Reconstruction of hind foot defects; a simplified workable solution

Reconstruction of traumatic as well as non-traumatic hind foot defects is always a challenging task. We share here a simple and practical protocol [working solution] to select the most suitable method for soft tissue coverage of hind foot defects, customizable for every patient. We carried out this study, in our department on 75 cases from March 2009 to May 2012. All cases with wound/defect in hind foot area were included. Majority of cases were traumatic rest included cases of malignancy, Trophic ulcers, infection. Patient's data including age, sex, site of injury, mode of injury, extent of injury [isolated or combined], if combined structures involved, type of wound, management of wound, wound healing time and complications were noted. Once optimal wound conditions were achieved the best possible reconstructive option was selected. The various reconstructive options include VAC therapy, Skin graft, local transposition flap, perforator based flapspedicled faciocutaneous/ muscle flaps, intrinsic foot muscles, Medial plantar artery flap and distant flaps like cross leg flap and micro vascular free flaps. All patients had satisfactory and stable reconstruction. They were ambulating freely by 4-6 weeks post operatively. There were few complications like patchy graft loss, peripheral flap necrosis, flap congestion, but none was serious and did not require repeat surgery. The simplified protocol followed by us is a practical customizable solution for difficult task of hind foot reconstruction. The choice of one or multiple techniques will vary from time to time from one surgeon to another depending upon his or her experience and liking

Surgical treatment of upper cervical spine injuries [C1-C2]: experience in 26 patients

To describe the spectrum of operations in unstable upper cervical spinal injuries in [atlanto-axial] region at our unit. A cross-sectional study. Spine Unit, Department of Orthopedics, Combined Military Hospital [CMH], Rawalpindi from Jan 2001 to Dec 2008. Frequency of different kind of operations in 26 patients operated for upper cervical spinal injuries was reviewed. A performa was made for each patient and records were kept in a custom built Microsoft access database. Average age of patients studied was 27 years with male pre dominance. Total 12[46%] patients had Atlanto-axial instability, 8[31%] had Hangman's fracture and 6[23%] patients had odontoid peg fracture. While 11[42%] patients had no neurological deficit according to American spinal injury association impairment scale [AIS-E] and 15[58%] had partial neurological deficit. The patients were divided into three groups. Group A had odontoid peg fracture, Group B had atlanto-axial instability and Group C had Hangman's fracture. The spine was approached posteriorly in 19[73%] cases and anteriorly in 7[27%]. Pedicle screw fixation was done in 6[23%] patients, odontoid peg screw fixation in 6[23%], Gallie's fusion in 5[19%], occipito-cervical fusion in 4[15%], posterior transarticular fixation in 3[12%], anterior transarticular fixation and decompression in others, 9[60%] patients improved neurologically postoperatively and there was no deterioration of neurological status. Nonunion in two [8%] cases and implant failure in one [4%] were complications. Upper cervical injuries [C1-C2] are rare and their management is complex, necessitating lot of experience for their management. Early diagnosis and appropriate treatment is essential for good outcome. Each injury has to be managed at its own merit and a single operation may not be appropriate in all situations. General guidelines can be drawn from our study for the management of these cases on modern lines

Surgical treatment in lumbar spondylolisthesis: experience with 45 patients

Spondylolithesis is forward slipping of upper vertebra in relation to its lower one, which at times requires surgery. The objective of present study is to document the outcome of surgical treatment in spondylolisthesis of lumbosacral region. We reviewed outcome of surgery in 45 patients with spondylolisthesis. Improvement in pain intensity, neurological status and union achieved after surgery was studied. All patients requiring surgical treatment were included in the study. The patients were operated by single spine surgeon. A Performa was made for each patient and records were kept in a custom built Microsoft access database. Majority of our patient were in 4[th] and 5[th] decade with some male domination. Pain was main indication for surgery which was excruciating in 6, severe in 33, and moderate in 6 cases. The neurological status was normal in 34 cases while 11 patients had some deficit. L5-S1 was affected in 26, L4-L5 in 13 and multi or high level was found in rest of cases. Slip grade was measured with Meyerding grades, 18 had grade II, 15 had I, 9 had III and 3 had IV spondylolisthesis. Posterior lumbar inter body fusion [PLIF] was done in 24 patients, posterolateral, transforaminal lumbar inter body and anterior inter body fusion in others. Translaminar screw fixation, transpedicular transdiscal transcorporial and Delta fixation in some cases. Pedicle screw fixation was done in most cases, AO fixator internae and 4.5 mm screw in others. Average follow up was 2 years and 5 months, max 5 years and minimum 6 months. Pain relief was achieved in 82%, neurological improvement 60% and union in 91% cases. There was no deterioration of neurological status, two implant failure and one wound infection. Surgical procedure for Spondylolisthesis must be individualised. Young patients with spondylolysis can be treated with osteosynthesis and sparing of motion segment. PLIF provides satisfactory results in majority of low to moderate cases with some reduction. Transpedicular transdiscal transcorprial and delta fixation is good procedure for severe slips in adult.

Epidemiology of non-disaster spinal injuries at a spine unit

To describe the demography, types of injuries and their management in all non-disaster spinal injury patients admitted to the Spine Unit of a tertiary care hospital in Pakistan from 2001-2008. Case series. Spine Unit, Orthopaedic Department, Combined Military Hospital, Rawalpindi, from April 2001 to December 2008. Data of all new non-disaster spinal injury patient admissions, kept in a custom-built database at Spine Unit, was analyzed. Demography, type of injuries and their management was described in percentages. Five hundred and twenty one non-disaster patients were selected out of a total 671 new admissions with spinal injuries. Mean age was 39.1 years and 77% were males. Mechanisms of injury included; fall in 62% and road traffic accidents in 32%. Fracture dislocations and burst fractures were equally distributed [36% each]. Most of the injuries [43.6%] were at T11-L1 level. Forty three percent patients had complete spinal cord injury [SCI], 33% had incomplete SCI and 24% did not have any SCI. Eight patients had concomitant spinal injury at a different level. Twelve percent patients had associated other major injuries. Seventy percent patients were treated surgically. Average follow-up was for 4 years. Non-disaster spinal injury was frequent in young males usually due to fall or road traffic accident. It involved fracture dislocation or burst fracture at T11-L1, level in most cases requiring surgical treatment

Outcome of instrumented spinal fusion for chronic low back pain: review of 100 patients

Objective of this study was to evaluate the outcome of instrumented spinal fusion in selected patients with Chronic Low Back Pain [CLBP] in our setup. Quasi-experimental study. Spine Unit, Orthopaedic Department, Combined Military Hospital, Rawalpindi, Pakistan. Jan 2002 to Dec 2007. Consecutive first one hundred patients were selected from spine unit database that underwent instrumented spinal fusion for chronic low back pain lasting more than one year, due to degenerative disease of spine. Average age was 42 years. There were 62 males and 38 females. Diagnosis included; spinal stenosis [26%], failed disc surgery [22%], spondylolisthesis [19%], degenerative disc disease [17%], and instability [16%]. Operations performed; Pedicle Screw Fixation [PSF] with Postero-lateral Fusion [PLF] in 3% patients. Trans Laminar Facet Screw [TLFS] with PLF in 24% patients. Anterior Lumbar Inter-body Fusion [ALIF] in 9% patients. Posterior Lumbar Inter-body Fusion [PLIF] in 40% patients and Trans-foraminal Lumbar Inter-body Fusion [TLIF] in 24% patients. Average follow up was for 30 months. 86% patients had full spinal fusion. 71% patients were fully satisfied with treatment, 28% were partially satisfied. Post-operatively, on average, visual analogue scale [VAS] showed 48 points significant improvement and Oswestry Disability Index [ODI] showed 53 points significant improvement. Instrumented Spinal Fusion is effective in our set up for relieving symptoms and improving functional outcome in selected patients with debilitating Chronic Low Back Pain due to degenerative disease of spine. Single fusion technique is not ideal for all types of patients and surgeon has to be versatile and trained in using different fusion techniques as the situation demands

Partial weight bearing; new quantitative approach

The objective of this study was to quantify scientifically the partial weight bearing advice to the patients so that the treating surgeons and treated patients know exactly how much weight they should bear on the treated limb. Descriptive study. The study was conducted at combined military hospital Sialkot and combined military Hospital Quetta from May, 2003 to Dec, 2006. We studied 150 patients who were operated for osteosynthesis in lower limb. We excluded all patients below age 10 years, poly trauma patients operated for bilateral leg fractures, and associated upper limb fractures. Patients were advised to place studied limb on weighing machine and exert required force. Depending upon implant used, quality of fixation and bone density, 5 to 10 kilogram of weight bearing was started two to three weeks after the operation. This force was gradually increased by 5 to 10 kilograms two weekly interval as union progressed. Average age of the patients was about 40 years most of them were young males, with 5:1 ratio to females. Femur was most commonly involved bone in 81 [54%] patients, while tibia in 69 [46%] patients. Road traffic accident was most common etiology in 95 [63.33%] patients, history of fall, nonunion, and field injuries were etiology in other cases. Locally made implants were used in all cases. External fixator was applied in 45 [30%] and internal fixation was done in 105 [70%] cases. Bone grafting was done in 24 cases. We achieved union in 97.3% patients. Union was achieved in mean 15.1 weeks in internal fixations and 17.3 weeks in external fixators. We had 21 [14%] minor and 8 [5%] major complications most of them in patients requiring external fixators. Quantifying partial weight bearing advice gives confidence to patient that how much weight bearing to be done depending upon fracture geometry, implant used its fixation and bone quality. By avoiding nonspecific terms toe touch, heel touch and partial weight bearing we can advise exactly to bear required weight by this simple method. The result of study shows excellent union rates even in open fractures and infected nonunion. To our knowledge this is the first attempt to quantify partial weight bearing advice. The result of this study will help in understanding the patient regarding weight bearing

Pin tract care in locally made external fixators: a new treatment protocol

To calculate the frequency of pin tract infection in locally made external fixator pins using our set protocol. Descriptive study. This study was conducted in Combined Military Hospital Sialkot and Combined Military Hospital Quetta over a period of 3 years and 6 months from May 2003 to November 2006. A total of 451 Pin tracts from 50 external fixator were studied in forty nine patients. Inclusion criteria was all external fixator pins to the limbs excluding the skeletal tractions. Local Shanz screws and Kirschner wires of two different sizes were studied. The protocol was twice a day cleaning of pin tracts with povidone iodine [pyodine], twice a week soap and water bath with soft brushing where main wound was healed. At the time of removal of fixator the pin tracts were curetted and washed with 0.9% normal saline. Average age of the patients was 32.91 years most of them were young males, 23 [47%] in 3rd and 4th decade. Only 4 [8.1%] were females. Tibia was most commonly involved bone in 38 patients [77.5%], while femur in 6 patients [12.2%] and foot and upper limb were affected in only a few cases. Road traffic accident was most common etiology in 33 [67.34%] patients either presenting as open fractures or infected nonunion. Out of 451 pin tracts, 233 [51.66%] were locally made shanz screw half pins and 218 [48.33%] were locally made Kirschner wires full pins. The mean fixator time was about 17 weeks with maximum 48 weeks and minimum 7 weeks. Maximum follow up was 12 months minimum follow up was 3 months after removal of fixator. We had 25 [10.72%] minor pin tract infections of shanz screws, 5 [2.29%] minor pin tract infections of kirschner wires. We had to remove and change 3 [1.28%] Shanz pins. We had no true complication. Standardizing a set protocol for pin tract care irrespective of wound type has shown excellent results with minimum morbidity. This simple method not requiring any expensive equipment can be tried in any hospital to avoid pin sores