En block excision and iliaccrest autograft intepositional arthrodesis for giant cell tumour of distal radius: [campanacci grade·III]

Objective: to study wide resection and arthrodesis of wrist, utilizing an autologous iliac crest for giant cell tumour of distal radius [Campanacci Grade-I I I]

Material and Methods: between Feb 2004 to Nov 2011 ,fourteen patients with amean age of 31 .5 years [21-42 years] with Campanacci Grade-Ill GCT of distal radius were admitted in orthopaedic ward Services hospital Lahore. Thirteen patients were managed with wide excision of tumour and reconstruction with ipsilateral iliac crest, fixed with small fragment plate to the remnant of radius. Primary autogenous iliac crest grafting was done at iliac crest radial junction in all the patients

Results: all the patients were followed to bony union, and twelve out of 14 patients were available at mean follow up of 24 months [10 to 26].The mean time to union was four months [3.0 to 6.0] at iliac crest-carpal site and 4.5 months [3.0 to 6.60] at iliac crest- radial site. Eleven patients had a reasonably good range of supination and pronation. The mean Musculoskeletal Tumour Society score was 23.21[77.38%, range21 to 25]. Among the complications, two patients developed radioulnar synostosis, one patient had a local recurrence, but with no bony involvement. Local excision was done and no local recurrence took place thereafter and he is disease free. One patient developed stiffness of fingers, which improved with physiotherapy. There was no other complications like nonunion at the graft bone junction, wound infection [superficial or deep], skin necrosis deformity and bony metastasis and refracture at the reconstruction site

Conclusions: iliac crest provides a local corticocancellous bone graft to reconstruct the defect left after excision of the distal radius for giant cell tumour. Iliac crest graft has advantage over the fibular and ulna graft of having the early union and better incorporation to the host bone, with no evidence of nonunion in our studies. It provides good stability at wrist with contouring of DCP over its concave surface, while retaining a good function of hand and forearm rotation

Evaluation of Test of Stability as an Aid for Osteotomy in Open Reduction for Developmental Dysplasia of Hip.

Background: Developmental dysplasia of hip (DDH) represents a spectrum of anatomic abnormalities that can result in permanent disability. The goals of treatment are to create normal anatomy of the proximal femur and acetabulum and then to maintain that anatomy to allow normal development of hip. Our aim was to identify significance of the test of stability in planning of appropriate osteotomy during open reduction in order to achieve stable concentric reduction in DDH in terms of Severin’s clinical and radiological outcome. Materials and Methods: In this study, 50 children with DDH, which required open reduction and osteotomy for stable concentric reduction, were admitted in Orthopaedic department of SIMS/Services Hospital from Mar 2004 - May 2008. Clinical assessment and radiograph of pelvis with both hips in anteroposterior view was done for all the patients to confirm the diagnosis. After the confirmation of diagnosis surgery was planned and during surgery test of stability applied. Test of stability are the maneuvers which included flexion, internal rotation and abduction performed by the operating surgeon to assess the need for a concomitant osteotomy. If hip found stable in internal rotation and abduction, varus derotational femoral ostetomy was done and fixed with 1/3rd tubular plate. If hip required flexion it was treated with innominate osteotomy and fixed with K-wires. Those hips which required flexion, abduction and internal rotation for concentric reduction were treated with both ostetomies and fixed with K-wire & plate. Postoperatively all the patients were applied hip spica. A descriptive and analytical statistical analysis was performed on SPSS, version 13. Results: The mean age of patients was 4 years (Mean ± SD: 4 ± 1.31), youngest patient being 3 years of age and oldest 7 years. Sex distribution with female to male ratio was 1.8:1. On an average follow up of 3.2 years Severin’s clinical outcome for 42 (84%) patients was excellent, 7 (14%) was good and 1 (2%) was poor. P-value was 0.001. Severin’s radiological outcome for 40 (80%) patients was excellent and for 10 (20%) patients was good. P value was 0.112. Conclusion: The test of stability is simple and effective aid for osteotomy in open reduction for developmental dysplasia of hip with excellent clinical and radiological results measured according to severin’s classification.

Hemorrhoidectomy VS rubber band; comparison of post operative complications

To compare open hemorrhoidectomy and Rubber Band Ligation [RBL] in the management of 2nd and 3rd degree hemorrhoids in terms post operative and hospital stay. Experiential Randomized Control Trial. Department of surgery, Allied Hospital and Independent University Hospital Faisalabad. Dec 2008 to May 2009. 100 consecutive patients with second and third degree hemorrhoids were randomly divided into two groups. Group A [50 patients] were operated by open hemorrhoidectomy [Milligan morgan technique] while in group B [50 patients] rubber band ligations was performed. Open hemorrhoidectomy was performed under spinal anesthesia while rubber bands were applied with local xylocaine gel using Barron's rubber band ligator. All the three hemorrhoids were ligated in single session. Average hospital stay was 24 hours in patient operated by open hemorrhoidectomy as compared to one hour in rubber band ligation. 60% patients in group A developed moderate to severe pain requiring I/V morphine derivatives while 40% developed mild pain and treated with NSAIDS. In group B only 20% patients developed moderate pain and were dealt with I/M diclofenac sodium. Eightyeight percent patients in group A and 60% patients in group B developed mild to moderate bleeding in first postoperative week, which was self limiting. 6 patients developed severe bleeding after hemorrhoidectomy requiring blood transfusion. During six month follow up, two patients [4%] of open hemorrhoidectomy and 3 patients [6%] of RBL presented with recurrence and respective procedures were repeated. Rubber band ligation is safe, quick, economical and effective method for the treatment of 2nd and 3rd degree hemorrhoids

Three port versus four port laparoscopic cholecystectomy

Objective: The objective of this study is to compare the outcome of three vs four port laparoscopic cholecystectomy and detect safety of three port laparoscopic cholecystectomy [LC] as routine procedure

Study Design: Simple comparative study

Setting: One year starting from June 2010 to May 2011. Sample size: 100 patients

Methods: All patients were divided into two groups. Group A: three port laparoscopic cholecystectomy was done. Group B: Conventional four port laparoscopic cholecystectomy was done. Outcome is determined in terms of postoperative pain [determined by visual pain scale] and complications [bleeding, infection, bile duct injury]

Results: 35 patients in Group A had low pain score and 15 were high pain score. In group B, 24 had low pain score and 26 high pain score. In group A only 10 patient needed nalbuphine as compared to 35 patient in group B. Both groups have almost same operating time [48.5min A and 48min B]. Hospital stay is same [48h]. Complications like port site bleeding [2 patient in A and 4 in B], wound infection [2 in A and 3 patients in B], abdominal pain [3 in group A and 4 in group B] of three port laparoscopic cholecystectomy are comparable with four port cholecystectomy. No patient in both groups suffered bile duct injury

Conclusion: The three-port technique is as safe as the standard four-port for LC. The main advantages of the three-port technique are that it is less painful, safe, less chances of wound infection and leaves fewer scars

Role of adjuvant topical oxygen therapy [Topox] versus conventional methods in the management of non- healing infected wounds

Objectives: To compare the role of adjuvant topical oxygen therapy versus conventional methods in the management of non-healing infected wounds

Study Design: Simple comparative study

Setting: The study was carried out in one year duration from January 2010 to December 2010 in Surgical unit-1 Allied Hospital Faisalabad

Sample Size: 60 patients

Methods: Total of 60 patients was divided into two groups. In one group [A] topical oxygen therapy was given along with conventional measures for management of wound. In second group [B] only conventional methods were used for wounds

Results: 60 cases included in this study,30 in group A and 30 in group B. From patients of group A, 16[53.3%] showed clinical improvement in first week and 25[83.3%] showed clinical improvement in second week. While in group B 5[17%] and 11[36.7%] showed clinical improvement in first and second week respectively.5[17%] patients in group A developed granulation tissue in first week and 19[63%] in second week. While in group B 2 [7%] developed granulation tissue in first week and 8[27%] in second week. From group A 10[33.3%] and 24[80%] patients showed complete wound healing in second and third months respectively. In group B 3[10%] patients showed complete wound healing in two months and 12[40%] in three months.1[3.3%]patient in group A deteriorated in first week and 2[7%] in second week.8[27%]patients from group B deteriorated in first week and 4[13.3]in second week

Conclusion: Use of TOPOX along with conventional method is more safe and effective in the management of nonhealing infected wound than conventional methods alone

Intestinal anastomosis; comparative evaluation for safety, cost effectiveness, morbidity and complication of single versus double layer

To evaluate the safety and cost effectiveness of single layer interrupted intestinal anastomosis in comparison with the double layer conventional method of intestinal anastomosis. Prospective comparative study. Surgical unit 4 DHQ hospital Faisalabad operated by single team during 12 months starting from Feb. 2007 to Jan. 2008. The cases were assigned to the two techniques, each being applied on alternate patient, single layer extra mucosal interrupted anastomosis and double layer anastomosis. In group 1 we used black silk 3/0 and in double layer we used vicryl 3/0 for inner continuous layer and black silk 3/0 for outer continuous layer. Comparison between two techniques was done on the bases of procedure time, cost effectiveness, morbidity in terms of rate of leakage. Average time for the construction of the single layer anastomosis was 20 minutes and in double layer was 35 minutes, the difference in average time is statistically significant [p<.001] while average duration of stay was 168 hrs and 216 hrs in group 1 and 2 respectively [p<.001]. Leakage rate was double [12%] in group 2 while 6% in group 1. Moreover structure material consumption was more in two layered technique and longer stay added to that lead to more hospital expenses on two layered technique. Anastomosis using a single layer interrupted extra mucosal technique was faster to perform, cost effective, less likely to leak and as strong as a 2-layer anastomosis

Incisional hernia repair by preperitoneal [sublay] mesh implantation

Incisional Hernia is a common surgical condition with a reported incidence of 2-11% following all laparatomies. Results of tissue repair have been disappointing. The optimal approach for abdominal incisional hernias is still under discussion. To evaluate the technique of preperitoneal [sublay] mesh repair of incisional hernias. This retrospective study of consecutive 50 cases was done from January .2004 to January 2006 using a computerized database. Preperitoneal [sublay] mesh implantation was done in all the 50 cases. Follow up of 12-24 months was carried in the OPD and on telephone with regards to postoperative complications, hospital stay and recurrences if any. In our study of fifty patients, eighty percent of females [n= 40] outnumbered twenty percent males [n=10]. The female to male ratio was 4: 1 and the highest incidence was in the 5th decade of life. The main presenting feature was swelling of the abdomen in all the fifty patients [100%] in the vicinity of the previous operative scar. In sixty percent of patients [n=30], the most common incision leading to incisional hernia was the midline incision of abdomen followed by Pfannensteil's incision in fourteen percent [n=7] and paramedian incision in twelve [n=6]. Major wound infection occurred in two patients [4%] only but without the removal of mesh. Forty patients [80%] attended for follow up ranging from 12 months to 24 months. Twenty seven patients [67.5%] attended OPD for follow up and thirteen patients [32.5%] replied the questions on phone. No recurrence was noted in follow up group. Based on this study, we conclude that preperitoneal [sublay] mesh repair is the ideal technique for incisional hernia. Though still there are few publications regarding this technique of repair