traction through tong or halo ring with extension

of the neck over a rolled up towel. Immobilization in a halo

vest does not achieve or maintain reduction and halo

traction with slight extension may be necessary for 3-6

weeks to maintain anatomical reduction , then the patient

can be mobilized into a halo vest for the rest of the 3

months period. In more severe form of this fracture there

may be a combination of bipedicular fracture with posterior

facet injuries.This injuries are the only type of Hangman

fracture that require surgical stabilization .Open reduction

and internal fixation are generally required and treated

appropriately. Treatment of this injury consist of reduction

of dislocation and stabilization of the atlanto occipital joint.

Rapid diagnosis by CT scan is so called gold standard

and treatment initiation using occipitocervical stabilization

if possible or temporary application of a halo fixator is

crucial because it is possible for adults to survive this

injury.7Cervical traction is contraindicated because

188 Ghosh JC, Mollah Ershadul Haq, Dulal Datta, Monaim Hossen, Noor Mhammad, Lokman Hossain


instability. Immediate application of a halo vestis

recommended to stabilize the joint. Patient’s respiratory

and neurological status must be carefully monitored.

Occipital condylar fracture: Occipital condylar fractures

are rare.19 This injury infrequently missed on initial

evaluation. The first description of occipital condylar

fracture inliterature was provided by Bell in 1817.18 These

injuries usually results from axial loading andlateral

bending during which force is applied to the head and

neck .Stable occipital condylerfracture can be treated in a

rigid cervical orthoses or halo vest. Potentially

unstableinjury needs immobilization in a halo vest for 12

weeks. After an adequate period of immobilization in a

halo vest if instability is indicated by flexion and extension

imaging film then occipital C2 fusion may be necessary. If

atlanto-occipital dislocation has been diagnosed in

addition to fracture then it require surgical stabilization

independent of occipital condylar fracture andit is a

significant predictor for outcome.24 Atlas fracture: Atlas

fracture represent 2% of all vertebral spine fracture and

occur when an axial compression of the skull on the atlas

forces it into the axis resulting in a fracture at the weakest

point. Most fracture in the atlas can be treated with

immobilization in a rigid cervical orthosis or in halo vest.

Isolated posterior arch fracture are stable injuries that can

be treated in a cervical collar for 8-12 weeks. Levine and

Edward found that53% of patient with atlas fracture had

additional cervical spinal injuries in their series. Non

displaced or minimally displaced fracture of the lateral mass

and Jefferson fracture can be treated by collar

immobilization to prevent displacement and allow fracture

healing. Fracture in which the lateral mass of atlas is

displaced laterally more than 7mm beyond the articular

surface of the axis should be reduced with halo traction

.Halo traction should be maintained for 3-6weeks before

application of a halo vest if the lateral mass is severely

displaced, since displacement may recur if a halo vest is

applied immediately after reduction. Rupture of transverse

ligament: This is a purely Ligament us injury and different

from other injuries involving C1-C2 complex. It is most

commonly results from a fall with blow to the back of the

head. The transverse ligament may be avulsed with a bony

fragement from the lateral mass on either side or it may

rupture in its midsubstances. Because rupture of the

transverse ligament is primarily a ligamentous injury ,

nonoperative treatment is ineffective in obtaining stability.

Surgical stabilization of the C1 complex is the treatment of

choice. Axis fracture: The mechanism of axis fracture is

hyperextension injury. Among the axis fracture odontoid

fracture most often result from trauma.tic flexion In young

patient these injury require a good deal of forces such as

motorvehicle collision, skiing or fall from a height.

Immediate death from medullary injury may occur. Fracture

through the base of the dens neck are the most common

type of dens injury and are usually unstable injury. ,fracture

displaced beyond 6mm in old or that are unstable even in

halo vest require surgery. Fracture through the body of

the axis may be displaced or undisplaced. Undisplaced

fracture are stable injuries that heal with 8-12 weeks of

immobilization in either a halo vest or cervical collar.

Displaced fracture may have multiple combination of

angulations and translation although most of these fracture

could be reduced with halo traction, continuous traction

with extension is required to maintain reduction. Traumatic

spondylolisthesis of axis (Hangman fracture) : Hangman

fracture was originally described as those neck injuries

that incurred during hanging of criminals. Their most

common cause now a days are motor vehicle accident

with hyperextension of the head on neck. The occiput is

forced down against the posterior arch of the atlas which

in turn is forced against the pedicle of C2. Minimally

displaced and stable Hangman fracture usually heal within

12 weeks of immobilization in a rigid cervical orthosis.

Hangman fracture with more than 3mm of anterior

translation and significant angulations require application

of skull traction through tong or halo ring with extension

of the neck over a rolled up towel. Immobilization in a halo

vest does not achieve or maintain reduction and halo

traction with slight extension may be necessary for 3-6

weeks to maintain anatomical reduction , then the patient

can be mobilized into a halo vest for the rest of the 3

months period. In more severe form of this fracture there

may be a combination of bipedicular fracture with posterior

facet injuries.This injuries are the only type of Hangman

fracture that require surgical stabilization .Open reduction

and internal fixation are generally required .

DISCUSSION

Upper cervical spinal injuries are potentially life threatening

injuries and most of them are associated with high energy

trauma.4 In older patient stiffness of the lower cervical

spine caused by degenerative changes and osteopenia

might contribute to upper cervical spinal injury in response

to low energy trauma.20 Achieving the correct diagnosis

and classification of a lesion is the first step towards

identifying the most appropriate form of treatment.19 ,23

Current protocol for evaluation of suspected cervical spinal

injury include combine information from history, clinical

examination and imaging evaluation to predictthe

instability ,identify neurological deficit and the need for

Upper Cervical Spinal Injuries : A Review 189

VOL. 29, NO. 2, JULY 2014

surgical intervention.12 The immediate clinical examination

of the spine should include inspection and palpation of

the spine as well as the complete neurological examination

.In addition cranial nerve examination should always be

performed. Nerve palsies related to cranial

nerves6,7,9,10,11,12 can occur in association with upper

cervical spinal injuries.13,14 There is a significant chance

of missing upper cervical spinal injury during evaluation

of the patient.23 The reported frequency of missed injury

in the cervical spine varies from 4%-30%.12 The most

common reason cited for missed injuries is an inadequate

radiological examination. 10,11,12 The complex regional

anatomy and overlying structure make plain radiological

images difficult to interpret these injuries adequqtely.21

CT and MRI are required in the course of diagnosis for the

traumatic injury of the upper cervical spine Management

of patient with cervical spine injuries is urgent as there

might be immediate death from some upper cervical spinal

injury , so early recognition and prompt treatment can

reduce the mortality and morbidity. The treatment option

may be either conservative or surgical depending on

fracture stability, status of the relevant ligamentous

structure , fracture pattern and alignment .3 Bony injuries

including occipital condylar fracture, atlas fracture ,most

odontoid fracture and traumatic spondylolisthesis of the

axis generally respond well to nonsurgical treatment .19

The indication for operative treatment of significant

injuries to cervical spine is basically determined by

instability and dislocation. Urgency of operation is based

on neurological status, if there is chance of recovery

operative treatment is urgent.4,5

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7. Muller FJ, Kinnel B, Neumann C,Nerlich M, Fuechtmeier

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42.

11. Gerrelts BD, Petersen EU, Mabry J, Petersen SR. Delayed

diagnosis of cervical spinal injuries. J

Trauma.1991;31:1622-6.

12. Joel A, Torretti and Dilip sengupta. Cervical spine trauma.

Indian J Orthop. 2007 Oct- Dec;41(4):255-267. doc

104103/0019-36985

13. Arias MJ. Bilateral traumatic abducens nerve palsy with

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14. Mc Cleary AJ. A fracture of the odontoid process

complicated by tenth and twelveth cranial nerve palsies:

A case report. Spine 1993;18:932-5.

15. Strohm PC1 ,Muller ChA, Kostler W, Reising K, Sudkamp

NP. Halo- fixator vest: indication and complications.

Zentralbl Chir .2007 Feb;132(1):54-9.

16. Basu S, Chatterjee S, Bhattacharaya MK, Seal K. Injuries

of the upper cervical spine:A series of 28 cases. Indian J

Orthop. 2007 Oct; 41(4): 305-11. doc 10.4103/0019-

5413.36992

17. Danerymez M, Kahraman S, Gezen F, Sirin S. Cervical

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20. Watanabe M1 ,Sakai D, Yamamto Y, Sato M, Mochida J.

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SmailysA. Upper cervical spinal injuries and their

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24. Muller FJ, Fuechtmeier B, Rosskopf M, Neumann C,

Nerlich M, Englert C. Occipital condyle fracture:

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VOL. 29, NO. 2, JULY 2014

Case Report

Health Seeking Behaviour of Road

Traffic Accident Victims: A Qualitative

Study among the Slum Dwelling

Disabled People of Dhaka City

Mohammad Mahbub Alam Talukder1, Md. Ali Imam2, Nasrin Akter3, Nasir Uddin Sheikh4

ABSTRACT

Road traffic accident is a global problem which is severe in the developing countries like Bangladesh. In

consequence, in developing countries road trauma has now been recognized as an increasing public health

hazards and economic burning issue. And after road traffic accidents the lack of management and economic

costs related with health seeking behabiour have a disproportionate impact on lower income groups, thus

contributing to the persistence of poverty in conjunction with disability. This cross sectional study, carried out

during July 2012 to June 2013, aimed to explore health seeking decision and culture of handling the road traffic

accident related victims, as taken from experiences of the poor disabled people of slum dwellers of Dhaka city.

The present study has been designed based on qualitative techniques such as in-depth interview and case

studies. Additionally, a survey questionnaire was used to collect the demographic characteristics of the study

population (n=150) and to select participants purposively for in-depth interview (n=50) and case study (n=30).

Content analysis of qualitative data was done through theme coding and matrix analysis of case study was done

to use relevant verbatim. Most of the time the health seeking decision totally depended on the surrounded people

of the accidental place, their knowledge, awareness and remaining facility and capacity regarding proper

management of the victims. However, most of the cases the victims did not get any early treatment and it took 2-

12 hours to get even the first aid because of distance, shortage of money, lack of availability of getting the aid, lack

of mass awareness etc. Under the reality of discriminated and unaffordable health service provision better

treatment couldn’t turn out due to economic inability of the poor victims. To avoid the severe trauma, treatment

delay must be reduced by providing first aid within very short time and to do so mass awareness campaign is

necessary for handing the victims. Moreover, necessary measures should be taken to ensure cost free health

service provision to treat the chronic disabled condition of the road traffic accident related poor victims.

Key words: Accident, Injury, Disabled, Qualitative, Slum.

INTRODUCTION

Road traffic accident is a ‘global tragedy’ with ever-rising

trend and represents a major cause of premature deaths

and disabilities worldwide. Each year, 1.3 million people

are killed and 50 millions are injured by road accidents all

over the world. (iRAP, 2008a). Road trauma has now been

recognized as one of the significant diseases of industrial

societies and is an increasing public health hazards and

economic burning issue in developing countries.

Accidents are particularly prevalent in low and middle

income countries- around 88 percent of the world’s deaths

occur in developing countries (Mackay, 2003). According

to a study, the numbers of fatalities have been increasing

from 1009 in 1982 to 2082 in 2011 in Bangladesh (ARI

Database, 2012). It is estimated that by 2020 about two-

thirds of the world’s traffic fatalities might be in the Asian-

Pacific region. The economic costs of road crashes, which

range from 1 percent to 3 percent of GDP in Asia, have a

disproportionate impact on lower income groups, thus

contributing to the persistence of poverty. Also it has

been observed from the studies that up to 62 percent of

urban road accident deaths are pedestrians alone and in

1. Professor of Accident & Research Institute, BUET, Dhaka

2. Research Investigator, ICDDR,B, Dhaka

3. Operation Research Manager, Consult AID, Bangladesh\

4. Research Manager, Consult AID, Bangladesh

Correspondence: Dr. Mohammad Mahbub Alam Talukder, Professor of Accident & Research Institute, BUET, Dhaka


Dhaka city, they represented nearly 70 percent. Almost 80

percent of fatalities are vulnerable road users e.g.

pedestrians, bicyclists and motorcyclists (Hoque, 2006).

According to the World Health Organization report on

road traffic injury prevention (WHO, 2004), for every death,

there are far greater numbers of injuries- 04 persons with

severe/permanent disabilities, 10 persons requiring

hospital admission, and 30 persons were requiring

emergency room treatment. These facts demanded that

there is indeed an urgent need to develop an appropriate

and co-operative health system response to this man-made

epidemic by implementing strategic programs that will

effectively address such a major growing issue of road

traffic accidents and injuries.

In these circumstances this study aims to explore the

healthcare seeking decision and culture of handling the

road traffic accident related victims in the light of their

existing experiences. The study also tried to assess socio-

economic and demographic characteristics of the victims

who are the slum dwellers of Dhaka city. Simultaneously,

an attempt was made to explore the knowledge, beliefs,

norms, attitudes, behavior and practices related to health

seeking decision of the victims.

METHODS

This is a cross sectional descriptive study among poor

slum dwelling disable peoples of Dhaka city that had been

conducted during July 2012 to June 2013. The present

study was designed based on qualitative methods and to

do so qualitative techniques such as in-depth interviews

and case studies were used. Additionally, a survey

questionnaire was used to collect the socio-economic

background and demographic characteristics of the study

population. The study area included three differently

located slums of Dhaka city (Duaripara, Vasan tek and

Korail slums). The study populations were the poor

disabled persons and the victims of traffic related accidents

and their household members living with him/her in the

selected slum locations.

Participants were selected purposively to ensure both male

and female and to ensure category of the research

participants (road traffic accident victims). For interview

we also sought to enroll 150 road traffic accident victims’

those were generally disabled and aged between 21-60

years. It was a small survey of traffic accident related 150

disabled in slum community of Dhaka city and survey

interview was used for collecting the socio-economic

background and demographic characteristics of the study

population as well as to identify more vulnerable

participants for in depth interview. Based on survey

interview more disabled were invited to attend one to one

in depth interview and 50 qualitative interviews were

conducted by skilled research assistant and sequentially

identified 30 most disable victims for case study. Selection

was again purposive and was designed to reflect the views

of traffic accident related disabled of both the sexes and

their willingness to talk openly to the research team.

Diagram 1: Sampling, Sample size and Research tools

Mohammad Mahbub Alam Talukder, Md. Ali Imam, Nasrin Akter, Nasir Uddin Sheikh 193

VOL. 29, NO. 2, JULY 2014

Before interviewing with the informants the researchers

built rapport and described the objectives of the study.

The investigator sought the verbal consent from the

individuals to provide their personal information and their

related practices in the relevant study field and ensured

the confidential issues of their information that used only

for this research purpose.

Analysis of data was begun with the first field activities

and led to refinements as the study proceeded. The field

notes were regularly reviewed with the field team (initially

daily). The field team met the Principal Investigator (PI)

every other day to discuss the results of their activity

sessions/interviews and to determine the best practices

for further activity sessions/ interviews and note-taking.

From the beginning, thematic analysis took place to

understand the health seeking decision and culture of

handling road traffic accident related victims. The process

followed a sequence of interrelated steps recommended

by Ulin et al. that include reading, coding, displaying,

reducing, and interpreting. (Ulin 2002). Thus, data were

organized according to a sequence. After that, qualitative

findings were presented and discussed compared with

existing relevant studies and literature on this topic.

Moreover, the personal narratives presented in this report

are literal translations of the same language that was

delivered at the time of the interview. To present the

complex view of most disable victims verbatim from case

studies were used that were directly translated from the

transcripts. The triangulation of methods and comparison

of various accounts by different FROs were employed to

improve the quality of research results, which is also

recommended by Denzin (Denzin 1989). Cross tabs were

made to present the demographic characteristics of the

informants.

RESULTS AND DISCUSSION

The presentation of the findings is organized in three

different sections. The first section report from the finding

of survey interview and illustrates the major information

of the disabled person’s demographic characteristics. The

second section reports from the findings of the case

studies conducted among poor road traffic accident related

victims of slum of Dhaka city. This section focuses on

describing the (i) factors associated with health care

seeking behaviour. The second section reports from the

findings of in-depth interviews and focuses on explaining

(ii) first aid and culture of handling road traffic accident.

Verbatim quotations are used to illustrate findings in the

both sections. Speech reported in the article was translated

into English by the both first and second authors.

DEMOGRAPHIC CHARACTERISTICS:

There was preponderance of male (97 %%) and female

(3%) children with an age range from 21-60 years and

among them 50%% were 31-40 years aged. Of the 150

participants of both categories who participated in survey

interview, 38 (25%) never went to school and 56 (71%)

only got primary education. 33% of the victims reported

that in consequence of road accident they bound to take

begging as their main occupation 31% of them were

involved in small business to survive. All female victims

who participated in the research were housewife. A

significant number of families 80 (53%) had taka 2001-4000

per month income.

Table-I

Socio-demographic Characteristics of the informants

Characteristics Frequency (n) Percentage

(N=150) (%)

Sex

Male 145 97

Female 05 03

Age (years)

21-30 09 06

31-40 75 50

41-50 46 31

51-60 20 13

Education

Illiterate 38 25

primary 76 51

Secondary 30 20

SSC 03 02

HSC 02 01

BA 01 0.67

Occupation

Small Business 47 31

House wife 03 02

Beggar 50 33

Farmer 05 03

Government Service 04 03

Private Service 20 13

Unemployment 21 14

Income (monthly)

Up to 2000 24 16

2001-4000 80 53

4001-6000 25 17

6001-8000 15 10

194 Health Seeking Behaviour of Road Traffic Accident Victims: A Qualitative Study among the Slum Dwelling Disabled People


Factors associated with health care seeking decision:

The result of the study shows that most of the time the

health seeking decision totally depended on the

surrounded people of the accidental place, their knowledge,

awareness and remaining facility and capacity regarding

proper management of the victims. By analyzing the in

depth interview findings this study identified four causes

that hinders the health seeking behavior of the victims for

acute conditions and for injuries; these are lack of

opportunity even to get first aid due to limitations of

transport and weak communication systems, long distance

of the health facilities, poor victim’s shortage of money

and eventually lack of mass awareness about rapid

management of road traffic accident victims. Moreover,

from the case studies the scenario of health seeking

behavior of the victims has been explored to understand

the accidental incidents and the way of being gone under

any sort of treatment.

Limitations of transport and weak communication systems:

Lack of proper transportation and immediate

communication systems leads treatment delay which in

consequence forces the victims to accept the chronic

disability in life time.

CASE: 1

“One day I was going to bus stand by rickshaw to go to

my village. All of a sudden a truck stroked my rickshaw

and I fell down in road side and lost my sense. Few minutes

later I found that few people were carrying me to hospital

by van (one type of three wheelers). They admitted me in

a private medical hospital. I told everything to doctor about

the accident then they phoned my relatives and later my

mother and brother came and broke down into tears. But it

was too late. I tried to seat but could not, severe pain

graved me, and one of my hands was bended with bed.

Doctor confirmed to my elder brother that my right hand

had been damaged. As it was deteriorating day by day

lastly it had to cut. Till then I am fully crippled and have

been bearing disable life (Male, age-50, married).”

Long distance of the injury service health facilities:

The long distance of the health facilities related with road

traffic injury has been found in the study as hindering to

get proper treatment in proper time to avoid long term

disability.

CASE: 2

“Near about one year ago, one morning I was going to my

working station. As I was so busy at bus stand, so to ride

the bus suddenly I fell down. Last wheel of the bus ran

over on my two legs. I was groaning “mother, mother”. I

lost my sense. When I got back my sense I was in a nearby

private clinic at Savar. Taking consideration of my severity

the hospital authority sent the message to my guardian.

Later I was sent to the trauma Hospital in Dhaka. Lastly

my legs were cut out. After 10 months treatment I came

back at home. I am now physically challenged person (Male,

age-23, unmarried).”

CASE: 3

“Three years ago I was going to Comilla with my husband

during Eid –Ul-Azha. Our bus stroke another truck and

our bus turned out. I and my husband both were injured

but I was severely injured. I felt a severe pain in my waist

and legs. Passersby rushed me to a nearest hospital by

tempo. As my condition was deteriorating day by day

then I admitted into a clinic in Dhaka. Doctors decided to

cut off my ankle by a surgery. After the surgery I was

crippled (Female, age-35, married).”

Lack of affordability of poor victims:

The result of the study finds disability as consequence

the poor victims’ shortage of money to get proper

treatment from proper health facility. In addition, due to

the decision often taken by the strangers with minimal

knowledge, the victims often had been shifted to

commercial private clinics rather than shifted to

Government trauma hospitals.

CASE: 4

“Five years ago, one day I was crossing the busy road of

Shewrapara, Mirpur. Unexpectedly a rushed private car

stroked me and I fell down following senseless. Pedestrians

carried away me to Showrowardy Hospital and later I was

shifted to a private clinic and not to the pongu haspatal

(Public Orthopedic hospital). As I was not capable to

bear the cost of treatment, so my operation was not

successful. One of my legs had to cut. Later because of

lethal infection I fully lost my one leg. In this way I lost my

leg forever. It is my fate I have lost my leg now I am helpless

(Male, age-40, married).”

Lack of mass awareness about rapid management of road

traffic accident victims:

Most of the time the health seeking decision totally

depended on the surrounded people of the accidental

place, their knowledge, awareness and remaining facility

and capacity regarding proper management of the victims.


VOL. 29, NO. 2, JULY 2014

Often the lack of taking the right decision makes the poor

disable.

CASE: 5

“Just after accident local people shifted me to Dhaka

Showrowardy Hospital that was 8 kilometer away from the

accident spot. After almost 3 and half hours I got my first

aid in that hospital by the doctor of the hospital who was

on duty. (Male, age-40, married).”

Whereas, the study also finds some positive cases since

the road traffic accident related victims were managed

properly by the appropriate health seeking decision of

mass people. And it could assist the victims to recover

injury.

CASE: 6

“One day morning I was going to my office by bus. After

one kilometer ahead a truck stroke heavily to my bus, in

consequence the bus lost its way and hit the island on the

road. One of the heavy parts of the bus falls on my leg and

my ankle was broken. One passer-by took me to a private

hospital, later he took me disability hospital. I took

treatment seven days there and came back home (Male,

age-50, married).”

CASE: 7

“One day I determined to go Farmgate from Shahbagh.

When I was waiting for a bus, suddenly a microbus strokes

me from my back. I fell down on the street. People rushed

me into nearest pharmacy for first aid .They also collected

some money for me. As I had no money I came back home

by taking some medicine and I did not able to go to hospital

further. At last I lost both of my legs. Now I can’t walk

(Male, age-42, married).”

The study saw the sights of the depriving experiences of

the road traffic accident related victims since the moment

of accidental incident to health seeking behavior follows

to disability. This study reveals the facts how the

interviewees had to face these incidents. All the informants

of the study were sufferer but their experiences of health

seeking behavior and sufferings were not same. These

unexpected incidents came as a nightmare to their life.

The unbearable sorrows, thousands of adverse situations

and dependency to others started from the health seeking

moment to the lifelong passage of life.

First Aid and handling road traffic accident:

Distance, shortage of money, lack of opportunity of getting

the aid, lack of mass awareness again has been identified

as the main obstacles of getting the first aid assistance.

Most of the cases it took 2 to even 12 hours to get the first

aid. And findings of treatment seeking reveals the facts

that most often the victims did not get any early treatment

even the first aid. Moreover, in many cases it took more

and more time to get first aid. As one of the victims said-

“Few people took me away by helping me hand to hand

to hospital by CNG vehicle after my accident which is 12

km away from the accident spot. I took the first aid only

after reach at that hospital. “

Whereas, some victims would able to get the first aid

facilities and their recovery rate was higher. As one said-

“First the people of surroundings shifted me to a nearest

private clinic, 2 km away from the spot, by taxi. I got my

first aid immediately in that hospital and then they shifted

me to disability hospital.”

Diagram 2: First aid services in handling road traffic

accident related victims

In case of any road traffic accident first aid is the most

valuable issue after the accident. If the victim gets the

immediate first aid then the possibility of curing is higher.

However, the study explores the cause of treatment delay

that leaded to severe chronic disable condition of the

victims.

CONCLUSIONS AND RECOMMENDATIONS

The results of the study explore the health seeking

behavior after an incident of road traffic accident which

helps us to understand the context of existing first aid

facility and injury management. In Bangladesh, people are

vulnerable to different types of disability but treatment

facilities are not available to them. A large proportion of

196 Health Seeking Behaviour of Road Traffic Accident Victims: A Qualitative Study among the Slum Dwelling Disabled People


people do not get treated because they cannot afford it.

Eventually, the lack of productivity caused by disability

and high medical treatment costs drive them towards

poverty, and poverty makes people ill. However, less

attention is paid to factors influencing medical treatment

seeking patterns or economic impoverishment of the

household, which are also important factors. Broadly,

by understanding the health seeking behavior and

health system response to the victims of traffic related

accident this research has created opportunity to

develop more fruitful ways of new intervention

designing to diminish the road accidents as well as to

reduce the sufferings of the disabled people.

It can be concluded that treatment delay must be reduced

by providing first aid within very short time and mass

awareness raising campaign is necessary to avoid the

severe trauma. Moreover, necessary measures should be

taken to ensure cost free public health service provision

to treat the long term disabled condition.

REFERENCES

1. Accident Research Institute –ARID (2012), Database.

2. Hoque MM. (2006), Understanding Road Accident

Problems and their Remedies, Road Safety Training

Course, ARC, BUET.

3. International Road Assessment Program- iRAP (2008)

Country Report.

4. Mackay M. (2003). Global Road Traffic Injuries: An

Overview of the Problem, UN Technical Briefings on the

Global Road Safety Crisis.

5. World Health Organization-WHO (2004). Injury Report.


VOL. 29, NO. 2, JULY 2014

Book Review

Dr. Iqbal Qavi

“Current Progress in Orthopaedics” edited by Ashok Johar,i

MS(Orth), MCh (Orth), FRCS (Lo), FAMS from India, Keith DK

Luk, MD from Hong Kong and James P Wadell, MD, FRCSC from

Canada. List of contributors include 58 eminent academician,

clinicians and researchers from renowned institutes from different

parts of the world. The book has been endorsed by the

International Society of Orthopaedic Surgery and Traumatology,

SICOT.

Medical Knowledge is constantly changing. As new information

becomes available, changes in treatment, procedures, equipment,

and the use of drugs become necessary. The authors, editors, and

contributors have , as far as possible, taken care to ensure that the

information given in the text is accurate and up-to-date.

The book contains 24 chapters on different topics. The topics

include present status of treatment modules like Ponseti

management of clubfoot, management of cerebral palsy, and

brachial plexus birth palsy. The book includes difficult problems

in trauma such as management of open fractures, treatment of

displaced femoral neck fractures, operative management of distal

radial fractures in adults, and functional non-surgical treatment of

humeral fractures. Topics related to joint replacement surgery are role of joint registries in implant selection, role of

osteotomy, unicondylar arthroplasty and total knee arthroplasty in osteoarthritis of knee, role of cemented stem in total

hip replacement surgery, and role of hip resurfacing surgery. Topics related to arthroscopy are cartilage repair and

regeneration, advances in arthroscopic rotator cuff repair, and anatomic double-bundle ACL reconstruction. Spine

related topics include early onset scoliosis, sagittal alignment in degenerative lumber spine disease, prosthetic total disc

replacement, treatment of TB spine, and management of spinal metastasis. Other miscellaneous interesting topics are

femoroacetabular impingement, progress in limb lengthening, and joint preservation and biological reconstruction for

osteosarcoma around the knee.

The book is an interesting reading for update knowledge on recent developments in the above mentioned topics. The

authors hope to bring many more volumes in this series in the coming years.

The book is published by TreeLife Media, Kothari Medical Subscription Services Pvt. Ltd., Mumbai, India.


Documents

The Journal of Bangladesh Orthopaedic Society (JBOS)