Management of Adult Traumatic Brachial Plexus Injury.

Brachial plexus injury is not uncommon in our country like Bangladesh and it causes functional damage and physical disability of the upper limbs. Most of the cases were caused by motor vehicle accident. We have conducted a prospective study for the operative treatment of 105 adult traumatic brachial plexus injury cases in Hand unit in the department of Orthopaedics, Bangabandhu Sheikh Mujib Medial University (BSMMU) during January 2012 to July 2019. The main surgical options for brachial plexus injury include primary reconstructive surgery such as neurolysis, direct repair, nerve graft, nerve transfer (neurotization) and possibly free functioning (gracilis) muscle transfer and secondary reconstructive procedure such as tendon transfer, arthrodesis, FFMT and bony procedure. Each of these procedures is used either alone or in combination for particular clinical scenarios. Aims and objectives of this study was to restoration of shoulder abduction and external rotation, elbow flexion and hand function are goal of treatment of adult traumatic brachial plexus injury. Age range was from 14 years to 55 years (mean age 26 years). Male were 95 and female were 10 cases. Time from trauma to surgery was valid 3 months to 9 months. Motor cycle accident was most common mechanism of injury. Upper plexus (C5, C6) injury was 52 cases, extended upper plexus (C5, C6 & C7) injury was 19 cases and global brachial plexus injury was 34 cases. When there is high suspicion of root avulsions, early exploration and reconstruction is indicated. Operate these patients 2-3 months after their injury. In other patients without high suspicion of root avulsion, we routinely perform exploration between 3 to 6 months after injury when no adequate sign of recovery are present. Common reconstructive options are any injury with neuroma in continuity with conductive nerve action potential (NAP): only neurolysis or any injury with nerve rupture or postganglionic neuroma not conducting nerve Action potential (NAP) and good proximal nerve: Direct repair or repair with nerve graft or nerve transfer if possible. Follow up period from 6 months to 6 years. The best results were obtained in C5, C6 and C5, C6 & C7 brachial plexus injury cases. SAN to SSN, Oberlin II and long head triceps motor branch to anterior division of axillary nerve transfer for C5 & C6 injury or upper plexus injury and in addition intercostals nerve to anterior division of axillary nerve and AIN branch of median nerve to ECRB for C5, C6 & C7 (extended upper plexus injury). Extra-plexus and intra-plexus neurotization was done in global brachial plexus injury cases and 5 cases by contra-lateral C7 to median nerve by vascularised ulnar nerve graft and only 2 cases contra-lateral C7 to lower trunk through pre spinal or pre tracheal route were done and only one case by FFMT. Few cases gain shoulder abduction and elbow flexion but no improvement of hand function and most cases even by FFMT still in follow up. Results of surgical treatment of upper and extended upper brachial plexus injury cases were satisfactory on the other hand recovery of shoulder abduction and elbow flexion was acceptable and comparable to other study in global brachial plexus injury and recovery of hand function were poor.

Management of the Hand Tumors.

Tumors in the hand are relatively uncommon but 95% are benign. Tumors occurring in the hand, forearm and arm often have unique growth patterns and potential for metastasis that may be different from those seen elsewhere in the body. Secondary metastatic tumors in the hand are very rare (0.1%). Diagnosis is mainly clinical, but X-ray, USG and MRI help as a diagnostic aid. The aim of the study was to early diagnosis, see the pattern and proper management of the hand tumor and ensure good hand function. This prospective study was done from January 2004 to July 2019. We found 220 hand tumors in the hand unit, Department of Orthopaedic Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka Bangladesh. Among 220 patients, male were 114(51.81%) and female were 106 (48.19%). Out of 220 patients we found 190(86.36%) benign tumor and tumor like lesions and 30(13.64%) was malignant hand tumors. Out of 190 benign lesions, benign tumor was 158(83.15%) and 32(16.85%) was tumor like lesions. Among 158 benign tumor, bone tumors were 40(25.31%) and soft tissue tumours were 138(74.69%). Out of soft tissue tumor, peripheral nerve tumor was 20(12.66%). Enchondroma and Giant cell tumors are the most common among the benign bone tumors, on the other hand giant cell tumors of tendon sheath, Glomus tumor, haemangioma, neurofibroma, schwanoma are the common soft tissue tumors. Compound palmar ganglion, fibromatosis and tuberculosis of phalanx are the most common tumor like lesions. Synovial sarcoma 10(33.33%), osteosarcoma 03(10%), chondrosarcoma 03(10%), ewings sarcoma 02(6.66%), fibrosarcoma 04 (13.33%), Malignant fibrous histocytoma 01(3.33%), soft tissue sarcoma 01(3.33%), Merkel cell tumor 01(3.33%), pleomorphic Rabdomyosarcoma 01(3.33%), malignant melanoma 01(3.33%), clear cell sarcoma of tendon and aponeurosis 01(3.33%), undifferentiated carcinoma 01(3.33%) and extra skeletal chondro sarcoma 01(3.33%) were the malignant tumors. Most of the benign lesions recovered fully after excision except neurofibroma and malignant tumors were treated with excision (including amputation) and chemo-radiotherapy successfully, but 4 patients were refereed to higher center due to recurrence and deteriation of hand function and one patient died due to metastasis. Malignant hand tumor management is very difficult even after amputation with multidisciplinary approach. Hand tumor is uncommon and malignant tumors are rare but any abnormal lump or bump in the hand or wrist is considered as tumor. Early detection and intervention are essential for better prognosis and survival for malignant tumors of hands and upper limbs.

Management of Avascular Necrosis (AVN) of Femoral Head by Core Decompression with Tensor Fascia Lata (TFL) Muscle Pedicle Bone Graft.

Avascular necrosis (AVN) of femoral head is an increasingly common cause of musculoskeletal disability. Most of the cases caused by steroid induced and traumatic but idiopathic cause are not also uncommon. Almost all the patients presented with pain at the hip, limping gait, restricted movement and difficulty in waking and squatting and becomes disabled. Core decompression and muscle pedicle bone graft at stage IIA, IIB and III provides painless and mobile life. Core decompression supplemented with bone graft to enhance mechanical support and augment healing. We have started a prospective study for the treatment of AVN of Femoral head at stage IIA, IIB and III by core decompression and Tensor fascia lata muscle pedicle bone graft in the department of Orthopaedic surgery Bangabandhu Seikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from January 2009 to December 2019. Aim of the study was to assess the effectiveness of core decompression and tensor fascia lata muscle pedicle bone graft in the treatment of AVN of femoral head at stage IIA, IIB and III. A total 48 patients and 65 hips were operated. Out of 48 patients, male was 30(62.50%) and female was 18(37.5%). Male-Female ratio was 1.66:1. Age of the patients ranging from 20 years to 50 years, mean age 36±4.65 years. According to aetiology corticosteroid induced was 47/65 (72.31%), idiopathic was 8(12.31%), post traumatic was 4(6.15%), ITP was 2(3.08%), ALL was 2(3.08%), and alcohol induced was 2(3.08%) of femoral head involvement. According to Ficat and Arlet's staging, stage IIA hip involvement was 28/65(43.08%), stage IIB was 32(49.23%) and stage III was 5(07.69%). All patients were treated with core decompression along with tensor fascia lata (TFL) muscle pedicle bone graft. All patients were followed clinically and radiologically at regular interval. Follow up period was 6 months to 10 years. Harris hip score (HHS) was used for evaluation of clinical outcome. Among the 65 hips, 24(36.92%) was excellent outcome (HHS >90), 30(46.15%) was good outcome (HHS: 80-90), 7(10.78%) was fair outcome (HHS: 70-79) and 4(6.15%) was poor outcome. For valid statistical analysis excellent and good results were grouped as satisfactory that was 54(83.07%) and fair and poor results were grouped as unsatisfactory that was11(16.93%), p value is <0.001 that is significant. It has been concluded that core decompression and TFL muscle pedicle bone graft is a pain relieving, head preserving procedure and improve hip function for the management of AVN of femoral head in stage IIA, IIB and III.

Limb Salvage by Resection Arthrodesis with the use of Osteoarticular Allograft in the Treatment of Aggressive Giant Cell Tumour around the Knee.

Osteoarticular allografts have provided the chance of limb-sparing trial in tumor surgery. Several authors have reported 50-75% long term (>10 years) successful use of these types of grafts, and large well recognized series provide confirmation that limb reconstruction following extensive resection of bone and joints has been possible with their use. Infection has been a major problem, affecting up to 12 per cent of recipients and often resulting in re-operations and infrequently amputations. This prospective Interventional study was conducted in the Department of Orthopaedic Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU) and Biomedical Research division, Atomic Energy Centre, Savar, Dhaka, Bangladesh from January 2008 to December 2017. In this study patients' age were 20-50 years and male was 12(60%) & female was 8(40%). We assessed the results of 20 limb-salvage procedures (Resection-Arthrodesis Procedure) using 11-18cm of distal femur or proximal tibial osteoarticular allografts after wide resection of aggressive or malignant Giant Cell Tumour (GCT) around the knee joint, Campanacci Grade III or recurrent case of Campanacci Grade II. At the ten-year follow-up, two patients had died, one due to infection and tumor metastasis to the lungs and one due to medical causes. The allografts survived for more than five years was twelve patients (60%) all of whom had good function, ranging from 73% to 90% of normal. The allografts were removed because of fracture in two patients and infection in two patients. Remaining three patients allograft was survived with satisfactory function but follow up was 3 years. All postoperative problems related to the allograft reconstruction were documented. Functional outcome was evaluated using the Musculoskeletal Tumour Society Scoring System and at least more than 3 years follow up should be taken for categorization of the results. Among the 20 patients, satisfactory result was 15(75%) patients and unsatisfactory result was 5(25%) patients. P value was <0.001.