Effectiveness of Treatment in Children With Cerebral Palsy.

OBJECTIVE:  The objective of this study was to assess the effectiveness of conservative and surgical treatment in cerebral palsy children by evaluating the Medical Research Council (MRC) grading system, modified Ashworth scale, and Barthel Activities of Daily Life (ADL) scale. METHOD: This prospective case series was performed using a non-probability consecutive sampling technique at the Department of Orthopedic Surgery and Traumatology, King Edward Medical University/Mayo Hospital, Lahore from October 2011 to November 2013. Two hundred children of all ages, having cerebral palsy diagnosed on history and clinical examination were enrolled in the study. Children were treated with conservative and surgical treatment. Pre- and post-treatment, all children were classified based on movement disorder (spastic, athetoid, ataxic, and mixed), parts of the body involved (paraplegic, tetraplegic, diplegic, hemiplegic, monoplegic, double hemiplegic, and triplegic), and gross motor function (GMFCS level I-IV). Their muscle power and tone were assessed using the MRC grading system and modified Ashworth scale, respectively. Assessment of disability and daily function was done by ranking disability grading and Barthel ADL, respectively. The range of motion (ROM) of each joint was assessed clinically. Children were divided based on the treatment method as non-surgical versus surgical treatment. RESULTS: Out of a total of 200 children, the mean age of the children was 7.86±4.17year. There were 134 (67.0%) males and 66 (33.0%) female children. Classification on basis of movement disorder, body part involved, and gross motor function at three-month intervals till twelve months was performed. From the first presentation of children till the last follow-up time period, i.e., 12th month there was no change in the movement disorder (a type of CP, body parts involved, and GMFCS). The final rating of overall treatment results shows that there were 84 (42%) patients who had a poor outcome, and only 35 (17.50%) patients had a fair treatment outcome and 81 (40.50%) patients had good treatment outcomes.  Conclusion: The conservative and surgical management showed no effect on movement disorder of the child although, on the final rating scale fair to good treatment outcome was observed in all children. There was an improvement in muscle power grading on the ADL, but no significant improvement was seen on the improvement of type, parts of the body involved, gross motor function classification, modified Ashworth, and ranking disability grading of the children.

Effectiveness of locking compression plate in wedge fracture of diaphysis of radius and ulna in adults: A descriptive case series.

The aim of the study was to see the effectiveness of locking compression plate (LCP) in wedge fracture of diaphysis of radius and ulna in adults. This prospective descriptive case series study inducted total 45 patients presenting with wedge fracture (AO Type, 22-B) of radius and/or ulna. The treatment outcome of these patients were monitored for 24 weeks in 8 visits. Presence or absence of radiological union was noted. The functional outcome was evaluated in terms of Disability of Arm, Shoulder and hand (DASH) score and Grace and Eversmann criteria. Mean age of the patients included in this study was 28.76±6.16 years (range 18-47 years). Among them 28 (62.2%) were male while 17 (37.8%) were females. Union was achieved in all the patients at mean time of 12.62±2.24 weeks (range 8-16 weeks). Mean DASH score was 12.20±4.3 (range 5-19).According to Grace and Eversmann criteria, 41 (91.1%) had excellent result, 3 (6.7%) had good result, 1 (2.2%) had satisfactory results while there was no patient with unsatisfactory result. High rate of union along with good functional outcome and minimal complication can be achieved in patients with diaphyseal wedge fracture of radius and/ or ulna when managed with locking compression plate.

Acromion Types and Role of Corticosteroid with Shoulder Impingement Syndrome.

OBJECTIVE: To determine the association between shoulder impingement and morphological characteristics of acromion and the role of sub-acromial injection of methylprednisolone in the short-term treatment for relieving pain and improve functional disability of these patients. STUDY DESIGN: A descriptive study. PLACE AND DURATION OF STUDY: Department of Orthopedic Surgery and Traumatology Unit-I (DOST-I), Mayo Hospital, Lahore, between November 2013 to June 2014. METHODOLOGY: All patients presented in OPD with shoulder pain were included as subjects and evaluated by clinical test and categorised using X-ray scapula Y-view. Patients with impingement syndrome were correlated with Bigliani types and offered intra-lesional injection into sub-acromial space with 2ml of xylocaine 2% and 40 mg of methylprednisolone using 22 gauge needle. The effectiveness was assessed in terms of relieving pain and good functional outcomes; and rotator cuff tear was clinically assessed among impingement positive patient. The pain was assessed using visual analogue score before and after the administration of the injection. Demographic variables for frequencies and their associations were analysed using SPSS version 20.0. Significance level was p <0.05. RESULTS: Among the 101 cases, there was no case of tear of rotator cuff tendon on clinical assessment. Majority of the patients (58.4%) were females with mean age of 31.38 ±1.13 years. Majority 57 (56.4%) of the patients had acromion type II (curved), which was the most common cause of shoulder impingement. Most had moderate pain. Thirty-four patients required intralesional steroid, which relieved the pain in 31 of them. CONCLUSION: Shoulder impingement syndrome without tear of rotator cuff tendon was found in younger age group between 40 to 45 years, which was relieved by intralesional corticosteroid administration. These patients had type II (curved) acromion, according to Bigliani classification.

Role of addition of Dexamethasone and Ketorolac to lignocaine intravenous regional anesthesia (Bier's Block) to improve tourniquet tolerance and post-operative analgesia in hand and forearm surgery.

OBJECTIVE: To compare tourniquet tolerance and postoperative analgesia using lignocaine intravenous regional analgesia alone or with addition of dexamethasone and ketorolac. METHODS: The randomised, prospective study was conducted at Mayo Hospital, Lahore, from June 2013 to June 2014. Patients were divided into three groups: group I received lignocaine; group II received lignocaine and 30mg ketorolac; and group III received lignocaine, 30mg ketorolac and 08mg dexamethasone for intravenous regional anaesthesia. A total of 40ml solution was made by diluting it with normal saline. Motor and sensory block and recovery times were noted. Visual analogue scale was used to assess the severity of surgical and tourniquet pain, and total number of analgesic tablets taken in the first 24 hours after surgery were also recorded. RESULTS: The 180 patients in the study were divided into three equal groups of 60(33.3%) each, with each group having 30(50%) male and 30(50%) female subjects. In all the three groups, the sensory and motor onset and recovery time was the same (P> 0.05). Lower pain scores were reported in groups II and III compared to group I (p<0.001). Patients of group II and III also required fewer analgesic tablets postoperatively and had longer postop time during which no analgesia was given compared to group I (p<0.05). CONCLUSIONS: Bier block using lignocaine, dexamethasone and ketorolac provides better tourniquet tolerance in patients undergoing hand and forearm surgeries when compared to use of lignocaine alone and lignocaine and ketorolac.

A comparison of treating Unicameral bone cyst using steroids and percutaneous autologous bone marrow aspiration injection.

OBJECTIVE: To compare the results of percutaneous autologous bone aspiration injection and steroids injections in the treatment of unicameral bone cyst. METHODS: The prospective study was conducted at Mayo Hospital, Lahore, from January 2008 to March 2014, and comprised patients diagnosed radiologically as a case of unicameral bone cyst. The patients were divided into two groups, with group 1 being treated with bone marrow aspiration injection, while group 2 was given steroids injection. Aspiration of bone marrow was done from tibial tuberosity. RESULTS: The 30 patients in the study were divided into two groups of 15(50%) each. In group 1, 8(53.34%) patients and in group 2, 3 (20%) patients achieved healing after the first injection (p<0.05), while overall success rates were 13(86.67%) in group 1, and 11(73.33%) in group 2 (p> 0.05). The mean number of procedures required in group 1 was 1.57± 0.495 (range: 01-3) and for 2.19 ± 1.076 (range: 1-5) in group 2 (p<0.05), and mean interval-to-healing was 14.3 months ± 8.705 (range: 7-36) for group 1 and 12.5 months ± 7.88 (range: 4-32) for group 2 (p> 0.05). CONCLUSIONS: Bone marrow aspiration injection was better than steroids in treating unicameral bone cyst.

Improvement in Harris Hip Score after cementless total hip arthroplasty in young active adults with secondary hip arthritis- A short-term follow-up result.

OBJECTIVE: To determine the improvement in Harris Hip Score after non-cemented total hip replacement in younger patients with secondary hip joint arthritis. METHODS: The quasi-experimental study was conducted at Unit I, Department of Orthopaedic Surgery and Traumatology, Mayo Hospital, Lahore, and comprised patients diagnosed clinically and radiologically as secondary hip joint arthritis from September 2009 to December 2014. Harris Hip Score was calculated pre-operatively. All patients were operated by the same surgical team. One dose of second-generation intravenous cephalosporin after test dose was given at induction of anaesthesia followed by 3 times daily postoperatively along with aminoglycosides twice daily for three days followed by oral quinolones for 2 weeks. Patients were followed up for 6 months. The improvement in hip score was classified as poor, fair, good and excellent. Data entry and analysis was done using SPSS 11.5. RESULTS: Of the 65 patients in the study, 43(66%) were male and 22(34%) were females. Right hip was involved in 40(62%) patients and 25(38%) had pathology in the left hip. Overall mean age of male and female patients was 35.69±5.55 years and 35.72±5.95 years respectively. Harris Hip score improved over 6 months from poor to fair. CONCLUSIONS: The use of non-cemented total hip arthroplasty conferred a significant improvement in function in young patients with arthritis of the hip joint.

Burkhalter opponensplasty; role in isolated median nerve injury.

OBJECTIVE: To report the outcome of Burkhalter opponensplasty using Extensor Indicis Proprius with isolated traumatic low median nerve palsy. METHODS: The prospective study was conducted at the Mayo Hospital, Lahore, from June 2010 to June 2013, and comprised cases of Burkhalter opponensplasty using the Extensor Indicis Proprius to restore thumb opposition in isolated median nerve palsies. All patients had the condition for 16 to 20 months. The tendon was harvested just proximal to the extensor expansion and the insertion was to the distal attachment of abductor pollicis brevis. RESULTS: Of the 11 patients in the study, 6(54.5%) were females and 5(45.5%) were males, with overall ages ranging between 19 years and 51 years. There were no postoperative complications. Nine (82%) patients had excellent results, while the remaining 2(18%) had good result. CONCLUSIONS: In patients with isolated traumatic median nerve palsy, Burkhalter opponensplasty yielded excellent and satisfactory results.

Role of injecting bone marrow aspiration injection in treating delayed union and non-union.

OBJECTIVE: To access the role of bone marrow injection in the management of delayed union and non-union. METHODS: The prospective study was conducted at the Department of Orthopaedic Surgery and Traumatology, Mayo Hospital, Lahore, from January 2012 to December 2013, and comprised patients who had long bone fractures that resulted in delayed or non-union and were treated with bone marrow injections. Aspiration of bone marrow was done from tibial tuberosity and was injected percutaneously at the fracture site. The whole procedure was carried out as a day case. Fracture site mobility, tenderness and radiological features were assessed using the Union Scale score. RESULTS: Of the 25 patients, 18(72%)were male and 7(28%) were female with an overall mean age of 38±12.96SD years (range: 17-61 years). There were 19(76%) tibial shaft fractures, 4(16%) had shaft of femur fracture, and 2(8%) had humeral shaft fracture. Mean time duration between the injury and the procedure was 34 ±3.46 SD weeks (range: 30-42 weeks). Overall, 23 (92%) patients showed union and the mean time of healing was 15 ±2.73SD weeks (range: 12-22 weeks) after the procedure. CONCLUSIONS: Percutaneous bone marrow injection provided an alternative to open bone grafting, having least complications, especially for early intervention in the fracture-healing process.

Results of injection corticosteroids in treatment of De Quervain's Tenosynovitis.

BACKGROUND: De Quervain's tenosynovitis is defined as stenosing tenosynovitis of the synovial sheath of tendons of abductor polices longus and extensor pollicis brevis in the first compartment of wrist due to repetitive use. OBJECTIVE: To assess the results of injecting corticosteroids injections for De Quervain's tenosynovitis. METHODS: 80 patients with disease were included in this study. All had a mean of 5.87 weeks of treatment of the condition with NSAIDs and had shown no response. Using Visual analogue scale the severity of tenderness on first dorsal compartment and pain felt on Finkelstein test was recorded. A mixture of 1 ml (40mg) of methylprednisolone acetate and 1 ml of 2% lignocaine hydrochloride was injected in first dorsal compartment of involved wrist. Patients were followed for 28 weeks on monthly basis. Outcome measure was reduction in pain and tenderness on the radial side of wrist and negative Finkelstein test subsequent to injection. RESULTS: 65% patients after 1st injection were symptoms free at two weeks, 35% patients were given second injection two weeks after the first. 80% patients at four weeks, 95% patients at six weeks and 98.75% patients were symptom free at 12th week. One patient underwent surgical release. The adverse reaction of steroid was seen in 25% of patients, which were subsided in 20 weeks. CONCLUSIONS: We conclude that two or three local steroid injections in the first dorsal compartment lead to significant improvement in patients with de Quervain's tenosynovitis.

Amputations of limbs during the 2005 earthquake in Pakistan: a firsthand experience of the author.

PURPOSE: On 8 October 2005 a massive earthquake hit the northern mountainous areas of Pakistan and Kashmir causing 73,338 deaths and leaving over 125,000 severely injured. In a region which was less prepared for such an enormous disaster, mobilising rescue, relief and rehabilitation posed great challenges. The lead author (SMA) established two level 1 orthopaedic trauma and rehabilitation units in existing public hospitals through private philanthropy in the earthquake struck cities of Muzaffarabad in Kashmir and Mansehra in Khyber Pakhtun Khuwa (KPK) Province. The purpose was to combat the major catastrophe and later study the pattern of injuries especially amputations so as to improve the future strategies in similar scenarios. METHODS: This is a retrospective descriptive study of patients suffering from injuries of the limbs due to the earthquake who were managed in these centres with special emphasis on the patients with amputated limbs. The patients were received, worked up, investigated and prepared for definitive surgical procedures, in this case amputations. All patients were provided assistance for the fitting of a prosthesis and rehabilitation by referring them to specialised centres. RESULTS: Of 128,304 patients, 19,700 were managed in the centres established by the lead author over a period of seven months. Of these, 112 patients underwent amputations of upper and lower limbs. CONCLUSIONS: In a massive calamity over a wide geographic area away from big university hospitals, such as the 2005 Pakistan earthquake, the level 1 operating theatre facilities must be established within the area to meet the needs of the patients nearest to their homes and families, and run forever so that patients can have excellent follow-up and can use the same facilities regularly. For example, in this study we managed 112 amputees and placed them in a rehabilitation programme, and transferred these centres to the hospital authorities after five years.

Evaluation of management of tibial non-union defect with Ilizarov fixator.

BACKGROUND: Tibial bone defect lead to limb shortening and functional deficit and needs proper treatment. There are various treatment modalities for bone defect in long bone to restore length and function of the limb, i.e. bone grafting, vascularised bone graft, allograft and bone transport. Bone transport can be done through fixators (uniplaner or ring) and intramedullary nail system. This study was conducted on management of tibial non-union with Ilizarov external fixator. METHOD: This descriptive study was performed on 58 patients in Agency Headquarter Hospital, Bajawar and Lady Reading Hospital, Peshawar, from January 2000 to January 2006. Patients of either gender with age between 9 to 58 years, having nonunion (clean and infected nonunion) in tibia with defect of 2 to 7cm due to trauma or firearm injury were included in the study. These patients were followed up upto one year. Outcome measures were according to the classification of Association for the Study and Application of the Method of Ilizarov (ASAMI), which is based on radiological (defect filling) and clinical (functional) findings. RESULTS: Out of 58 patients, 44 (75%) were male and 14 (25%) were female. Mean age was 30 years (9 to 58 years). 38 (65.52%) patients had infected non-union while 20 (34.48%) had clean non-union. Right tibia was involved in 32 patients (51.17%) and left was involved in 26 (44.83%) patients. The cause of initial trauma was road traffic accident in 27 patients (46.55%), firearm injury in 23 patients (39.65%) and a simple fall in 8 patients (13.79%). The length of average bone defect was 2.90 cm (200-7.00 cm). Radiological results were excellent in 33 (58.89%) patients, good in 12 (20.68%) patients, fair in 8 (13.79%) patients and poor in 5 (8.62%) patients. The clinical results were excellent in 33 patients (56.89%), good in 18 patients (31.05%), fair in 4 (6.89%) patients and poor in 3 patients (5.17%). CONCLUSION: Ilizarov ring fixator is excellent treatment modality for tibial non-union with a defect, regarding bone union, deformity correction, infection eradication, limb length achievement and limb function but this needs prolonged learning curve for fresh orthopedic surgeons.

Management of femur shaft fracture with close locked intramedullary nailing: comparison of Variwall and predrilled Kuntscher nail.

A prospective and comparative study of 44 cases of close locked static intramedullary (IM) nailing of Femur shaft fracture with two nailing systems was done. Comparing the cheap predrilled Kuntscher nail with standard but expensive Variwall nail of Biomet Company England, we found almost equal result in both groups regarding complications and healing of the fracture. Average healing time in Variwall and Kuntscher nailing were 16.4 and 16.1 weeks respectively, P value being in-significant. In Variwall nailing, stable fractures healed at the average of 13.5 weeks and unstable fractures at 17.2 weeks; open fractures at 18.4 weeks and close ones at 14.2 weeks; fractures due to Road Traffic Accident (RTA) at 16.3 weeks, gunshot injury at 18.6 weeks and fractures due to fall at 14 weeks. Similarly in Kuntscher nailing these figures were 14 and 16.7 weeks; 19.6 and 14.5 weeks; 16.6, 22 and 13 weeks respectively. Pre-drilled Kuntscher nail with good quality cortical screws for interlocking is recommended for any variety of femoral shaft fracture. It is cost effective, at the same time gives acceptable result as compared to standard interlocking intramedullary nail.