Management of Adult Traumatic Brachial Plexus Injury.

Brachial plexus injury is not uncommon in our country like Bangladesh and it causes functional damage and physical disability of the upper limbs. Most of the cases were caused by motor vehicle accident. We have conducted a prospective study for the operative treatment of 105 adult traumatic brachial plexus injury cases in Hand unit in the department of Orthopaedics, Bangabandhu Sheikh Mujib Medial University (BSMMU) during January 2012 to July 2019. The main surgical options for brachial plexus injury include primary reconstructive surgery such as neurolysis, direct repair, nerve graft, nerve transfer (neurotization) and possibly free functioning (gracilis) muscle transfer and secondary reconstructive procedure such as tendon transfer, arthrodesis, FFMT and bony procedure. Each of these procedures is used either alone or in combination for particular clinical scenarios. Aims and objectives of this study was to restoration of shoulder abduction and external rotation, elbow flexion and hand function are goal of treatment of adult traumatic brachial plexus injury. Age range was from 14 years to 55 years (mean age 26 years). Male were 95 and female were 10 cases. Time from trauma to surgery was valid 3 months to 9 months. Motor cycle accident was most common mechanism of injury. Upper plexus (C5, C6) injury was 52 cases, extended upper plexus (C5, C6 & C7) injury was 19 cases and global brachial plexus injury was 34 cases. When there is high suspicion of root avulsions, early exploration and reconstruction is indicated. Operate these patients 2-3 months after their injury. In other patients without high suspicion of root avulsion, we routinely perform exploration between 3 to 6 months after injury when no adequate sign of recovery are present. Common reconstructive options are any injury with neuroma in continuity with conductive nerve action potential (NAP): only neurolysis or any injury with nerve rupture or postganglionic neuroma not conducting nerve Action potential (NAP) and good proximal nerve: Direct repair or repair with nerve graft or nerve transfer if possible. Follow up period from 6 months to 6 years. The best results were obtained in C5, C6 and C5, C6 & C7 brachial plexus injury cases. SAN to SSN, Oberlin II and long head triceps motor branch to anterior division of axillary nerve transfer for C5 & C6 injury or upper plexus injury and in addition intercostals nerve to anterior division of axillary nerve and AIN branch of median nerve to ECRB for C5, C6 & C7 (extended upper plexus injury). Extra-plexus and intra-plexus neurotization was done in global brachial plexus injury cases and 5 cases by contra-lateral C7 to median nerve by vascularised ulnar nerve graft and only 2 cases contra-lateral C7 to lower trunk through pre spinal or pre tracheal route were done and only one case by FFMT. Few cases gain shoulder abduction and elbow flexion but no improvement of hand function and most cases even by FFMT still in follow up. Results of surgical treatment of upper and extended upper brachial plexus injury cases were satisfactory on the other hand recovery of shoulder abduction and elbow flexion was acceptable and comparable to other study in global brachial plexus injury and recovery of hand function were poor.

Management of the Hand Tumors.

Tumors in the hand are relatively uncommon but 95% are benign. Tumors occurring in the hand, forearm and arm often have unique growth patterns and potential for metastasis that may be different from those seen elsewhere in the body. Secondary metastatic tumors in the hand are very rare (0.1%). Diagnosis is mainly clinical, but X-ray, USG and MRI help as a diagnostic aid. The aim of the study was to early diagnosis, see the pattern and proper management of the hand tumor and ensure good hand function. This prospective study was done from January 2004 to July 2019. We found 220 hand tumors in the hand unit, Department of Orthopaedic Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka Bangladesh. Among 220 patients, male were 114(51.81%) and female were 106 (48.19%). Out of 220 patients we found 190(86.36%) benign tumor and tumor like lesions and 30(13.64%) was malignant hand tumors. Out of 190 benign lesions, benign tumor was 158(83.15%) and 32(16.85%) was tumor like lesions. Among 158 benign tumor, bone tumors were 40(25.31%) and soft tissue tumours were 138(74.69%). Out of soft tissue tumor, peripheral nerve tumor was 20(12.66%). Enchondroma and Giant cell tumors are the most common among the benign bone tumors, on the other hand giant cell tumors of tendon sheath, Glomus tumor, haemangioma, neurofibroma, schwanoma are the common soft tissue tumors. Compound palmar ganglion, fibromatosis and tuberculosis of phalanx are the most common tumor like lesions. Synovial sarcoma 10(33.33%), osteosarcoma 03(10%), chondrosarcoma 03(10%), ewings sarcoma 02(6.66%), fibrosarcoma 04 (13.33%), Malignant fibrous histocytoma 01(3.33%), soft tissue sarcoma 01(3.33%), Merkel cell tumor 01(3.33%), pleomorphic Rabdomyosarcoma 01(3.33%), malignant melanoma 01(3.33%), clear cell sarcoma of tendon and aponeurosis 01(3.33%), undifferentiated carcinoma 01(3.33%) and extra skeletal chondro sarcoma 01(3.33%) were the malignant tumors. Most of the benign lesions recovered fully after excision except neurofibroma and malignant tumors were treated with excision (including amputation) and chemo-radiotherapy successfully, but 4 patients were refereed to higher center due to recurrence and deteriation of hand function and one patient died due to metastasis. Malignant hand tumor management is very difficult even after amputation with multidisciplinary approach. Hand tumor is uncommon and malignant tumors are rare but any abnormal lump or bump in the hand or wrist is considered as tumor. Early detection and intervention are essential for better prognosis and survival for malignant tumors of hands and upper limbs.

Management of Avascular Necrosis (AVN) of Femoral Head by Core Decompression with Tensor Fascia Lata (TFL) Muscle Pedicle Bone Graft.

Avascular necrosis (AVN) of femoral head is an increasingly common cause of musculoskeletal disability. Most of the cases caused by steroid induced and traumatic but idiopathic cause are not also uncommon. Almost all the patients presented with pain at the hip, limping gait, restricted movement and difficulty in waking and squatting and becomes disabled. Core decompression and muscle pedicle bone graft at stage IIA, IIB and III provides painless and mobile life. Core decompression supplemented with bone graft to enhance mechanical support and augment healing. We have started a prospective study for the treatment of AVN of Femoral head at stage IIA, IIB and III by core decompression and Tensor fascia lata muscle pedicle bone graft in the department of Orthopaedic surgery Bangabandhu Seikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from January 2009 to December 2019. Aim of the study was to assess the effectiveness of core decompression and tensor fascia lata muscle pedicle bone graft in the treatment of AVN of femoral head at stage IIA, IIB and III. A total 48 patients and 65 hips were operated. Out of 48 patients, male was 30(62.50%) and female was 18(37.5%). Male-Female ratio was 1.66:1. Age of the patients ranging from 20 years to 50 years, mean age 36±4.65 years. According to aetiology corticosteroid induced was 47/65 (72.31%), idiopathic was 8(12.31%), post traumatic was 4(6.15%), ITP was 2(3.08%), ALL was 2(3.08%), and alcohol induced was 2(3.08%) of femoral head involvement. According to Ficat and Arlet's staging, stage IIA hip involvement was 28/65(43.08%), stage IIB was 32(49.23%) and stage III was 5(07.69%). All patients were treated with core decompression along with tensor fascia lata (TFL) muscle pedicle bone graft. All patients were followed clinically and radiologically at regular interval. Follow up period was 6 months to 10 years. Harris hip score (HHS) was used for evaluation of clinical outcome. Among the 65 hips, 24(36.92%) was excellent outcome (HHS >90), 30(46.15%) was good outcome (HHS: 80-90), 7(10.78%) was fair outcome (HHS: 70-79) and 4(6.15%) was poor outcome. For valid statistical analysis excellent and good results were grouped as satisfactory that was 54(83.07%) and fair and poor results were grouped as unsatisfactory that was11(16.93%), p value is <0.001 that is significant. It has been concluded that core decompression and TFL muscle pedicle bone graft is a pain relieving, head preserving procedure and improve hip function for the management of AVN of femoral head in stage IIA, IIB and III.

Limb Salvage by Resection Arthrodesis with the use of Osteoarticular Allograft in the Treatment of Aggressive Giant Cell Tumour around the Knee.

Osteoarticular allografts have provided the chance of limb-sparing trial in tumor surgery. Several authors have reported 50-75% long term (>10 years) successful use of these types of grafts, and large well recognized series provide confirmation that limb reconstruction following extensive resection of bone and joints has been possible with their use. Infection has been a major problem, affecting up to 12 per cent of recipients and often resulting in re-operations and infrequently amputations. This prospective Interventional study was conducted in the Department of Orthopaedic Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU) and Biomedical Research division, Atomic Energy Centre, Savar, Dhaka, Bangladesh from January 2008 to December 2017. In this study patients' age were 20-50 years and male was 12(60%) & female was 8(40%). We assessed the results of 20 limb-salvage procedures (Resection-Arthrodesis Procedure) using 11-18cm of distal femur or proximal tibial osteoarticular allografts after wide resection of aggressive or malignant Giant Cell Tumour (GCT) around the knee joint, Campanacci Grade III or recurrent case of Campanacci Grade II. At the ten-year follow-up, two patients had died, one due to infection and tumor metastasis to the lungs and one due to medical causes. The allografts survived for more than five years was twelve patients (60%) all of whom had good function, ranging from 73% to 90% of normal. The allografts were removed because of fracture in two patients and infection in two patients. Remaining three patients allograft was survived with satisfactory function but follow up was 3 years. All postoperative problems related to the allograft reconstruction were documented. Functional outcome was evaluated using the Musculoskeletal Tumour Society Scoring System and at least more than 3 years follow up should be taken for categorization of the results. Among the 20 patients, satisfactory result was 15(75%) patients and unsatisfactory result was 5(25%) patients. P value was <0.001.

Assessing the Rehabilitation of Achilles Tendon Ruptures using Modified Teuffer and Lindholm Technique.

The aim of this study is to assess the optimum rehabilitation and the functional outcome of open repaired Achilles tendon ruptures. This study was conducted for the 18 consecutive patients of complete ruptures at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from 2012 to 2013. Two groups were considered during 6 to 18 months post-operative observation and each group consist 9 patients. In the Group I, modified Teuffer's and in Group II, Lindholm operative methods were employed for the open repair of Achille tendon. The post operative outcomes were assessed for both of the groups through the modified Thermann's scores. In this study the patients median age was seen 39 years with 72.2% male and 27.8% female. The Thompson test was found positive in pre-operative and negative in post-operative outcome. The results shown that Achilles tendon ruptures occurred in 4 to 6cm rupture site, where the rupture side was 61.1% left and 38.9% right. The subjective overall assessment of total Thermann's scores were found very good (91 to 96) in 4 cases and (90 to 98) in 3 cases for Group I and Group II, respectively. Both of the operative techniques were found accountable results for rehabilitation. Therefore, based on the further statistical evidence of higher correlations and errors it may be concluded that Achilles tendon ruptures can be treated by modified Teuffer's or Lindholm technique.

Close Intramedullary Interlocking Nailing Versus Locking Compression Plating In the Treatment of Closed Fracture Shaft of the Tibia.

Fracture of tibial shaft is the commonest site of long bone fractures due to its superficial location involving young or middle-age people. Proper management is an important issue regarding the future effective movements. In this study patients were grouped in closed Intra medullary interlocking nailing and locking compression plating. Post-operative follow up at 2 weeks, 6 weeks, 12 weeks and 3 months thereafter up to 6 months were done. Each of the patients was evaluated clinically and radiologically by tucker criteria of Tuker et al. Patients were assessed for pain on full weight bearing and kneeling, shortening and range of motion of knee and ankle joints. Radiological assessment for union of fracture, alignment of fracture and angulations and position of nail and screws and infection were observed during follow up. A total number of 32 patients were selected but only 27 patients were available for follow up for a period of 6 months. They were grouped into Group A, consisting of 15 patients who took the treatment in the form of closed intramedullary interlocking nailing and Group B, consisting of 12 patients those underwent ORIF with locking compression plating. In both of the groups Motor Vehicle Accident was the main mechanism of trauma. Fracture involving the middle 3rd of the tibia is common in both the groups. During post-operative follow up, four patients in Group A complained anterior knee pain, one patient in Group B had superficial infection, most of the patients had no restriction of movement in the ankle and knee joints and a single patient in Group B showed 1.5cm shortening of the lower limb. Period of hospital stay and fracture union time were less in Group A, which was statistically significant. Both groups showed excellent result with minimum complications. So this study permits to conclude that close IM interlocking nailing and open reduction and internal fixation by locking compression plating is equally effective for the management of close fracture shaft of the tibia.

Surgical Decompression of Resistant Cases of DeQuervain's Disease.

DeQuervain's disease of the first dorsal compartment of the wrist, is a common wrist pathology, pain results from resisted gliding of the abductor pollicis longus and the extensor pollicis brevis tendon in the fibroosseous canal. Management of resistant cases of DeQuervain's disease with failed conservative treatment treated by surgical decompression yield satisfactory outcomes. A large number of patients being dissatisfied with the medical treatment, still present with persistent pain and positive clinical finding. Surgical decompression is an effective method for the treatment of resistant cases of DeQuervain's disease. Outcome variables were measured by Scheller, Forget and Macey evaluation criteria. Most of our patients were female 28(93.3%), housewife 17(56.7%) with mean age of 41.57 years, ranging from 25-60 years. Right sided involvement was 20(66.7%) and Left sided involvement was 10(33.3%). Restricted movement of thumb in 30(100%) were the predominant symptoms. One (3.3%) patient develop chronic tenosynovitis, 1(3.3%) patient develop hypertrophic scar. There was no wound infection in the follow-up period of 3-18 months. Satisfactory results were found in 29(96.7%).

Evaluation of outcome of surgical excision of the nidus of osteoid osteoma of long bone.

Osteoid osteoma is a benign bone tumour usually found in the lower extremities of children and young adults. This tiny bone tumour causes pain out of all proportion to its size and hinders the daily activities. This Quasi-experimental study conducted in the department of Orthopaedic surgery of BSMMU from January 2008 to December 2009. Twenty one patients were included in the study where purposive sampling technique was used on the basis of inclusion and exclusion criteria and all the ethical conditions were fulfilled. Diagnosis was almost obtained by taking history, clinical examination, and relevant investigations. Clinical variables were age, sex, site, pain, swelling, deformity and outcome variables were painless active life, removal of swelling, prevention of deformity, rate of recurrence. After localization of the tumour with the help of C arm, the nidus was excised in a small block of bone. The outcome is categorized by consensus, as clinically successful, only if the patient was free of pain and was taking no medication. The treatment was considered to have failed if a subsequent procedure had been performed to remove tumour. Among 21 cases, 14(66.7%) were male and 7(33.7%) were female. Maximum number of patients 15(71.4%) was between 10 years to 20 years. Most of the patients (76.2%) affected by osteoid osteoma were young students and most of the patients (95.2%) experienced moderate aching pain, usually aggravating at night which was typically relieved by aspirin or other NSAIDs (71.4%). Lower limbs (76.2%) particularly femur and tibia were commonly affected. Out of 21 patients, 19(90.5%) patients have got immediate pain relief or required no medication. In only 2 patients (9.5%), subsequent procedure has been performed to relief pain. So, successful outcome (in 19 out of 21) was significantly (p<0.001) higher in comparison to failed. Surgical excision of the nidus is a simple and easy procedure and does not require extensive resection of bone. If localization is done properly success rate is high and patients can return to normal daily activities.

Management of unicameral bone cyst by using freeze dried radiation sterilized bone allograft impregnate with autogenous bone marrow.

Unicameral bone cyst is a common benign bone tumor and most frequent cause of the pathological fracture in children. We have started a prospective study for that treatment of unicameral bone cyst by using freeze dried radiation sterilized bone allograft impregnated with autogenous bone marrow in the department of Orthopaedics, Bangabandhu Sheikh Mujib Medical University (BSMMU) during May 1999 to April 2012. Aim of this study was to see Freeze dried radiation sterilized bone allograft impregnate with autogenous bone marrow a satisfactory graft material in the treatment of unicameral bone cyst as well as factors such as patients age, sex, cyst size and site of lesion influence on cyst healing. A total 35 patients of unicameral bone cyst were operated. In this study out of 35 patients, male were 22(62.86%) and female were 13(37.14). Male Female ratio 22:13(1.70:1) Age of the patients ranging from 2 years 6 month to 20 years, mean age 12.18 years more common 11 years to 20 years 29(82.86%) patients. Common bones sites involvements are proximal end of Humerus 20(57.14%), proximal end of Femur 7(20 %), proximal end of Tibia 3(8.57%), Calcanium 2(5.71%), proximal end of Ulna 1(2.86%), shaft of Radius 1(2.86%) and Phalanx 1(2.86%). Final clinical outcome of unicameral bone cyst treated by thorough curettage of cavity and tightly filled with freeze dried radiation sterilized bone allograft impregnate with autogenous bone marrow in which healed (success rate) 88.57% (31) and recurrence rate is 11.43% (4). P value is <0.001. Follow up period was 6 month to 11 years. From our study it was realized that freeze dried radiation sterilized bone allograft impregnated with autogenous bone marrow is useful graft material for healing of the lesional area as well as restoring structural integrity for the treatment of unicameral bone cyst.

Outcome of early active mobilization in flexor tendon repair in zone II in hand.

Early controlled motion programs after flexor tendon repair in zone II of hand are designed to minimize adhesion formation by promoting the excursion of repaired tendons. The flexor tendon surgery especially in zone II is complicated. It is simplest in the newly injured and unscarred digit and the results of correctly rehabilitated primary repair are likely to be the best attainable. We conducted a study including 18 patients with 52 digits involving 80 flexor tendons in zone II to observe and record the result of the primary or delayed primary repair with early active mobilization protocol. Thirteen (72.22%) patients were below 30 years of age. Sixteen cases (88.89%) were sustained injury by sharp instrument either accidentally or by assault. Ring and little finger were involved in 50% instances. The repair was done with the modified Kessler core suture technique with locking epitendinous sutures with a knot inside the repair site, using polypropylene 4-0 and 6-0 sutures. The final assessment was done at 6 months post repair using the Louisville system of Lister et al. 61.54% (n=32) digits were shown excellent result whereas good results were seen in 23% (n=12) digits. Fair was shown 7.69% (n=4) digits and 7.69% (n=4) digits were shown poor results. P value was <0.001 by Z test which is significant. Complications included tendon rupture in 3(5.77%) cases (one thumb, one ring and one little finger) and contracture in 4(7.69%) cases whereas superficial infection and flap necrosis was seen in one (1.92%) case each. The primary or delayed primary repair of cut flexor tendons in zone II using the modified Kessler core suture and epitendinous suture with early active mobilization protocol has been given good result, with minimal complications.

Baker's method in the management of equinus deformity in cerebral palsy.

This prospective study was conducted in the department of orthopedic surgery in Bangabandhu Sheikh Mujib Medical University (BSMMU) Dhaka, Bangladesh, from January 2005 to December 2007. Total number of 20 patients with 37 feet of equinus deformity due to cerebral palsy was managed by Baker's method. Equinus deformity in cerebral palsy is not uncommon in our outpatient department. Before operation patient walks on tip toes and after operation by Baker's method by apponeurotic lengthening of gastrocnemius muscle, with extensive physiotherapy, patients can able to walk normally in plantigrade feet. Among 20 patients only the spastic diplegic or hemiplegic equinus deformity in cerebral palsy was between 3 years to 12 years with a mean age of 5 years 9.6 months (SD+/-2 years 4.97 months). There were 3(15%) unilateral and 17(85%) bilateral cases. Among 20 cases, 13(65%) were male and 7(35%) were female. All cases were followed up for period ranging from 4 month to 28 months. Final clinical outcome was satisfactory (excellent and good) in 34(92%) feet and unsatisfactory (fair plus poor) in 3(8%) feet (p<0.001).

Atypical presentation of non-ossifying fibroma.

Non-ossifying fibroma is a common benign bone lesion but extensive involvement of almost whole of the shaft of right tibia is a rare presentation. The patient was a young lady of 35 years admitted at the department of Orthopaedics in Bangabandhu Sheikh Mujib Medical University (BSMMU) on June 2006 with pain and swelling of right distal tibia and unable to walk without support, was diagnosed clinico-radiologically as a case of fibrous dysplasia. The lady was undergone surgery and biopsy confirmed a case of non-ossifying fibroma. Within the follow up period of 28 months, the patient was well with full functional limb and the lesion was also healed radiologically.

Management of old Tendo Achilles injury by surgical reconstruction with Lindholm technique.

This prospective study was carried out in the department of orthopaedic surgery, Bangabandhu Sheikh Mujib Medical University from January 2006 to December 2007. Main aim of this study was to improve the power of planter flexion by reconstructive method with Lindholm technique to prevent walking disability. We had a study on 21 patients whose age range was 7 to 58 years. Mean age 34.19 years. Out of 21 cases male were 18(85.75%) and female were 3(14.25%). Chronocity of Tendo Achilles injury on average 2.64 (SD+/-1.08 month). Final clinical outcome of 21 cases 18 (85.75%) patients were satisfactory and 3(14.25%) were unsatisfactory. Lindholm technique is a good method of treatment for the management of Tendo Achilles injury was evident from this study. In Bangladesh toilet pan injury was more common. All patients were treated by surgical method of reconstruction by Lindholm technique.

Application of mixed bone graft (autograft+allograft) in the management of giant cell tumor of bone.

Giant cell tumor is a common bone neoplasm. We have initiated a prospective study for the treatment of giant cell tumor of bone by mixed (Autograft+Allograft) bone graft in the department of orthopaedics, Bangabandhu Sheikh Mujib Medical University (BSMMU), during January 2002 to March 2008. A total 28 patients of giant cell tumor of bone were operated. In this study out of 28 cases, male were 11(39.28%) and female were 17(60.72%). Female were predominant. Age of the patients ranging from 11 years to 49 years, mean age 27.03 years. More common in 21 years to 30 years 16(57.14%) of cases. Common sites of lesion were distal & proximal end of femur 11(39.28%), proximal end of tibia 6(21.43%), proximal humerus 3(10.71%) and distal radius 3(10.71%). Final clinical outcome of giant cell tumor of bone treated by thorough curettage of the cavity and filled with mixed bone graft (freeze dried radiation sterilized bone allograft+autogenous bone graft) in which success rate is 75%(21) and recurrence rate is 25%(7). P is <0.001. Follow up period was 4 months to 4 years. From this study it was realized that mixed bone graft is useful graft material for enhancing osteogenic potential as well as maintaining structural integrity for the treatment of giant cell tumor of bone.

Polymicrobial genital gangrene (Fournier's gangrene): clinical, microbiologic, and therapeutic features.

The microbiologic and therapeutic aspects of polymicrobial genital gangrene (Fournier's gangrene) studied in nine patients are presented. Seven patients had both aerobic and anaerobic bacteria isolated from the site of infection; four had Bacteroides and two, Clostridia. Broad-spectrum penicillins such as ticarcillin, mezlocillin, and piperacillin, or combined clindamycin and gentamicin therapy were used. One patient died of fulminating infection and eight patients were cured of their infections. Anaerobic bacteria and appropriate antibiotic therapy should be considered in all patients with genital gangrene.