Basrah Journal of Surgery

41 patients with clinical features of discogenic sciatica during the last 25 years, proved later on by investigations and imaging to be a nondiscogenic in origin, The aim of the study is to inform spinal surgeons of possible differential diseases that mimic discogenic sciatica. All patients present clinically with a sciatica. They were recorded and treated accordingly and sent for investigations. Patients proved to have discogenic sciatica were excluded. Others further investigated and followed until finding a cause for the symptoms and recorded as nondiscogenic sciatica syndrome. 22 individual aetiologies were found to cause nondiscogenic including infectious, traumatic, oncogenic, degenerative, metabolic and ischemic causes. In conclusion a proper history and thorough physical examination, in addition to imaging and investigations were very useful in detecting the exact etiology of sciatica. The pain pattern and the related clinical features were the guide for the diagnosis. High index of suspicion is vital to achieve the definite diagnosis to avoid missing the diagnosis of nondiscogenic sciatica. One should maintain a high index of suspicion in patients with intractable sciatica. Keywords: [Nondiscogenic Sciatica syndrome, pseudosciatica, spine surgery, radicular pain.]

(It is always easy to be wise after the event. Arthur Conan Doyle) "There are three methods to gain wisdom; the first is reflection which is the highest. The second is imitation which is the easiest. The third is experience which is the bitterest. Confucius 551-479 BC"

Global comparison of The outcome of surgical techniques for spondylodiscitis
 
Jessica Burton^@, Thamer Hamdan^*, Bisola Ajayi^#, Mohsen Raza^$, Angelo Fragkakis^&, Cristina Lupu^{^}, Timothy Bishop^%, Jason Bernard^! & Darren Lui^**.
 
^@MB,ChB student. *Professor of Orthopaedic Surgery at Basrah University, Visiting Professor at London Imperial College and Research Fellow as Saint George’s Hospital London. ^#Orthopaedic and Spine Physician Associate. ^$Orthopaedic Registrar. ^&Spine Fellow. ^{^} Spine CNS. ^%Orthopaedic Spinal Surgeon. ^!Orthopaedic Spinal Surgeon. ^**Orthopaedic Spinal Surgeon. Department of Trauma and Orthopaedics, Saint George’s University Hospital, London, UK.
 
Abstract
 Spondylodiscitis is an infection of the intervertebral disc and neighbouring bone. It is treated conservatively or surgically using a range of techniques.
 The aim of this review is to determine whether the surgical techniques between different countries have an effect on clinical outcome: postoperative complications, relapse rate, treatment failure rate or mortality rate.
 Many articles were screened using Ovid and Pubmed databases for studies pertaining to the surgical treatment of spondylodiscitis. Paediatric studies, tubercular/brucellar/fungal/ postoperative infection and case reports were excluded from this review.
 The results shows that no differences in the outcome of surgery between countries was found, and reasons for this along with solutions for moving forward with comparing surgical techniques worldwide are noted.
Key words: Spondylodiscitis, Surgery, Outcome, Comparison, Literature review

NONUNION OF LONG BONES IN BASRAH; EVALUATION AND MANAGEMENT Thamer A Hamdan* & Mofeed Y Alwaaly@*FRCS, FRCP, FICS, FACS, American Board (Orthopedic Surgery), Professor of Orthopedic Surgery. @MB,ChB, FIBMS, Specialist Orthopedic Surgeon, Basrah Teaching Hospital, Basrah, IRAQ.Abstract Nonunion of long bone fracture holds a big challenge for both the patient and the orthopedic surgeon. This study aimed to explore the possible causes and to evaluate the effectiveness of the treatment of nonunion in our region. Eighty-four patients with established nonunion of long bones were enrolled. All patients with primary fracture underwent; conservative, immediate or delayed operative treatment. Evaluation of nonunion was done by; careful general & local clinical examination, general & specific laboratory investigation, and radiological assessment with special emphasis to classify as atrophic or non-atrophic types. According to treatment modalities of nonunion, the patients were divided into three groups: Conservative (for those who refuse surgery or unfit for anesthesia), early, and delayed operative treatments. From the total 84 patients, 68 patients (81%) were males while 16 patients (19%) were females. Their age range was 13-77 years with a mean of 36.5 years. Five patients (6%) had co-morbidities including; diabetes, bronchial asthma, renal failure, hypertension. Cigarette smoking was not significant (p-value: 0.827). Tibia was the commonest bone involved in nonunion representing 46% (39 patients), followed by femur 36% (30 patients) and humerus 18% (15 patients). Forty-Five patients (54%) developed hypertrophic nonunion while 39 patients (46%) have atrophic nonunion. Non-union in this study was in seventeen cases (20.2%) due to single cause, while in fifty-five patients, (65.5%) due to two causes and the other twelve patients (14.3%) were due to combinations of three causes. Internal fixation with bone graft was performed for thirty patients (36%), external fixation with bone graft was applied to eighteen patients (21%), external fixation alone was done for 14 patients (17%), internal fixation alone was applied to 7 patient (8%), bone graft alone was done for 3 patients (4%), external and mini internal fixation with bone graft was done for 2 patients (2%). The mean time of follow up after definitive treatment for nonunion was 12.4 weeks. The majority of our patients (36 patients, 43%) were followed for 12-24weeks. The commonest bone that showed complete union in this study was femur (48%), tibia (30%), and humerus (22%). In conclusion, the chief causes that stand behind nonunion of the long bones which we revealed by our successive clinical, radiological, labrotary and active operative judgments in this study were; infection, insecure fixation, comminution, and soft tissue interposition. Internal fixation with autogenous bone graft proved to be the vital step to dissolve the obstacle of nonunion.Keywords: nonunion, bones, long, evaluation, treatment


 

 





thics is defined as moral principles that govern a person's behavior, the conductivity of an activity, or the branch of knowledge that deals with honest attitude.
 Ethics is a branch of philosophy that involves systematizing, defending, and recommending concepts of right and wrong conduct.
 Ethics was found in Hammurabi code law (Babylon 1754 B.C.), then followed by    Hippocratic Oath, prayer of Moses maimonides, declaration of Helsinki, code of ethics of the American Medical Association, and all Holy Books which insist on ethical points.
 Ethics in general is governed by four principles which are; respect for autonomy, beneficence, non maleficence, and justice. To the above, I added; respect for the dignity of the patient.
 Ethics start from humanitarian handling of the patient in the first visit with a big smile and soft welcoming words, a lot of respect, careful listening and understanding followed by very gentle physical examination.

This study is a systematic review and meta-analysis. The routine use of anticoagulants for the prevention of venothromboembolism in spinal patients is controversial and the risk benefit analysis is poorly described. The objective of this study is to collate the current evidence and quantify the risk of bleeding associated with anticoagulant thrombophylaxis in the spinal patient, both in the elective and trauma settings. 
Medline, Embase, Cochrane Trial Register databases and the grey literature were searched. Data were pooled via a meta-analysis from randomized trials and cohort studies comparing the rates of spinal epidural haematoma and wound haemorrhagic complications in spinal surgery patients receiving low molecular weight and low dose unfractionated heparin (LMWH/UFH) thromboprophylaxis and those not anticoagulated. The risk of bias within individual studies and across all the studies was assessed using the Cochrane risk of bias tools and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool, respectively.
 The meta-analysis included 10 studies of 96,042 patients with 1,007 relevant bleeding complications. A significant increase in the risk of extra-spinal wound haemorrhage was found in patients receiving peri-operative LMWH/UFH thromboprophylaxis compared to controls (OR 1.56, 95% CI 1.18-2.06, p=0.002, I2=8%). The same comparison revealed no significant increase in the risk of spinal epidural haemorrhage (OR 1.20, 95% CI 0.65-2.22, p=0.56, I2=0%). The quality of evidence for both outcomes was low. There was insufficient data to conclude about the risk of haemorrhagic complications in spinal trauma and in patients receiving non-heparin thromboprophylaxis agents.
In conclusion, the results of this study raise concern about a possible increased risk of extraspinal wound haemorrhage associated with LMWH/LDUFH thromboprophylaxis in spinal surgery.  Level of evidence: Therapeutic level III.
 

The aim of this study is to determine whether there is a benefit of using stereotactic radiosurgery (SRS) versus surgery or conventional external beam radiotherapy (cEBRT) for spinal oligometastatic disease in terms of tumor control, pain control, toxicity and morbidity.
 This systematic review was conducted by searching electronic databases such as Pubmed, Medline (Ovid) and Oxford Academic using an adapted version of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses” (PRISMA) checklist. Retrospective and prospective studies were identified and investigated for methods of treatment such as SRS, surgery and radiotherapy of spinal oligometastatic disease. Local Control rates, Overall Survival (OS) rates, Pain Response (PR) and toxicities were extracted to be investigated and compared. A study eligibility criterion was made to ensure that results were valid, statistically significant and relevant to the investigation.
 One hundred and five articles were relevant to oligometastatic disease with the mention of spinal metastases however 89 of these articles were excluded based on irrelevance to investigation, title, abstract and duplication. Sixteen full text articles were thoroughly screened including 9 of them in the review. For 601 patients the average one year local control rate was 89%, average one year overall survival rate was 88%, evidence of pain relief was present, and some patients suffered low grade toxicities.
 In conclusion, stereotactic radiosurgery is an excellent modality of treatment of spinal oligometastatic disease as local control rates, overall survival rates, pain response and toxicities indicate improved outcomes in comparison to studies that investigated the same factors with the treatment of surgery or cEBRT. However, there is a lack of data here to make statistically valid claims and require more studies & data to be analyzed and compared.
 

The lack of knee flexion is an increasingly recognized complication especially after trauma. This is a significant challenge for both surgeon and patients. In 1956, Judet proposed a quadricepsplasty technique that allow a graded release without the disruption of the vastus medialis, vastus lateralis, or rectus femoris.
 The aim of this study is to evaluate the beneficial outcome of the Judet quadricepsplasty in improving the range of movement of knee joint in those patients complaining from post-traumatic stiffness.
 This research was done for evaluating the clinical outcome of 15 patients who underwent a Judet's quadricepsplasty, they were 12 men and  3 women. The definitive flexion gain was classified according to Judet's criteria; excellent, if flexion was greater than 100°; good, from 80° to 99°, fair result are from 50° to 79°; and poor flexion degree is less than 50°. Patients were operated upon after an average of 19.40±17.63 months (range, 6-72 months) after first initial surgery. Average follow-up period was 6.5±3.6 months (range, 3-15 months). According to Judet criteria, 7 patients (47%) achieved excellent, 5 patients (33%) good, 2 patients (13%) fair, with zero poor results.  Final average flexion arc improvement was 97.67±18.6 degrees with a range of 60-120 degrees. The noticed complications included; one case of extension lag excluded from the study and one case of small area of skin necrosis.
 In conclusion, even though it was proposed in 1956, the Judet procedure seems to give a reproducible amount of good results today and still holds its leading role in the treatment of extra-articular knee stiffness.
Key words: Quadricepsplasty, Post-traumatic, Stiff joint, Knee joint, Judet procedure, Surgery

 The existing dream in the mind of every physician allover the globe is to find a solution for so many problem cases such as; an incurable condition, a degenerative process, congenital anomalies and even more serious like malignancy.
 Every now and then a window opens for hope and optimism, makes all the physicians happy for a while, then it collapse because it did not stand the test of time like; the biological therapy, the immune therapy, the plasma rich platelet, and the serum therapy. So far all needs further approval, and more solid bases.
 We are to some extent optimistic with great hope to be capable of finding a solution for so many unsolved problems.

LOCAL EXPERIENCE OF TOTAL KNEE REPLACEMENT IN BASRAH Thamer A Hamdan@, Khalil I Sadek# & Mohammed AbedYasir* @FRCS, FICS, FACS, FRCP, American Board of Neurological & Orthopedic Surgery, Professor of Orthopedic Surgery. # FICMS, Orthopedic specialist, Basrah Teaching Hospital. * CABHS Orthopedic specialist, Al-Sadr Teaching Hospital, Basrah, IRAQ. Abstract Total knee arthroplasty (TKA) represents a major advance in the treatment of degenerative joint disease providing excellent restoration of joint function and pain relief. This is a prospective study undertaken in the Department of Orthopedic Surgery in Basrah Teaching Hospital, from October 2009 to June 2011. Thirty-three patients who underwent primary total knee arthroplasty were included (25 females 75.7% and 8 males 24.2%). The diagnosis was osteoarthritis in 20 knees and rheumatoid arthritis in 13 knees. The operation included primary cemented TKA (25 cruciate-retaining and 8 cruciate-substituting), by anterior approach. The knee function was evaluated by knee society score system. Preoperative functional knee scores were uniformly poor and improved postoperatively with excellent results in 18 knees (54.54%), good in 9 knees (27.27%), fair in 5 knees (15.15%), and poor in 1 knee (3%). Thus, excellent and good results were achieved in 81.8% of the cases (27 of 33 knees). For knee scores, 2 knees (6%) were fair preoperatively and another 31 knees (93.9%) were poor. Post TKA results were excellent in 28 knees (84.84%), good in 5 knees (15.15%), fair in (0%) and poor in (0%). Excellent and good results were achieved in 100% of cases. The most common complications were superficial infection and deep venous thrombosis In conclusion, this study showed good outcome for total knee replacement surgery in our region. Excellent relief of pain, range of motion, and restoration of function. Keywords: Total Knee Replacement, Osteoarthritis, Rheumatoid arthritis, Basrah, Surgery.



 

The intervertebral disc is an avascular tissue, and penetration of antibiotics occurs by passive
diffusion. Cefotaxime penetration has not been well studied. The aim is to investigate the
penetration of cefotaxime into the intervertebral disc removed from patients undergoing
discectomy.
Twenty-six patients undergoing discectomy were recruited for this study. They were given one
gram of cefotaxime intravenously as a prophylactic antibiotic. Cefotaxime was extracted from
nucleus pulposus and serum and analyzed using an HPLC method with cefuroxime axetil as
internal standard.
Cefotaxime penetrated into all the 26 samples of nucleus pulposus resulting in a mean
concentration of 0.66±0.13 µg/gm. The mean serum concentration at time of disc removal was
13.61±3.54 µg/ml. The concentration in 16 samples were below the minimum inhibitory
concentration against Staph. aureus with an average of 0.27±0.03 µg/g. There is a statistically
significant correlation between time after intravenous cefotaxime administration and its
concentration in the nucleus pulposus. The greater increase is in the third hour after
administration. Factors like age, body weight, gender, number of associated diseases and
surgical history did not seem to affect nucleus pulposus cefotaxime concentration.
In conclusion, cefotaxime can penetrate into the nucleus pulposus but its concentration is
relatively low. This concentration has a strong positive correlation with time after cefotaxime
intravenous administration. Cefotaxime, therefore, needs to be given at least two hours before
disc removal, with re-dosing immediately before operation to maintain high serum concentration.