Traumatic Spondyloptosis Causing Complete Transaction of Spinal Cord

Traumatic spondyloptosis is a rare presentation and is usually due to very high energy trauma. It is accompanied with cord injury, mostly complete transaction of the cord. In managing such cases special consideration should be given to soft tissues, surrounding structures and organs in the traumatized area. We present a case of traumatic spondyloptosis of D12/L1 in a middle aged gentleman with complete cord transaction. DOI: http://dx.doi.org/10.3126/noaj.v3i2.9527 NOAJ July-December 2013, Vol 3, Issue 2, 38-40

Human Resources and Logistic Requirements in Problem Based Learning Compared to Traditional Learning

Problem-based learning (PBL) is a student-centered pedagogy in which students learn about a subject in the context of complex, multifaceted, and realistic problems. Working in groups, students identify what they already know, what they need to know, and how and where to access new information that may lead to resolution of the problem along with discussion of the solution within the group. Few medical schools in Nepal have already incorporated problem-based learning into their curricula and other medical schools are planning to adopt. However, when PBL is introduced into a curriculum, it has implications for staffing and learning resources and demands a different approach to timetabling, workload, and assessment. So, issues like human resources requirements and logistic requirements need to address specifically from Nepal Medical Council for the assurance quality of medical education which, in turn, has contributed in enhancing the quality of health care services in Nepal. Hence, this paper is prepared for developing further understanding about major difference between conventional method of Medical education and PBL in relation to human resources requirements and infrastructure. This article ends with some of the important recommendations that could be considered additionally to existing minimum requirements from Nepal Medical Council for the Medical Schools/ Universities in Nepal who are running or planning to implement Problem-based Learning in their curricula. DOI: http://dx.doi.org/10.3126/noaj.v3i2.9530 NOAJ July-December 2013, Vol 3, Issue 2, 46-47

Fracture Dislocation of Shoulder

Simultaneous dislocation of shoulder with fracture of the ipsilateral humerus is extremely rare and very little reported in the literature. We report a case of forty three year old man who got right shoulder dislocation with proximal humerus fracture. The patient was treated with open reduction and internal fixation by three 4.5mm screws. The operation went uneventful and has good range of motion of the shoulder after six months of follow up. DOI: http://dx.doi.org/10.3126/noaj.v3i2.9529 NOAJ July-December 2013, Vol 3, Issue 2, 44-45

Conservative treatment of TB Spondylitis in Dorsolumbar and Lumbar spine

Introduction: Tuberculosis (TB) is endemic in South Asia including Nepal. TB spine is the most common musculoskeletal manifestations and can have devastating complications. Early diagnosis by proper history, physical and radiological examination is mandatory. Chemotherapy is effective in most cases while some require surgical treatment. Methods: Forty-four patients with clinico-radiological evidence of TB were treated with four drug regime for 18 months and all patients were followed up till the end of the chemotherapy. Results: All 44 patients (M-28/ F-16) had back pain not responding to analgesics and physiotherapy while few had constitutional symptoms. Localized tenderness and paravertebral muscle spasm was present in 32/44 (72.7%) and the rest had palpable swelling at the dorsolumbar and lumbar regions. According to the classification by Oguz et al. the majority of the patients were in the Type I B. Six patients who did not show any improvement in pain and resolution of swelling were admitted and two more drugs (Steptomycin and Ofloxacin) were added. Conclusions: Conservative treatment of TB spondylitis of the lumbar spine can be treated with chemotherapy and appropriate investigations should be performed in patients with back pain who do not respond to rest, analgesics and physiotherapy. DOI: http://dx.doi.org/10.3126/noaj.v3i2.9526 NOAJ July-December 2013, Vol 3, Issue 2, 33-37

Low Molecular Weight Heparin versus Aspirin plus Intermittent Compression Devices for Thromboprophylaxis in Indian Patients Undergoing Total Hip and Knee Arthroplasty

Introduction: Thromboembolic complications is common after arthroplasty. The purpose of this study was to find out the incidences of deep vein thrombosis, symptomatic, and fatal pulmonary embolism in Indian patients undergoing arthroplasties and to compare the effectiveness and safety of thromboprophylaxis with low molecular weight heparin versus aspirin plus intermittent pneumatic compression device. Methods: Patients who had a total hip and knee arthroplasty were randomized to receive prophylaxis with LMWH or aspirin plus intermittent pneumatic compression device. After four to six days, all patients underwent bilateral lower-extremity color Doppler ultrasonography to screen for deep venous thrombi in the calf and thigh. Any clinical symptoms of pulmonary embolism were evaluated with pulmonary CT angiography. Bleeding events in both groups were documented. The patients were followed up at 6 week and 3 months with Color Doppler to look for the evidence of deep venous thrombi. Results: 300 patients (409 joints) were randomized into 2 groups and studied regarding the incidence of deep vein thrombosis, pulmonary embolism, safety of the thromboprophylaxis in regard to its efficacy. Demographics were similar clinically between the groups. The rate of major bleeding events was 0.67% in the aspirin and compression group and 6% in the low-molecular-weight heparin group. Overall, prevalence of DVT and PE in Indian patients who underwent total hip or knee arthroplasty was 0.67% and 0.33% respectively. The rates of deep venous thrombosis were 1.33%, in the aspirin plus compression group compared 0% in the LMWH group. The rates of pulmonary embolism were 0.67% in the Aspirin plus compression group and 0% in the heparin group, and there were no fatal pulmonary emboli. Within the six week and three month follow-up period, no events occurred. There was no difference between the groups with regard to the prevalence of venous thromboembolism. Conclusions: An inexpensive multimodal protocol, consisting of aspirin, exercises, and the use of intermittent compression devices, was associated with relatively higher thromboembolic complications. However, major bleeding events were significantly lower in Aspirin group. DOI: http://dx.doi.org/10.3126/noaj.v3i2.9525 NOAJ July-December 2013, Vol 3, Issue 2, 26-32

Oxygen Embolism During Surgical Lavage of Chronic Osteomyelitis of Femur with Hydrogen Peroxide

Hydrogen peroxide, an over the counter irrigation solution used in infected and dirty wounds, has been reported mainly in the anesthesia literature to have life threatening complications. We report a case of near fatal gas embolism during an orthopedic procedure of irrigating the wound of a 30 year old female with chronic osteomyelitis of the femur using hydrogen peroxide solution. DOI: http://dx.doi.org/10.3126/noaj.v3i2.9528 NOAJ July-December 2013, Vol 3, Issue 2, 41-43

Osteoporosis Self Assessment Tool for Asian (OSTA) Index in Comparison to Quantitative Ultrasound of the Calcaneal in Predicting Low Bone Density.

Introduction: Osteoporosis represent a worldwide public health problem, frequently resulting in fractures and leading to psychological problem, social consequences, functional limitation and poor quality of life. So it is important to identify those people who have high risk of osteoporosis, in order to reduce the incidence of osteoporotic fractures. The Osteoporosis Self-Assessment Tool for Asians (OSTA) index is a simple tool based on age and body weight. Calcaneal quantitative ultrasound (QUS) is another simple and low-cost instrument used to prescreen osteoporotic subjects. The aim of this study was to correlate between these two screening methods and to validate usefulness of Osteoporosis self assessment tool for Asian ( OSTA) in comparison with QUS of the calcaneum for the prediction of low bone density in Nepalese women. Methods: This was a two-year descriptive observational study comprising 100 subjects performed at TU Teaching Hospital, Kathmandu, Nepal, from 2007 January to 2009 January who completed semi structured questionnaire with subsequent measurement of Quantitative Ultrasound (QUS) of the calcaneum. The sensitivity, specificity, and diagnostic accuracy of OSTA index was validated with the QUS T-score. Results: When the risk category was defined as OSTA index ≤ -1, and low QUS value as t-score ≤ -2.5, the sensitivity, specificity and diagnostic accuracy of the index were 93.3%, 56.5%, and 62% respectively, and the area under the curve was 0.7651. When the low QUS value was taken as t score ≤ -1.0, the sensitivity, speciÞ city and diagnostic accuracy was 85.2%, 89.1% and 87% respectively. Conclusions: The OSTA index, a simple and free risk assessment tool, can be used to estimate the prevalence of low QUS values in Nepalese women and may help to increase awareness and prevention of low bone mineral density. DOI: http://dx.doi.org/10.3126/noaj.v3i2.9524 NOAJ July-December 2013, Vol 3, Issue 2, 20-25

Outcome of Surgical Decompression in Simple Degenerative Lumbar Canal Stenosis

Introduction: A sensory or motor deficit occurs in about half of patients with symptomatic lumbar canal stenosis. There is no study evaluating neurologically deficient patients with simple degenerative lumbar canal stenosis using validated measures and there are no consensus about outcome predictor of surgical decompression is available in literature. Only one study assessed outcome of patients with neurological deficit but it had not excluded either patients with comorbid conditions that affect outcome or those with lumbar canal stenosis secondary to spondylolisthesis and scoliosis. The aim of this study was to assess overall result and to compare the surgically treated patients of simple degenerative lumbar canal stenosis using validated outcome measures like Oswestry Disability Scale (ODS), Neurogenic Claudication Score (NCS), Visual Analogue Scale (VAS) and Satisfaction, this study also aimed to find outcome predictor of surgical decompression. Methods: This was a retrospective comparative study with homogenous cohorts with control of comorbid conditions that affect outcome. Each cohort ( Those with neurological deficit and without neurological deficit) had 11 patients who had adequate decompression with laminectomy and foraminotomies. Outcome was evaluated using validated ODS, NCS, VAS and Satisfaction in overall and also evaluated by each section of ODS, NCS with appropriate statistical analysis of both cohorts. Results: Neurologically deficient patients had more back pain, tingling, numbness, weakness and heaviness preoperatively. In neurologically deficient patients there was a trend to have poorer outcome, but overall recovery rate was higher than neurologically normal patients. Sensory deficit did not recover. The index surgery may not have effect on sitting and sleeping in both cohorts and may not have effect on lifting in neurologically normal patients and may not have effect on social life in neurological deficient patients. Additionally the index surgery may not have effect in relieving symptoms of numbness, tingling and heaviness and weakness in neurologically normal patients and may not have effect on standing in both cohorts. Recovery according to VAS was higher in neurologically normal patients. Preoperative NCS and preoperative heaviness and weakness severity contributed up to 43 % in ODS recovery rate. Conclusion: Overall there is a trend to have poorer outcome in neurologically deficient patients though recovery rate is better than neurologically normal patients. Recovery in term of VAS is better in neurologically normal patients. Preoperative NCS and preoperative heaviness and weakness severity score predict or contribute up to 43 % in ODS recovery rate. DOI: http://dx.doi.org/10.3126/noaj.v3i2.9512 NOAJ July-December 2013, Vol 3, Issue 2, 2-9

Dynamic Compression Plate Versus Intramedullary Interlocking Nail for Managemaent of Humeral Shaft Fractures

Introduction: With the dramatic success of intramedullary fixation for fractures of the femur and tibia, there was speculation that Intramedullary Interlocking Nails might be more appropriate for humeral shaft fractures in comparison to Dynamic Compression Plates. There are very few studies comparing these two methods of fixation in shaft of humerus fractures and virtually no study in this part of world. The aim of the study was to compare these fixation methods in terms of duration of operating time, amount of blood loss, rate of infection, pain at the fracture site, time to achieve union, functional outcome(DASH score) and complications of surgery. Methods: This was randamised control trial in which all patients with fractures of shaft of humerus that met the criteria for operative interventions ( intramedullary interlocking nailing and dynamic compression plating) presenting to the department of Orthopaedics BPKIHS during the study period and giving informed consent were included in the study. The patients were randomized using Excel random number generation technique into two groups. N Group: Cases treated with intramedullary interlocking nail and P Group: Cases treated with dynamic compression plate. Results: Most of the patients were right handed. The operating time for nailing was 100±11.24 minutess in comparision to 90.25± 15.6 minutes for humerus plating. The mean blood loss in nail group was 148.75 ±36.70 while in plate group blood loss was 205±45.60. Post operative hospital stay was similar in both groups with mean stay of 4.5 days.The peroperative radial nerve palsy was 4% in nailing group as compared to 2% in plating group. Radiologically four cortices union was only 50% in nailing group while it was 80% in plating group at 24 weeks post operatively. Dash score gradually improved in both nail and plate group but Dash score was significantly higher in plating group at 6,12,18 and 24 weeks follow up. Conclusion: Dynamic compression plating is better for fracture shaft of humerus. Plate osteosynthesis remains the gold standard of fixation for humeral shaft fractures. DOI: http://dx.doi.org/10.3126/noaj.v3i2.9513 NOAJ July-December 2013, Vol 3, Issue 2, 10-13

Developing Sub-specialty Education and Societies in Orthopaedic Surgery

NOAJ July-December 2013, Vol 3, Issue 2, 1 DOI: http://dx.doi.org/10.3126/noaj.v3i2.9511