Plaster immobilization versus anterior plating for dorsally displaced distal radial fractures in elderly patients in Pakistan.

This prospective, multi-centred, randomized trial examined outcomes of 3- and 12-month follow-ups of 159 elderly participants aged more than 75 years with isolated distal radial fractures, treated by anterior locking plate or closed reduction and cast immobilization. The primary outcome was the patient-rated wrist evaluation (PRWE) score. The PRWE score at 12 months was not significantly different between the two groups; however, the radiological outcomes and complications rates were worse in the casting group.Level of evidence: III.

Fixation of distal radius fractures using wide-awake local anaesthesia with no tourniquet (WALANT) technique: A randomized control trial of a cost-effective and resource-friendly procedure.

AIMS: We hypothesized that the wide-awake local anaesthesia with no tourniquet (WALANT) technique is cost-effective, easy to use, safe, and reproducible, with a low learning curve towards mastery, having a high patient satisfaction rate. Furthermore, WALANT would be a suitable alternative for the austere and developing nation environments where lack of funds and resources are a common issue. METHODS: This was a randomized control trial of 169 patients who required surgery for closed isolated distal radius fractures. The study was performed between March 2016 and April 2019 at a public sector level 1 trauma centre. General anaesthesia was used in 56 patients, Bier's block in 58 patients, and WALANT in 55 patients. Data were collected on pre-, peri-, and postoperative parameters, clinical outcome, hospital costs, and patient satisfaction. One-way analysis of variance (ANOVA) was used with a p-value of 0.05 being significant. RESULTS: Operations with WALANT proceeded sooner, and patients recovered faster, resulting in mean fewer missed working days (7.8 (SD 1.67)) compared with general anaesthesia (20.1 (SD 7.37)) or Bier's block (14.1 (SD 7.65)) (p < 0.001). The WALANT patients did not develop complications, while the other patients did (p < 0.04). Clinical outcomes did not differ, nor did surgeon qualification affect clinical outcomes. Mean hospital costs were lower for WALANT ($428.50 (SD 77.71)) than for general anaesthesia ($630.63 (SD 114.77)) or Bier's block ($734.00 (SD 37.54)) (p < 0.001). Patient satisfaction was also higher (p < 0.001). CONCLUSION: WALANT for distal radius fractures results in a faster recovery, is more cost-effective, has similar clinical outcomes, and has fewer complications than general anaesthesia or Bier's block. This makes WALANT an attractive technique in any setting, but especially in middle- and low-income countries.Cite this article: Bone Joint Res 2020;9(7):429-439.

Use of the wide-awake local anaesthetic no tourniquet in the management of distal radius fractures.

OBJECTIVE: To evaluate the Wide-Awake Local Anaesthesia with No Tourniquet (WALANT) method in fixation of distal radial fractures. METHODS: Forty patients admitted to the Jinnah Postgraduate Medical Centre, Karachi, Pakistan were recruited from March 2017 to December 2018. All patients had a distal radial fracture which was appropriate for internal fixation with a locked volar distal radial plate. The surgical site was infiltrated to achieve tumescent local anaesthesia using a solution of 0.9% normal saline and 1% lidocaine with 1:1,000,000 epinephrine. The patients were followed up until fracture union and were evaluated clinically, with goniometry, radiologically and with standard outcome scores (Mayo and qDASH). RESULTS: The patients were marginally more male than female (55% versus 45%), and mostly the dominant hand was injured (65%). The mean time to union was just over 3 months (15.2 weeks). All were united by 11 months. Good outcomes were achieved at final review with mean qDASH and Mayo scores of 13.3 and 81.6 respectively. The mean flexion and extension range at finalreview was 64 and 53 degrees respectively, and the mean grip strength was 73% when compared with the opposite side. CONCLUSIONS: The WALANT technique seems to be an acceptable and safe technique for fixation of distal radial fractures. There seem to be added benefits in terms of costs, reduced disposables, and intra-operative assessment of active movement.

Giant cell tumours in hand bones.

OBJECTIVE: To describe the clinical features of Giant cell tumour of hand, in terms of aggressiveness, multicentricity and radiological grading at presentation, surgical procedures and final outcome. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: Jinnah Postgraduate Medical Centre (JPMC), Karachi, from January 1990 to January 2009. METHODOLOGY: Seven cases of Giant cell tumour of hand bones were diagnosed in last 19 years and included in this study. Patients with infections in hand and procedure performed at other centre were excluded. Clinical and radiographic features were analyzed, definitive operative procedures performed and follow-up of the patient were studied and updated. RESULTS: Two hundred ten cases of Giant cell tumour of bones were seen in last 19 years at JPMC, Karachi; 7 cases were of GCT of hand bones which constitutes around 3.3% of all GCT. Four patients (57%) were male and 3 (43%) female with mean age of 24.28+5.7 years. Four (57%) cases were in metacarpal and 3 (43%) in phalanges. Average duration of symptoms was 5.78+3.26 months; all presented with radiological stage 3 lesions. One case of multicentric lesion presented after treatment of primary GCT of distal radius. Excision of the tumour and reconstruction by autogenous graft was performed in 6 cases and ray amputation in one case. No complication or recurrence noted in any case on an average of 4.5 years (ranging from 1.5-8 years) follow-up. CONCLUSION: Giant cell tumour in hand bones is rare tumour and shows specific clinical and radiographic features with early involvement of entire bone, more aggressive behaviour and multi centricity. The treatment of choice is resection of the tumour with reconstruction or ray amputation.Ansari.

Giant cell tumour of the proximal ulna.

The report describes a rare case of giant cell tumour of proximal end of ulna occurring in 22 years old lady. Pain and gradual increase in swelling was noticed for last 7 months. X-ray showing complete absorption of proximal ulna. The tumour was excised en-bloc; reconstruction by fibular graft and fusion of elbow in functional position was performed. Postoperatively neurovascular status was normal. Patient is tumour-free and having stable elbow after 5 years of resection and reconstruction.

Influence of age on the outcome of single stage reconstructive surgery for congenital dislocation of the hip joint.

OBJECTIVE: This study was conducted to assess the effect of age on the ultimate outcome measures following single stage surgical procedure of soft tissue release, relocation, capsulorrhaphy, femoral shortening with varus/derotation osteotomy and pelvic osteotomy. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: The study with two groups of pretest-posttest design was conducted at Department of Orthopaedic Surgery, Jinnah Postgraduate Medical Centre (JPMC), Karachi, from 1993 to January 2008. METHODOLOGY: Patients included were having neglected, congenital dislocation of the hip joint, aged over 3 years. Patients with failed previous surgery, paralytic, teratological, traumatic or septic dislocations and patients with less than 5 years follow-up were excluded from the study. The patients were divided into two groups, 3-7 years (37 hip joints) and over 7 years (13 hip joints). The single stage surgical procedure of open relocation, femoral shortening/derotation/ varus osteotomy and pelvic osteotomy was the dependent variable; whereas, the final clinico-radiological results based upon Tonnis grading, Severin's clinical/radiological grading, Klisic's overall rating and acetabular index were the independent variables of the study. Pre- and postoperative data was assessed for overall improvement and the difference in outcome measures between the two age groups. RESULTS: Significant overall improvement on all parameters was achieved after surgery. When results were compared between two age groups, there was no significant difference in the final outcome as per Tonnis grading and Severin's clinical typing as modified by Gibson (97.3% versus 84.4% normal hip joints or Tonnis grade 1 and 78.37% versus 53.85% Severin's type 1) but the results based upon Severin's radiological grading (62.16% versus 15.38%) and Klisic's overall rating (62.16% versus 15.38%) were significantly better in 3-7 years as compared to those over 7 years. There was no significant difference between the two age groups when compared for improvement in acetabular index. On further analysis, a progressive deterioration of results with increasing age was observed, yet the results in those aged over 7 years were reasonably justified surgical correction of congenital dislocation of the hip joint. Majority of the complications were seen in children operated at the age of 4-5 years. There were 7 cases (14%) of redislocation/subluxation and 6 were in 3-7 years age group. There were 4 cases (8%) of the avascular necrosis of the femoral head. Three patients had residual coxa vara and 2 had significant limb shortening. Limb lengthening was done in these 2 cases. CONCLUSION: The final results displayed progressive deterioration of clinical, radiological and functional outcome measures with aging after single stage reconstructive surgery for the congenital dislocation of hip joint. However, despite this, the results in children over 7 years were also good/excellent in most of the cases justifying surgery.

Transfer of extensor carpi radialis brevis as an extensor to extensor motor transfer (EEMT) in ulnar nerve palsy.

OBJECTIVE: To evaluate functional outcome and correction of deformity with extensor carpiradialis brevis motor transfer to replace the intrinsic muscles as an extensor to extensor motor transfer (EEMT). METHOD: This was a prospective observational study with one group pretest posttest design conducted from 1996 to 2004. Convenience sampling technique was used and the sample size was twenty one. The independent variable was transfer of extensor carpiradialis brevis to replace the intrinsic muscles. The dependent variable was functional outcome and the correction of deformity. The extraneous variables were age, sex interval between injury and transfer as well as local factors related to wound and grafts used. The average follow up was 22.5 months. RESULTS: The mean preoperative unassisted extensor lag was 56.79 +/- 10.39 which improved to 9.6% +/- 5.4 (correction of 83%) at six months after surgery. With open hand assessment 76.19% reported good to excellent results, while 79.89% achieved good to excellent results with closed hand assessment. The mechanism of closing was good to excellent in 89.42% cases, however only 71.42% patients considered their hands good to excellent. Significant problems were seen with use of tendoachilles as a graft. CONCLUSION: Extensor carpiradialis brevis transfer to replace the intrinsic muscles as an extensor to extensor motor transfer can achieve good functional outcome as well as correction of deformity despite shortcomings in physical rehabilitation.

Malignant fibrous histiocytoma: vascular invasion and metastasis to heart.

Two cases of biopsy-proven malignant fibrous histiocytoma are presented which showed local as well as vascular spread resulting in cardiac metastasis and peri-and postoperative complications leaving palliative surgery as the prime management.

Frequency, presentation and postintervention prognosis of chondroblastoma.

OBJECTIVE: To evaluate the frequency of clinico-radiological presentation and the prognosis after treatment of chondroblastoma. DESIGN: A descriptive, observational study. PLACE AND DURATION OF STUDY: The study was carried out at the Department of Orthopaedic Surgery, JPMC, Karachi over the period of 16 years, January 1986 to June 2002. METHODOLOGY: Patients in teenage, presenting with signs and symptoms of a primary bone tumours, were included by retrospectively reviewing the tumour registry record. Detailed scrutiny of clinical record was carried out to analyze the clinico-radiological presentation and posttreatment prognosis criteria of healing was symptom-free centripetal and homogeneous ossification. RESULTS: Seven (1.24%) out of 563 primary bone tumour cases were chondroblastoma. The clinico-radiological presentation in the 2 out of 7 (28.57%) cases was classical, 2 simulated osteomyelitis and other 3 as chondromyxoid fibroma, aneurysmal bone cyst and giant cell tumour. Lesions were treated with curettage and bone grafting. One patient (14.28%) developed recurrence within 2 years after curettage and healed after re-curettage and bone grafting. Five out of 7 (71.42%) tumours showed good response and 2 out of 7 (28.57%) showed satisfactory response. CONCLUSION: Chondroblastoma is very rare benign primary bone tumour with high local recurrence rate. The lesions confined to epiphysis of weight-bearing bone present early with symptoms of mild arthritis. Lesions in non-weight-bearing bones often present late and simulates epiphysio-metaphyseal tumours. Lesions heals with centripetal healing and need more than 2 years follow-up to achieve recurrence-free healing.

Bilateral treponema periostitis.

Symmetrical exuberant periostitis is a rare disease caused by variety of infectious and non-infectious causes. Treponematosis is one of the rare causes of this condition. We report a patient who presented with left arm swelling, secondary to onion peel periostitis of the humerus, which was caused by Treponema species.