Two stage brachio-basilic transposition fistula provides superior patency for chronic haemodialysis: our experience in SIMS/ SHL

Background: Adequate vascular access is of utmost importance for hemodialysis treatment. Upper arm fistulae, obesity and deep or tortuous veins may impair cannulation and can cause significant complications and inconvenience for the technicians and patients

Objective: We intended to present the technique of superficialization [transposition] of the brachiobasilic fistula [BBF] and its clinical outcome regarding patency and complications

Materials and Methods: Twenty two brachiobasilic fistulas were fashioned in 20 patients between October 2010 to November 2011.The second stage superficialization [transposition] was carried out at a median of 59.1 days [range: 40-90 days] after fistula formation and involved mobilizing the arterialized basilic vein through a curved longitudinal incision on the antero-medial aspect of the arm and transposing it beneath skin

Results: During the study period 20 brachiobasilic fistulas [BBF] were fashioned in 20 patients. There were 8 [40%] males and 12 [60%] females. The mean age was 53.45years + 12.34 years [range: 21-70years]. The patency rates were 90% at 6 months. Surgical complications of transposition were infection in 2 [10%] patients and lymphocoele in 4 [20%] patients

Conclusion: Transposition of brachiobasilic fistulas is technically feasible and relatively safe procedure. Patency rates at 6 months are excellent

Functional outcome of the minimally invasive plate osteosynthesis for the supracondylar fractures of femur using dynamic condylar screw

To assess the functional outcomes of minimally invasive plate osteosynthesis [MIPO] for the extra-articular and undisplaced intra-articular supracondylar fractures of femur using dynamic condylar screw [DCS]. Descriptive case series. Department of Orthopaedic Surgery, Jinnah Postgraduate Medical Centre Karachi, from April 2009 to October 2011. Patients were enrolled from accident and emergency and OPD. OPD follow-ups were carried out at 2nd, 6th, 12th, 18th, and 24th weeks, then every 2nd month for the assessment of rate of union and range of motion of knee joint. A total of 83 patients were included. There were 55 males and 28 females. Male to female ratio was 1.96:1. Patients were 25-50 year of age. Seventy four [89.2%] of the injuries were caused by road traffic accident and 9 [10.8%] due to fall from height. Forty six [55.4%] patients had fractures on right side and 37 [44.6%] on left side. Radiological union was achieved in 79 [95.2%] patients at an average period of 19.05 weeks. The radiological bony union was achieved in 16-18 weeks in 25[30.1%] patients. Four patients developed nonunion for which bone graft from iliac crest was placed after 24 weeks. Two achieved union in one year follow up while two were lost to follow up. At end of one year, forty-three [51.8%] cases had knee flexion from zero to 90° - 120°, 25 [30.1%] cases had knee flexion of > 120° and remaining 15 [18.1%] cases had knee flexion of <90°. At the end of one year satisfactory [knee motion > 90°] functional outcome as achieved in 68 [81.9%] cases. High rates of both radiological union [95.2%] and satisfactory [knee motion > 90°] functional outcome [81.9%] were achieved in large number of cases

Exchange nailing for delayed or non union of diaphyseal femoral fractures

To determine the effectiveness of exchange nailing for delayed or nonunion of diaphyseal femur fractures. Descriptive case series. Department of Orthopaedics Jinnah Postgraduate Medical Center Karachi, from March 2009 to February 2012. All patients with delayed or hypertrophic nonunion of diaphyseal femur fractures diagnosed on clinical and radiological examination, were included. Patients with infective nonunion, segmental fractures or fractures with bone loss and open fractures were excluded. Exchange nailing was performed. A total of 36 patients were managed which included 27 males and 9 females. Twenty-four [66%] patients were between 30 - 40 year of age. Left femur was predominantly involved [56%]. The non union involved middle third in 61% cases. Following surgery union was achieved in 33 [92%] cases. In 14 patients union occurred between 4 to 6 months. Superficial infection occurred in 2 patients. Exchange nailing is the one of best options for delayed or nonunion of femoral diaphyseal fractures.

Giant cell tumours in hand bones

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. A case series. Jinnah Postgraduate Medical Centre [JPMC], Karachi, from January 1990 to January 2009. 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. 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. 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

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

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. A case series. 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. 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. 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. 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

Frequency, presentation and postintervention prognosis of chondroblastoma

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 homogenous ossification. 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. 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

Comparative study pin and plaster and AO monoplane external fixator in treatment of gustilo type I and II open fracture of tibia

To evaluate effectiveness of pin and plaster as against AO external fixator in open fractures of tibia and fibula in developing countries. Design: It was a prospective, randomised comparative study. Place and Duration of Study: The study was conducted at Jinnah Postgraduate Medical Centre, Karachi, Pakistan from February, 1998 to January, 2000. Materials and A total of 96 patients were included in the study with tibial shaft fracture AO type A and B and Gustilo Grade I and II. More severe fractures were excluded from the study as those required more versatile fixator. Patients were divided into two groups using randomisation. Group I patients were treated with the AO monoplane external fixator and Group II patients with pin in plaster. Formal debridement was done in both the cases. No significant differences in treatment outcomes in both groups were noted as far as soft tissue management, healing time and complications are concerned. It was felt that pin and plaster is equally effective treatment for Gustilo Grade I and II open fractures of tibial shaft more so in our country for economic reasons

Limb salvage in malignant tumours of appendicular skeleton

A study was conducted at Jinnah Postgraduate Medical Centre, Karachi, to evaluate the results of various limb salvage techniques. Average age of the group of 12 subjects was 26.6 years and male to female ratio was 2.1. The histopathological diagnosis yielded recurrent GCT in 4 cases, chondrosarcoma in 3 cases, osteosarcoma, Ewing's sarcoma, parosteal osteosarcoma, adamantinoma and malignant fibrous histiocytoma in one case each. The surgical procedures included a wide variety of reconstructive methods. Adjuvant chemotherapy and radiotherapy were used where indicated. In terms of functional results, upper limb procedures scored 20.5 points [68%] and the lower limb procedures scored an average of 19 points [63%]. Local recurrence rate was 25%. Minimum follow up period was four years. Complications included recurrence in three patients, pulmonary metastasis, soft tissue implantation, deep infection, nonunion and graft absorption in one case each

Extensor mechanism sparing approach to the elbow for reduction and internal fixation of intercondylar fracture of the humerus

OBJECTIVE: To evaluate the short term results of extensor mechanism sparing approach to the elbow for fixation of intercondylar fractures of the distal end of humerus and compare it with existing Surgical approaches. DESIGN: This is a prospective study conducted from June, 1992 to June, 1997. SETTING: Department of Orthopaedic Surgery, Jinnah Postgraduate Medical Centre and Mehran Clinic [Pvt.], Karachi. PRINCIPLE OF SURGICAL APPROACH: This approach is based upon the principle that by sparing the extensor mechanism, we reduce the amount of surgical trauma and help in early rehabilitation which can contribute in improving the results of this difficult fracture. There were nine type 2 fractures, eight type 3 fractures and four type 4 fractures according to Rise borough and Radin classification. Based upon the same authors criteria, there were over all 57.14% good 23.81% fair and 19.04% poor results. Adequate exposure was achieved in all of type 2 and seven [87.5%] out of eight type 3 fractures. We failed in type 4 fractures. Mean operating time was 107.38 [ +/- 24.67] minutes. The results in this series are comparable to other studies. They can however be improved with proper selection of cases, experience with the technique along with better fixation and rehabilitations

Role of non-vascularized autogenous fibular graft in bridging large bone effects

The aim of this study was to evaluate the role of autogenous non-vascularized fibular bone graft augmented by corticocancellous bone graft from the iliac crest to bridge large bony defects. A total of 21patients were included in the study with bone gaps ranging from 5 to 25 cms resulting from various pathologies or surgical procedures. Twelve patients had lesions involving lower limbs and nine had lesions of upper limbs. A variety of implants were used for stable fixation of the fibular graft. Primary union was achieved in 18 patients. In patients with lower limb lesions 75% had good and 8% fair results whereas in those with upper limb lesions 55% had good and 45% fair results. The major complications included: infection [2] absorption of graft [2], and those non-union at host graft junction [2]. One patient required above knee amputation at donor site and one had transient common peroneal nerve palsy which recovered completely. It was concluded that non-vascularized autogenous fibula is still a good procedure to bridge large bone defects

Tumoral calcinosis

Two cases of Tumoral Calcinosis are reported. It is a rare condition, hence the key to diagnosis lies in increased awareness of such lesions amongst orthopaedic surgeons and pathologists. Precise histopathological diagnosis is crucial, as the management of such a tumor is successful if appropriately treated. Advances in radiology and histology have helped immensely in the diagnosis of this condition. Complete excision of the mass has conferred very good results and is recommended

Analgesia quality achieved by buprenorphine hcl as compared to diclofenac sodium in postoperative orthopaedic patients

This study was conducted to compare the quality of analgesia achieved by buprenorphine [2.5-4.0 ug/kg body weight I.M] and diclofenac sodium [75 mg I.M] in post-operative pain. This was an open, comparative trial and patients were randomly allocated in the post-operative period, once they started complaining of pain. The buprenohine group achieved analgesia quicker which also lasted longer as compared to diclofenac group. The pain score [measured on visual analogue scale] was lower in buprenorphine group and pain free internal [time in between doses] was longer as compared to diclofenac

Giant cell tumor of bone management with resection arthrodesis

Eleven patients of Giant Cell tumor of bone were managed with resection arthrodesis in Department of Orthopedic surgery, Jinnah Postgraduate Medical Center, Karachi, from January 1990 to April 1992. In all cases, diagnosis was made on clinical presentation and plain radiology. It was confirmed by Incisional biopsy before performing resection arthrodesis. According to Enneking's surgical staging system, four patients were in stage II A while seven were in stage II B [Enneking]. Arthrodesis was achieved by the use of various Implants and bone graft. Iliac bone was used in four cases, fibula in seven and patella in one as bone graft. Results were good and fair in ten patients and poor in one. In one patient there was soft tissue recurrence. In our circumstances resection arthrodesis is the best treatment for Giant Cell tumor in Enneking stage II A and II B, where the alternative could be custom prosthesis, which is expensive and not easily available