Tibial shaft fractures: interlocking nail versus plating

Objective: To evaluate and compare the treatment results of tibial shaft fractures treated by two different methods, interlocking nail and plating

Study design: Randomized controlled trial

Place and Duration of study: Department of Orthopaedics and Traumatology, Lady Reading Hospital Peshawar, from February 2014 to February 2017.Methodology: A total of 50 patients with closed tibial shaft fractures were randomly assigned to two equal groups [one treated with closed interlocking nail and the other with plating]. Postoperative results were assessed at one year follow up with Ekeland and Thoresen criteria and graded as excellent, good, fair and poor. Complications like infection, delayed union, nonunion and knee pain were assessed and compared for each groups

Results: Mean age of interlock group was 36+/-10.6 year and plating group 35.1+/-9.9 year. Plating achieved excellent results in 72% patients while interlocking in 44% [p value = 0.04]. Postoperative infection, delayed union, knee pain and screw breakage were 20%, 24%,11% and 20% [ p value = 0.05] respectively in interlocking nail group but none in plating group

Conclusions: Tibial shaft fractures treated with plating gave excellent results with minimal postoperative complications than interlocking nail. We therefore recommend plating as a treatment of choice for treating such fractures

Autologous blood injection for lateral epidcondylitis of elbow

Objective: to determine the outcome after autologous venous blood injection in patients with lateral epicondylitis of elbow

Study design: descriptive case series

Place and Duration of study: Ayub Teaching Hospital Abbottabad and Saidu Teaching Hospital Swat, from August 2014 to March 2015

Methodology: patients having lateral epicondylitis of elbow were selected from the outdoor department.Two ml of autologous venous blood was drawn from the contralateral antecubital fossa of the patient and slowly injected into the site of maximum tenderness. Patients were advised to continue their normal daily activities and followed up at 2nd, 4th, 8th and 12th weeks post-procedure for assessment of intensity of pain using VAS pain score and Nirschl staging

Results: there were 38 males and 61 females with ratio of 1:1.6. The mean age was 40.91+/-8.21 year. The mean pre-injection Visual Analogue Score [VAS] and Nirschl score were 6.9+/-1.2 and 6.0+/-0.9. At follow up it decreased to 0.9+/-1.0 and 1.5+/-1.1 respectively

Conclusion: autologous blood injection is an effective way to treat patients of epicondylitis of elbow especially in refractory cases

Frequency and antimicrobial susceptibility pattern of methicillin resistant staphylococcus aureus in open fractures

Objective: to determine the frequency and antibiotic sensitivity of methicillin resistant staphylococcus aureus [MRSA] in open fractures

Study design: descriptive case series

Place and Duration of study: Orthopaedics and Traumatology Unit A Lady Reading Hospital Peshawar, from January 2014 to June 2016

Methodology: patients of both gender and all ages fulfilling the inclusion criteria were included in this study. Swabs were taken from wounds with Levine's technique and sent to the hospital laboratory immediately where standard methodology was adopted for culture and sensitivity of the pathogens in all cases and results were reported as per Clinical and Laboratory Standards Institute [CLSI] guidelines. All MRSA positive cases were isolated within 24 hours and the standard MRSA protocol implemented immediately

Result: a total of 200 open fractures were sampled over a period of two and a half years. Positive cultures of MRSA were obtained in 47[23.5%] patients. The mean age of the patient was 24 year [range 18 year to 52 year]. Males were 43[81.4%] while females 4[8.5%] in number. Open tibial fractures were highest [n=21, 44.6%] in number followed by femur [n=12, 25.5%]. Majority [n=15, 31%] of the fractures were Type IIIA. All of the isolated MRSA cultures were 100% sensitive to vancomycin, linezolid, teicoplanin, chloramphenicol and tigecycline while resistance was observed for ciprofloxacin, levofloxacin, clarithromycin, and erythromycin

Conclusion: methicillin resistant staphylococcus aureus infection in open fracture wound is not uncommon. The isolated pathogen showed a variable pattern of sensitivity and resistance to the antibiotics tested

Diagnostic accuracy of anterior drawer test in detection of anterior cruciate ligament tear using magnetic resonance imaging as gold standard

Objective: to determine the diagnostic accuracy of anterior Drawer test in detection of anterior cruciate ligament [ACL] tear, using MRI as gold standard

Study design: cross sectional study

Place and Duration of Study: department of Orthopaedics and Trauma, Khyber Teaching Hospital Peshawar, from March 2013 to September 2013

Methodology: patients presenting with post-traumatic knee pain and instability, were subjected to anterior Drawer test and then MRI of the involved knee was performed to match the findings of the two. The data was analyzed with SPSS version 10. Sensitivity, specificity, positive predictive value and negative predictive value were determined by taking MRI as gold standard

Results: a total of 115 patients were enrolled. There were 96 [83.48%] males and 19 [16.52%] females. On anterior Drawer test, true positive and true negative patients for ACL tear were 64 [55.65%] and 42 [36.52%] respectively while false positive and false negative patients for ACL tear were 3 [2.61%] and 6 [5.22%] respectively. The sensitivity and specificity of anterior Drawer test were 91.43% and 93.33% respectively while positive and negative predictive values were 95.52% and 87.50% respectively. The diagnostic accuracy was 92.20%

Conclusions: Anterior Drawer test has better specificity than sensitivity and high positive predictive value. It is more accurate in ruling out an anterior cruciate ligament injury

Non operative treatment; functional outcome of radius ulna diaphyseal fractures in children

Pediatric forearm fractures result in substantial morbidity and costs. Despite the success of public health efforts in the prevention of other injuries, the incidence of pediatric forearm fractures is increasing. Most forearm fractures occurred during the spring season. Objective of the study is to determine the functional outcome of conservatively treated radius ulna fractures in Children. Descriptive study. Department of Orthopedics and Traumatology, Khyber Teaching Hospital Peshawar. March 2009 to April 2010. Total 236 children with radius ulna fractures were manipulated and above elbow plaster Cast applied for 6-8 weeks and reviewed every second week. After plaster cast removal Pronation and supination measured with goniometer and fortnightly thereafter for 6 weeks. All the fractures united. Normal range of pronation and supination at the end of follows up period was in 182 [80.53%] children. Loss of pronation and supination of average 10 degrees were in 9[3.98%] patients. Patients having displacement of the fracture and opted for surgery were 35 [15.46%]. Closed reduction of diaphyseal fractures in children results in normal pronation and Supination in majority of the patients

Chronic gout and hyperuricemia; treatment with febuxostat versus allopurinol

To assess the urate-lowering efficacy and safety of Febuxostat versus Allopurinol in subjects with hyperuricemia and gout. Randomized controlled trial. Department of Orthopaedic and Trauma Surgery Mardan Medical Complex Teaching Hospital Bacha khan Medical College Mardan from February 2012 to March 2013. Fifty patients of chronic gout and hyperuricemia fulfilling the inclusion criteria were divided into two equal groups by random method having 25 patients each and received either a fixed dose [80 mg] of Febuxostat [Group A] or Allopurinol [Group B] 300mg once daily for 16 weeks. The primary end point was the percentage of patients reaching serum urate level <6.0 mg/dl [360 micro mol per liter] at final visit. The secondary end points include reduction in the incidence of gout flares and adverse drug reactions. There were 16[64%] males and 9[36%] females with mean age 44.92 years in group A while group B had 15[60%] males and 10[40%] females with mean age 46.24 years. At final visit Febuxostat group had mean uric acid level of 4.72 mg/dl +/- 1.56 SD while Allopurinol group had mean serum uric acid level of 6.34 mg/dl +/- 1.82 SD with majority of patients [84%, n=21] in group A achieving serum uric acid level of < 6 mg/dl [360 micro mol/l] while only 60 percent [n=15] of the patients in group B had serum urate level of < 6 mg/dl.[P= <0.05]. Gout flare was reported in 12% [n=3] of group A patients and 36% [n=9] in group B patients. Adverse drug reactions were reported in 12% [n=3] of group A patients while 24% [n=6] in group B. Febuxostat lowerd serum uric acid levels more potently than Allopurinol while having minimal gout flares and side effects

Role of percutaneous autologous bone marrow grafting in non-union tibia

To evaluate the efficacy of percutaneous autologous bone marrow grafting in patients with tibial diaphyseal non-union. Descriptive case series. Orthopaedic Surgery Unit, Mardan Medical Complex Teaching Hospital, Bache Khan Medical College Mardan, from March 2011 to October 2012. Fifteen patients [mean age 41.6 year] with tibial non-union were treated with a single percutaneous autologous bone marrow injection. The bone marrow was aspirated from the anterior iliac crest and injected at fracture site. The procedure was carried out under general or spinal anesthesia. The patients were followed up after every four weeks and the rate of healing was assessed clinically as well as radiologically. Union Scale Score was used to assess the progress of union. A score of six or more was considered as sound union. Majority [73.3%, n=11] of the patients achieved a solid union after an average period of 14 weeks [range 12-20 weeks]. Four [26.6%] patients however could not achieve union. The average time duration between the procedure and injury was 37 weeks [range 36-40 weeks]. The average pre injection Union Scale Score was 2 [0-3]. The mean Union Scale Score at the end of study was 5.8 [0-7] and in united cases it was 6.4 [6-7]. Percutaneous autologous bone marrow injection provided an effective safe and easy bone grafting in non-union tibia

Primary osteosarcoma distal femur; incidence of pulmonary metastasis detected at the time of diagnosis

This study was designed to estimate the incidence rate of pulmonary metastasis at the time of diagnosis of primary osteosarcoma distal femur in a tertiary care hospital. Descriptive case series. Orthopaedic Surgery Unit, Mardan Medical Complex Teaching hospital, Bacha Khan Medical College, Mardan, KPK, Pakistan from March 2011 to September 2012. Nine patients of primary osteosarcoma distal femur were assessed with CT chest for pulmonary metastasis. The frequency and patterns of pulmonary metastasis on CT chest were documented. After the biopsy reports all patients were referred for neo adjuvant chemotherapy before any definite surgical procedure. The histological types of osteosarcoma were noted. Nine patients including 7 male [77.7%] and 2 females [22.2%] with mean age 12.4 years were included in our study. 66.6% [n=6, 5 males, 1 female] had pulmonary metastasis on CT chest at initial presentation while 33% [n=3,2 males,1 female] had no pulmonary metastases on CT chest. Three [50%] patients had pulmonary metastasis in the right lung, 1[16.6%] had on left side while 2[33.3%] had bilateral pulmonary involvement. Of the cases with metastases at diagnosis, 55.5% had osteoblastic histology of osteosarcoma compared with 33.3% of those with non metastatic disease. Majority of osteosarcoma distal femur presented with pulmonary metastasis at initial presentation. A high index of suspicion accompanied by careful examination of the limb and appropriate radiographs at initial assessment may reduce the incidence of such delays in diagnosis and the associated risks

Chronic osteomyelitis; microbiology of long bones in a tertiary care hospital

To determine the causative organism of long bone chronic osteomylitis through culture of the sequestrum. Descriptive case series. Orthopaedic Surgery Unit, Mardan Medical Complex Teaching hospital, Bacha Khan Medical College, Mardan, KPK, Pakistan from September 2011 to April 2012. Twenty five patients with radiologically proven chronic osteomyelitis of long bones who had been free of antibiotic therapy for at least 48 hours, excluding those with diabetic foot, decubitus ulcers, and infected implant. At least one specimen of sequestrum was taken from each individual and subjected to complete microbiologic analysis. Staphylococcus aureus was the most frequently found organism [n=11, 44%], followed by Enterobacteriaceae [n=5, 20%], coagulase-negative staphylococci [n=3,12%] Escherichia coli [n=2, 8%] P aeruginosa [n=1, 4%], Streptococcus species [n=1, 4%] and no growth [n=2, 8%].More than one microorganism was isolated in two [8%] patients. Staphylococcus aureus was the most common organism isolated. Sequestrum culture provides accurate identification of causative bacteria

Fractures in children; Distribution in orthopedic unit at THQ hospital tangi Charsadda NWFP Pakistan

The epidemiology of orthopedic and traumatic disorders is as important as that of communicable diseases and as that of surgical audit. Some sort of surveillance system is essential for this purpose. A retrospective study. Jan 2001 to June 2006. Orthopedic unit at THQ Hospital Tangi. The population of adults and children less than 16 years in the population studied is 57% versus 43%, while the fracture rates were 40% and 60% respectively. ln children under 16 years fractures of the radius and ulna were the most common followed by fractures of the distal end of the humerus i.e. 45.93% and 33.40% respectively in the upper limb injuries. Comprehensive data regarding orthopedic disorders are few[5]. Studies of specific injuries and specific age related disorders are even more limited. Fractures rates vary across a country and similarly it is variable in different seasons[13].

Outcome of supracondylar fractures of humerus in children treated with open reduction and internal stabilization with cross kirschner wires

To determine the surgical outcome of the open reduction and internal stabilization of supracondylar fracture [SC] of humerus in children. Descriptive case-series. District Headquarter Hospital Hangu, from May 2007 to May 2008. Thirty supracondylar fractures of the humerus [Gartland type III] were treated through Campbell posterior approach. Eighteen patients were males and twelve were females. Mean age of the patients was 6.5 year, ranging from 2-13 year. Patients having vascular compromises were excluded. All the fractures were reduced through open approach and stabilized with two cross Kirschner wires. All patients were assessed post-operatively for deformity, range of motion and pain through Flynn's criteria. Sixteen [53.4%] cases yielded excellent results, 6 [20%] had good results, 5 [16.6%] fair results, while 3 patients [10%] had poor results. Open reduction and internal stabilization of supracondylar fractures give better functional results

Chronic tennis elbow; outcome of autologous blood injections for the treatment

To evaluate the results of autologous blood injection as a treatment for chronic tennis elbow [Lateral Epicondylitis]. Study Descriptive case-series. Orthopaedic Surgery Unit Mardan Medical Complex Teaching hospital Bacha Khan Medical College Mardan KPK, from April 2010 to June 2011. A total of 22 patients with tennis elbow [lateral epicondylitis] were injected with 2 mL of autologous blood under the extensor carpi radialis brevis in the Out-Patient Department [OPD]. Patients rated their pain on a Visual Analogue Scale[VAS] scale of 0 to 10 with 0 representing no pain and 10 the worst pain they had ever experienced, and categorized themselves according to Nirschl score[1-7]. After the procedure pain rating and Nirschl score were recorded every 3rd week for a minimum of 6 months. If pain relief was not relieved entirely 6 weeks after the autologous blood injection a repeat injection was offered to the patient. Seventeen patients [77.2%] received one injection of autologous blood and had resulted in lowering their mean pre-injection pain score and Nirschl sore of 6.2 and 6 to 0.1 and 1.1 post-injection respectively. Five patients [22.7%] received two injections and their average pre-injection pain score of 6.8 and Nirschl score of 6.2 were lowered to 0.2 and 1 respectively. Autolgous blood injection is an effective way to treat patients of chronic tennis elbow as demonstrated by decrease in pain and fall in Nirschl score and we therefore recommend it as a first line treatment for chronic tennis elbow

Outcome of intramedullary kirschner wire fixation in children

To know the functional outcome of Intramedullary Kirschner Wire fixation of unstable Radius-Ulna fractures in children. Descriptive study. 27/03/2009 to 26/03/2010. Department of Orthopedic and Trauma, Khyber Teaching Hospital, Peshawar. All patients were admitted from OPD. Children less than 16 years with Unstable Radius-Ulna fractures were included in the study. Patients with open fractures and adults with polytrauma were excluded from the study. Unstable Radius-Ulna fractures were treated by Intramedullary Kirschner Wire fixation under general anesthesia and tourniquet control. Follow up till radiological and clinical union was done. K-wires were removed after healing of fractures. Patients were assessed functionally and radiologically and results were graded according to Price et al Criteria. A total of 64 children with unstable radius and ulna fractures were included in the study. The age range was 6 to 15 years with average age of 10.41 years. 47 were male and 17 were female. The average time of radiological union was 7 weeks and K-wires were removed at 8 weeks time. At final assessment there were 47 Excellent, 10 Good and 7 Fair results. Excellent results can be achieved by Intramedullary K-Wires fixation. In children with unstable Radius-Ulna fractures. It should be the method of choice for treating these fractures