ALI ABDUL HASSAN MOHAMMED

AL-JADRIA HOSPITAL - BAGHDAD.

A review of 23 cases of the Putti Platt procedure for recurrent anterior shoulder dislocation is presented. Their age ranged from 16 to 44 years, averaged 19 years. A follow up of 3-10 years, averaged 5.5 years revealed only 2 recurrences, one of them for only one time and no serious complication . The clinical results were excellent in 18 cases (78.2%), satisfactory in 4 cases (17.4%) and bad in 1 case (4.4%). The restriction of outward rotation of less than 10 degrees could be observed in 1 8 cases, and of 10-20 degrees in 5 cases. On1y three cases had pain.

Putti Platt repair permitted good function without significant pain in most cases.

KHORBI A.- GHARSALLI A.-HACHEM A.

AZIZA OTHMANA HOSPITALSERVICE OF PR. HACHEM.1008 - LA KASBA – TUNISIA

The actual treatment of recurrent anterior dislocation of the shoulder is based essentially on two techniques: Bankart procedure and Bristow Latarjet procedure. Often, those techniques provide excellent functional results. However, the high prevalence of arthrosis and residual pain related to Latarjet technique and in another part the development of intra-osseous fixation for Bankart technique led many authors to renounce to Latarjet technique for Bankart procedure.

Our serie is composed of 42 cases reviewed with an average follow up of 5 years.

SIALA A.- MSEDDI.M- BEN HMIDA.R- DAHMEN J. - BEN AYECHE M.L.- MOULA.T

D'ORTHOPEDIC SERVICE - C.H.U- SAHLOUL- SOUSSE- TUNISIA

I-INTRODUCTION:

Elbow stiffness may be of extrinsec origin secondary to neurogenic paraosteoarthropathy, intrinsecor mixte in post-traumatic etiologies.The aim of this study is to report results of 18 elbow joint arthrolysis realised on 16 patients between 1988 and 1999 and sort our deductions. Only flexion-extension is studied. prono-supination is out of study since upper and lower radio-ulnar joint ,connecting tissue membrane and radial bone configuration interferes.

II-MATERIALS AND METHODS:

12 males and 4 females were invo1ved ,mean age was 27 years. The right elbow was implicated in 10 cases. the left elbow in 8 cases with 2 bilateral cases. 13 cases were linked to neurological injury and 5 cases were of post- traumatic origin .

5 patients had multiple localisations of heterotopic ossification about the shoulder. hip and the knee .

Heterotopic ossification seat was mainly postero-medial.

According to the SOFCOT criteria stiffness gravity was graded in 4 stages, all our patients were classified severe grade with specially 16 anky1osis. The mean time of arthrolysis was 2,5 years. 2 peroperatives incidents were reported , the first was nervous and the second as a joint instability , evolution was marked by occurrence of bilateral recidive in the same patient which one was complicated of sepsis.

III-RESULTS:

Our results were evaluated with a mean follow-up of 19 months .The relative gain defined by the average of the achieved gain on the possible gain was good or very good on 61% of cases. Peroperative functional gain study shows that only 5 elbows reaches functional sector global per operative motion was 107°with extremes of 65 and 13O°. Final functional gain study showed a results degradation with time since 10 elbow joints involved in mixed stiffness group which 3 in ankylosis position around 90°.The final range of motion was a mean of 68° with extremes of 30 to 105°. Loss of motion interest either flexion or extension. Apart from 3 failures ,15 elbow joint obtained useful range of motion.

IV-CONCLUSION:

Arthrolysis is revealed as an efficient operation in stiffness elbow joint. It permits to regain a useful range of motion for a better function of the upper limb.

MR MUSTAFA DIAB

THE CENTRAL POLICE HOSPITAL – KHARTOUM - SUDAN.

In this communication, we report our experience with four patients who underwent forequarter amputation due to various indications.

There were two males and two females. Their ages ranged between 9 and 35 years with a mean of 20 years. All patients had advanced malignant disease involving the shoulder girdle at presentation. Radiological examination of the affected bones revealed evidence of bone involvement and huge soft tissue masses. All had uneventful postoperative recovery with no complications and were discharged in a good condition. The histopathological examination of the biopsies revealed Ewing’s tumour (Enneking G2B), osteosarcoma, osteosarcoma (Enneking 2°) with aneurismal bone cyst and fibrosarcoma. Patients had postoperative chemotherapy and were followed up in the out-patient department.

BAGHDAD MEDICAL COLLEGE – IRAQ

The Functional interaction provided by the cruciate and the meniscus for a knee joint stability were assessed using and casted modeles.

After analysing different forces , the friction , compression , tension and shear were measured with each of' these structures in place and out of place. The tribology of the joint was formu1ated and related to the deformation at the joint surface.

It was concluded that the menisci and the cruciat provide a constant compression and tension, through this interaction ,they decrease friction and deformability and mantainte a stable articulation through all arches of knee movement.

M.HAMDI ,T.BEN CHAABANE, M.ZRIG ,A.BOUGHOUFA , F.BELKHIRIA , L.NOUISRI , A .KHELIL

DEPARTMENT OF ORTHOPEDIC SURGERY – MILITARY HOSPITAL – TUNISIA

Patello femoral joint pathology is one of the most frequent complaints in orthopaedics . Clinically, it’s main symptoms are pain and instability or pseudolocking or both .

Sixty five patients underwent anteromedial displacement and rotation of the high tibia tuberosity :

ATIRTTA(Avancement Translation Interne Rotation Tuberosite Tibiale Anterieure), during the period between 1988 -1998 ( 37 men 28 women Mean age 39 years)

According to clinical finding’s and radiological measurements, patients were divided in 3 groups :

Objective patellar instability 35 cases

Potential patellar instability 16 cases

External patellofemoral arthritis 14 cases

M.H. ATIA – A.G. CHORFA – A. YAHIA – R. ATIA

DEPARTEMENT OF ORTHOPEDICS AND TRAUMATOLOGY - IBN ROCHD HOSPITAL ANNABA ALGERIA

The addition’s osteotomy in osteo-arthrosis of knee on genu varum are often forsake for subtraction’s osteotomy.

A new approaching of the addition’s osteotomy with oblique line of osteotomy oriented to the fibula’s head permits a correction without touching the fibula.

This one make easy the correction and offer a better laying for osteosynthesis materiels by internal way.

We bring you by this work our recent experience about a Seri of twenty (20) cases with a receding of two years. The results were very satisfying.

AHMED M ABDEL-AAI

ASSIUT UNIVERSITY HOSPITAL - EGYPT

Sixteen patients with non-union septic or aseptic of one or more of their long bones have been treated by Ilizarov frame during the last two years in our department. One patient refused to continue treatment with the frame after three months, so fifteen patients only will be included in the study. Thirteen patients were males and two patients were females. The youngest patient was 12 years old and the oldest was 65 years (average 34 years) .Eleven patients had non union tibia , two patients had non Union after femoral fractures , one patient had non union after infected open type II fracture radius and ulna ,and the last patient had non union at the site of failed arthrodesis of the knee .

All non unions have healed after distraction only of the non union or bone transport to compress the non-union site , bridge the gap , and to correct shortening .The bone result was excellent in nine patients(60%), good in three (20%) fair in two (13%), and poor in one(7%)

( patient who needed bone graft). As regards functional result , all patients were active so no poor functional results.Ten patients(66%) had excellent functional result . Three patients(20%) had good results, Two patients(14%) had fair functional result.

GHANEM, MD – K. KHARRAT, MD – F. DAGHER, MD

HOTEL DIEU DE FRANCE HOSPITAL – BEIRUT - LEBANON

Purpose : To evaluate the complications of surgical correction of equinus deformity in cerebral palsy (CP), and to identify the factors that may contribute to their development.

Materiel & Methods : A retrospective chart review was conducted on all CP patients who underwent surgical correction of their equinus deformity, between 1985 and 1997 , and who fulfilled the following criteria’s : 1/ community of household ambulatory , 2/ hemiplegic, diplegic or mild quadriplegic ie with mild involvement of the upper limbs ; 3/ complete clinical and radiological chart ; 4/ minimum follow-up 2 years. Twenty one patients with a total of 38 extremities were selected. There were 14 diplegic, 3 hemiplegic, and 4 quadriplegic. Gastrocnemius recession (GR) was done when the equinus was apparent only with an extended knee, whereas Achilles tendon lengthening (ATL) was done for irreducible equinus even with a flexed knee. The same patient could therefore have a gastrocnemius recession on one side, and an ATL on the other . One diplegic patient had a unilateral surgery GR was done in 28 extremities (16 patients, 12 diplegic, 3 hemiplegic ! and 2 quadriplegic) and ATL in 10 (7 patients, 5 diplegic, 2 quadriplegic) . Assessment of the results was based on :

1/ clinical evaluation of ambulation, and for some patients a video film of the gait

preoperatively and at regular intervals postoperatively.

2/ Residual dynamic equinus

3/ Passive dorsiflexion of the ankle in knee flexion and extension. The influence of age, associated lengthening of hamstrings and hip flexors, severity of involvement, as well as the type of surgery (GR v/s ATL) was also evaluated.

Results : Gr I : Eight patients (16 extremities, 5 diplegic, and 3 quadriplegic, 12 GR, 4 ATL) developed calcaneus deformity : insufficient triceps with excessive ankle dorsiflexion (> 25°) and decreased plantar flexion (<30°). 12/16 extremities did not have any associated lengthening of the hamstrings or the hip flexors, and 4/16 had undergone an isolated tenotomy the hip flexors. Average age at surgery was 3,1 years (2,5y - 4,9y). A deterioration of ambulation was noted in all the patients of this group, and improved only after secondary tenotomies of hamstrings and hips flexors, as well as the use of AFOs .

Gr II : four patients (6 extremities, 3 hemiplegic and 3 diplegic, 5 GR, 1 ATL) had residual equinus at last follow-up ; 4/6 did not have any associated surgery at the hips or knees, and 2/6 had undergone isolated tenotomy of the hip flexors.Average age at surgery was 4 years (3,6y – 7,2y). At last follow-up, ambulation was improved in 3/4 patients as compared to the preoperative situation.

Gr III : Nine patients (16 extremities, 2 hemiplegic, 6 diplegic, 1 quadriplegic, 11 GR 5 ATL) showed an almost normal ankle mobility with improved ambulation. ; 10/16 had undergone associated hip flexors and hamstrings lengthening , and 6/16 either hip flexor or hamstring surgery. Average age at surgery was 8.2 years (6.3y – 13.4y).

Discussion : Surgical lengthening of the triceps surae in children with CP should be done with a lot of caution because of the high rate of complications. Despite the small number of patients we didn’t find any statistically significant correlation between the type of surgery, the severity of involvement, and the final outcome. However, young age at surgery (<5y), as well as the absence of associated correction of hip and knee flexion contractors seem to jeopardise the end results. Restoration of a good sagittal alignment of the lower limbs seems to be essential.

ZRIBI M. – ZRIBI W. – ABDALLAH T. – ACHOUR S. – TOUNSI N. – AYADI K. –

KESKES H.

ORTHOPEDIC SERVICE - C.H.U. HABIB BOURGUIBA-SFAX- TUNISIA

30 double arthrodesis were evaluated with a minimal follow up of 2 years.

These feet were treated by double arthrodesis for a variety of lesions including post traumatic deformities, paralytic lesion, flat foot and others conditions.

The importance of obtaining a good correction of hind foot is emphasised.

The long term results of feet correctly aligned was good. The fate of the neighbouring joints and the functional adaptability of the foot have been studied.

T.A. HAMDAN

MEDICAL COLLEGE, BASRAH - IRAQ

Bone changes in sickle cell disease are usually due to marrow hyperplasia, tissue ischemia and infarction due to vaso-occlusive crisis and the increasing susceptibility to infection. Between 1988 and 1998 , 280 patients were treated in the University Department of Orthopaedic Surgery with bone and joint manifestation of sickle cell disease.

150 patients were male and 130 patients were female aged between 5 and 56 years (mean 31 years). 202 patients showed multiple structural bone and joint lesion, and the rest had transient manifestation related to their haemoglobinopathies .The Hb electrophoresis pattern was SF in 180 patients, SS in 100 patients. 214 patients had some sort of diffuse myalgia and back pain.

Fusion of sacroiliac joint was discovered on plain radiography in 160 patients, 40 patients had established bone infection and 20 patients presented with joint infection. In both bone and joint infection, the organisms were dominantly Staphylococcus aureus. Avascular necrosis was proved in 124 patients. Only 94 had surgical intervention. Almost all patients with sickle

cell disease will end up with some complications irrespective of their age. For that reason, clinical awareness, early diagnosis, aggressive treatment and close follow-up are always necessary to reduce the expected disability complications.

H..K. MOHAMED

AL-FURDOS PRIVATE HOSPITAL IRAQ

Orthopaedic surgeons have always volunteered themselves to improve patient' s movement with minimal energy consumption, which means to improve the gait of disabled patients.

The abnormal gaits were analysed by Clinical observation and by videotape by standard and slow motion, the causes regarding muscles, nerves , tendons, joints and bones were recorded and corrected each case accordingly.

Our report deals with some points about normal and abnormal gaits with special reference to the hand-knee gait in adult poliomyelitis.

Clinical classification was applied to this aspect, which comes from our 20 years experience in this field.

The technique of supracondylar femoral osteotomy to correct flexion deformity of the knee was discussed thoroughly.

Room B

ABDUL AZIZ A. AL-KAISI

SADDAM'S RECONSTRUCTION CENTRE - IRAQ

This is a prospective and retrospective study of management of forty cases severe open fractures of the forearm bones, most of them are the result of high velocity shells and missiles. Fourteen of the cases were gap fractures and the range of the gap 4-7cm.

Proper soft tissue management was the key to successful end results. Heavy antibiotics may be needed and minimal bony stripping is advised.

The outcome of this management was: Union of all the fractures, negligible rate of infection and the restoration of the function of the limb was in proportion to the original soft tissue damage of the forearm.

KARRAY M., BOUZIDI R, FEKIH S., KOOLI M., EZZAOUIA K, LEBIB H, MESTIRI M., ABDELLAOUI K.,ZLITNI M.

ORTHOPAEDIC SERVICE - E.P.S CHARLES NICOLE - TUNISIA.

The purpose of the study was to present the advantages of intramedullary nailing of long bones for treatment of fractures of the forearm. These advantages are :

1 - preserving fracture hematoma

2 - non exposure of bone.

*materiel and methods : in a five year period (1993 - 1998) we performed Hacketal nailing in 35 patients (30 men, 5 women) with 61 fractures 26 patients had fractures of both bones

and 8 patients had a single fracture of radius and one of ulna, the mean age of the patients was 30 years (range fifteen to 73 years). In 10 cases the fracture was open with 8 type I and one type II and III of Gustillo and Anderson classification. Surgery was performed within 7 days. Cast was necessary in 33 cases for a period of two months. The mean follow up was thirty three months with minimum follow up of ten months.

The criteria described by Anderson have been used. Union occurred in 35 cases (100%).

The global results were excellent and good in ( 92%) poor in (08%) with two cases of synostosis ( 06% ), and one case of iterative fracture.

There are 4 importants beneficts of this treatment :

First with this principle bone Healing is achieved after three months but with plate fixation it lasts 4 to 7 months

Second the rate of non union goes down from almost 6 percent to 1 or 0 percent.

Third the post-operative infection rate is reduced and forth joint motion is preserved.

Our bad results are mainly caused by the polytraumatic conditions of some

patients.

CONCLUSION In conclusion with the confined spectrum of indications. Hacketal Nailing is a low risk method which leads to rotational stability and early bone healing.

GHARSALLI A. CHEBIL M. KHORBI A, SALLEM R, BEN DALI N., HACHEM A.

AZIZA OTHMANA HOSPITAL. TUNISIA

Conservative treatment of femoral neck fractures remains controversial

The high rate of pseudarthrosis reported in pauwels II and III fractures led many authors to realise an upper femoral osteotomy in order to enhance the stability of the fracture.

In our institution we continue to realise osteosynthesis by a simple triple screw for theses fractures. The aim of our work is to evaluate the anatomic result of 22 cases

of Pauwels II,III femoral neck fracture treated by a triples screw ; and if we should renounce to this technique .

R. ATIA – B. RAHMANI – A.G. CHORFA

DEPARTEMENT OF ORTHOPEDICS AND TRAUMATOLOGY IBN ROCHD HOSPITAL ANNABA ALGERIA

The morbidity in the femur’s neck fracture continues to be graft by early deceases, head’s necrosis and pseudarthrosis.

Authors bring a Seri of patients with age is between 15 years and 101 years old.

These are women and men, but this kind of fracture stays the old’s women fracture.

Unilaterality is always founds, and beside the question of osteoporosis, the bilaterality has been found on a pathological’s bone.

The clinical’s check up finds that the activity was poor before the traumatism and that general condition was often impaired.

The existence of medicals disease treating is frequent.

The anatomo-radiological’s classification used has been the GARDEN-PAWELS AND LAMARE’S, each case. In the majority of cases it was a fracture of :

Type IV Garden – type

preserving treatment has consisted to an osteosynthesis by different materials :

- simple screwing – nail plaque – screw plaque – compression’s screw plaque DKP and DHS

The results has been appreciated on the neck’s pseudarthrosis and on the head’s necrosis.

The head’s necrosis is not influenced by the used materials

The neck’s pseudarthrosis is influenced by anatomy pathological type’s, by the manipulations during the surgical operation and by the used materiel.

The compression’s materials is benefice.

The association of free screw to a monobloc material is benefice too. Arthrotomy is luckless

The simple screwing could find an indication in no displaced fractures or in coxa valga ones. This screwing stays better than prosthesis replacement in morbidity and mortality cases.

The earlier raised and the earlier walk does not have an influence on the mortality rate.

MUDHAFFAR K. AL – FALLOUJI , FRCS

HAMMAD SHIHAB MILITARY HOSPITAL. BAGHDAD. IRAQ

Attempting to reduce the frequency of amputation in severely injured limb with wide loss of the articular ends at the knee or ankle, this method was tried in 10 cases with loss of the tibial articular ends. It consists of 2 parts. First, the joint is exposed & the ends reshaped with excision of remained articular cartilage. Second, a locally made sliding compression external fixation device" Salah- Eddin" applied and proximal or distal osteotomy done & a segment of the bone slided gradually by 1 mm. daily until full fusion of the joint occur forming one bone limb. This paper discusses the technique & the result of this method.

ABDUL KARIEM ABDUL WAHID AL-AZAWY

AL YARMOUK TEACHING HOSPITAL

A prospective study designed to evaluate a new Iraqi system (SALAH-EDDIN external fixture device) used for bone carrying and to define the indications of bone carrying in a severely injured limb with bone defect versus amputation. 183 tibias with bone defect (between 2 cm to 27 cm) caused by sever injuries were treated by bone carrying technique (with callotasis and without callotasis) using the new device. The result of the study as classified by Ilizarov : excellent (82,1 %), good (11,9 %), fair (3,5 %) and (2,3 %) in addition the new device was easily applicable technically and more rigid with good biochemical stability. The procedure is a semi-invasive technique having the advantage of minimal surgical intervention and no implant application, besides , the device was comfortable to the patient during activities and rest. By using the technique of callotasis which was easily achieved by the new device the time required for healing of 1 cm of bone gap foun! d t be half that required by other devices. The complications encountered during the course of treatment all were minor and treatable during the course of bone carrying . Proper patient selection is a pre-request for the application of this device as patients with sever neurovascular injury will not benefit much from this procedure although they will get good bony result by the functional result will be poor.

SIALA.A- MTAOUMI.M- MSEDDI.M.- BEN HMIDA R.- DAHMENE J.- BEN AYECHE ML.- MOULA T.

ORTHOPAEDIC SERVICE - SAHLOUL- SOUSSE- TUNISIA

I-INTRODUCTION: For several years, the ilizarov fixator was devoted a special role in traumatology. In shaft both bone leg fractures, bone fragmentation or soft tissue lesions will not ease the application of conventional methods, an ilizarov system seems to be interesting alternative in this indication . The aim of this study is to evaluate the results of 51 complex fractures of both bones leg treated by ilizarov fixator between 1993 and 1998 .

II -MATERIALS AND METHODS: 45 men and 5 women were involved in this study, mean age was 38 years old. One case was bilateral. Fractures were secondary to a road traffic accident in 76% of cases . Skin wound was present in 33 cases. Six neurologic and two vascular immediate complications were noted. Fracture was comminuted in 34 cases, spiroid longue in 11 cases and oblique long with third fragment in 6 cases. Bone loss was seen in 3 cases. The standard system was composed by 4 rings, two proximal and two distal, it was mono-segmentary in 45 cases and deck the knee or the ankle in 6 cases. Weight bearing varies from 3 to 10 weeks according to associated lesions and patient the cooperation .

III-RESULTS: our results were evaluated with an average follow-up of 18 months varying from 9 months to 6 years.

Evolution was marked by occurrence of certain complications such as wire sepsis in 11 cases . Two deep venous thrombosis and three septic arthritis of the knee. All the above complications respond well to prompt treatment.

Primary Union was obtained in 41 cases within a mean time of six months. There was 7 cases of delayed union which healed after bone grafting in 3 cases, corticotomy-lift in 2 cases and dynamisation of the system in 2 cases. One case of pseudarthrosis and 2 failures of the method because of intolerance of the system .

Anatomical results were satisfactory in 80% of cases. Most angular deformities were valgum and recurating functional results evaluated on pain, knee and ankle mobility were favourable in 90% of cases. Four patients have an ankle stifness and six patients a knee stiffness.

IV-CONCLUSION: Ilizarov method appears like a good procedure in the treatment of complex shaft both bone leg fractures. It favour bone union by permitting early weight bearing and system dynamisation .

SAAD AZIZ AUDA

HOSPITAL  OF RECONSTRUCTIVE SURGERY - BAGHDAD -IRAQ

We evaluated in this study the effect of early aggressive wound debridment and gastrocnemius muscle flap on 13 patients with grade III compound fractures of the legs. Average follow

Up was 21 months (Range 12 - 30 months). There were 11 males and 2 females. Early bony fixation consisted of external fixation in 8 patients. Pop post slab in four, plate and screw in one_, skeletal traction in one. Average age 35.5 years (11-47 years) . Local rotational gastrocnemius flap performed on 12 patients 85.7%, Cross leg G.M. flap in 2 (14.2%) .

3 patients underwent bone grafting. 3 patients developed early infection 28.5%. one patient

developed chronic osteomyelitis 7.1%. Bone union occurred in 92.8% (13 out of 14). 3 patients had shortening of more than 2 cm. one patient developed non union. No limb loss.

JOEL COUTINHO FRCS, AYRNAN SHARAWY MS

KHOULA HOSPITAL, MUSCAT, SULTANATE OF OMAN.

23 Acetabular fractures over a period of two years were reviewed. The purpose of the review was to study the pattern of acetabular fractures, the CT scan findings and the treatment

options. And to study the influence of associated injuries on the final outcome.

There were 20 males and 3 females, their mean age was 39 years (1 8-60yrs.) (Judet

All the patients had Plain X-rays views), C.T Scan with 3D reconstruction to identify the nature of the fracture.

After an initial period of traction (5 15 days), the patients had open reduction and internal fixation 19 of the 23 patients had the internal fixation 1thi-ough the Kocher approach, while 2

patient were operated through the ilioinguinal approach.

The final outcome of the fracture fixation was measured by assessing the following criteria

Reduction of the fracture on X-rays. Pain & disability.

Complications DVT, infection, heterotopic calcification, AVN, OA changes in the hip.

The influence of associated injuries on the management of the acetabular fracture.

SAID ABDUL MAJEED, FRES

AMMAN – JORDAN

External fixation of pelvic fractures could save life. Especially for multiply injured patient if done swiftly. It can definitely be done in the accident department.

Hypovolaemic shock is the main killer in unstable Pelvic fracture – dislocations due to severe arterial and venous bleeding.

EX FIX of the pelvis combats shock not only via cessation of bleeding but also via immediate stoppage of pain. It also serves as the definite treatment for most pelvic fractures.

The author presents experience with 80 patients with unstable pelvic injuries treated by EX.FIX. , showing immediate and late results using the author’s unuerical scoring system in assessing both functional and radiological outcome.

EX.FIX. of pelvis is a quick procedure having the two virtues of safety and simplicity.

KARRAY S. – GHROUBI S. – GHATTASSI M. – BAKLOUTI S. – ELLEUCH MH

SERVICE OF MEDICINE PHYSIQUE PHYSIQUE AND REHABILITATION CHU HABIB BOURGUIBA SFAX

SERVICE OF RHUMATOLOGY CHU HEDI CHAKER SFAX-TUNISIA

The sporting muscular lesion is an important injury which may stop his racecourse. A good knowledge of the mechanisms and lesionnal levels and a perfect control of the therapeutics’ indications are very important for a good recovery.

We report in this study our experience about 200 cases of muscular lesion going on for five years. (1994 to 1999). Among competitor sporting belonging to different local clubs.

The mean of age of our patients is 20.2 years (limit 14-40 years) with a masculine predominance (93 % of cases). 72 % of patients practice a team’s sport (specially football); The mechanism of the lesion was a direct contusion in 22.5 % of cases, an elongation in 71 % of cases a clapping in 5 % of cases and a rupture in 3 cases. The injured muscles in decrease order : were quadriceps, adductors, ischiotibialis, and musculus triceps surae.

The echographia was practised among 49 patients ; an haematoma was detected among 24 cases. A long this two last years our behaviour when treating an elongation was changed, the systematic indication of the echographia, have disclosed 11 times an haematoma which are not clinically suspected. The resort to MRI was exceptional.

The results, according to the delay of retaking of sport, the level of retaking and the presence of sequels, was good and excellent in 94 % of cases. Two types of sequels occurs : calcification and fibrous organisation were reported in 3 cases.

A recurrence was reported among 5 patients.

In conclusion a precocious diagnosis and an adaptable treatment are the best guarantor to come back at the sportive activity as soon as possible at the same level and without sequels.

NAJIM A. AI-AZZAWI M.B.CH. B. D.S.

AI-ZAHRAWI TEACHING HOSPITAL, MOSUI-IRAQ.

A new below-ankle amputation technique is described. The techniques is called the "hero-heel" technique in reference to the patient for whom the technique is suitable. He is usually a soldier who suffered a traumatic foot amputation as a victim to a personnel mine. The technique overcomes the known shortcomings of established procedures, viz: backward migration of the heel pad, shortening of the affected limb, and difficulty of prosthesis fitting.

The hero-heel procedure is carried out by creating a wedge between the talus and the calcaneus after excising the head and neck of the talus and rotating the calcaneus anteriorly by 90 degree to fuse it with the talus, sparing the ankle joint in the process.

The procedure was performed on 50 patients during from July 1986 to January 1989 in Mosul Military Hospital. These patients were followed tip to 1998 to monitor their physical and social rehabilitation. Excellent end-bearing stump with no shortening of the limb and no equinus deformity was the result in all patients. The problem of posterior migration of the heel-pad was eliminated. Most patients did not need to fit sophisticated prosthesis. Shoe filling was enough.

Six months after operation, all patients got complete fusion of talus and calcaneum that could move as a single bone at the ankle joint.

The hero-heel technique solved the chronic problems associated with other known , below amputation techniques. The new technique is easy to perform and avoids the removal of bones as in other established procedures.

After ten years of follow up, all fifty patients were economically active and perform their daily activities without the use of crutches or other aids.

14 h 30 - 16 h 30

J. GHANEM MD – G. KREICHATY, MD – K. KHARRAT, MD – F. DAGHER

HOTEL DIEU DE FRANCE HOSPITAL – SAINT JOSEPH UNIVERSITY BEIRUT - LEBANON

Introduction : The clinical presentation of atlantoaxial rotatory dislocation, also called rotatory fixation is often indistinguishable from that of regular torticolis. Radiographs of this area are usually difficult to interpret in severe torticolis due to overlapping of bony structures Static and/or functional CT scan is now largely used to confirm the diagnosis. A universally admitted classification of C1-C2 rotatory dislocation is that proposed by Fielding who recognise four types : I and II without or with minimal forward displacement of C1.

III with anterior displacement greater than 5 mm.

And IV with posterior displacement.

The purpose of the present study was / to analyse the CT scan images produced by a simple torticolis, and 2/ to assess the relevance of the Fielding’s classification.

Methods : CT scan was used to examine the C1– C2 complex in 20 normal children. The head was intentionally put in the position of severe torticolis, as far as voluntarily possible. Three positions per patient were analysed : 1/ right inclination, left rotation flexion, 2/ left inclination, right rotation, flexion, 3/neutral position (2pseudotorticolis positions per patient, i.e a total of 40 scan cuts in torticolis). Three measures were done for every position. 1/The dens-atlas distance. 2/ right, and 3/ left dens-lateral mass distances. A 3D CT scan was undertaken in two cases, and the position of the dens with regards to the lateral masses was assessed, as well as the relationship between the lateral masses of C1 and C2. The CT scan images were then evaluated by 3 independent radiologists who were not given any clinical information, and who gave separately a written report.

Results : The dens-atlas distance did not increase passed 3 mm in any case. However, a big asymmetry was found between the right and left dens-lateral mass distances. For example, in right distance was increased and the lest decreased. The asymmetry was greater than 4 mm in 28 cases. The diagnosis given by the 3 independent radiologists was concordant for 24/40 images, C1 C2 rotatory dislocation, Fielding I or II. The 3D CT scans showed images compatible with typical C1-C2 rotatory dislocation Fielding I or II.

Discussion : There have been several reports in the literature about the difficulty to distinguish a C1-C2 rotatory displacement produced by a benign torticolis, and a true C1-C2 rotatory dislocation. Our study shows clearly that in many instances they are indistinguishable. Type I and II of Fielding do not seem to be relevant for dislocation, since they can be compatible with a normal C1-C2 ROTATORY DISPLACMENT. Furthermore, muscle spasm associated with an acute torticolis, may prevent the head from turning freely in the opposite direction while attempting to perform a functional CTD scan, thus possibly leading to the wrong diagnosis of C1-C2 rotatory dislocation CT scan images should thus be interpreted with a lot of caution. The denomination "C1-C2 rotatory dislocation" should no longer be used but rather replaced by "fixed C1-C2 rotatory displacement.

S. A. ABDUL GAFFAR – ALI AL KHALIFA

BAHRAIN DEFENCE FORCE HOSPITAL - BAHRAIN

This is a study on the results of fifty consecutive patients who underwent endoscopic removal of herniated lumbar disc by interlaminar extra-dural approach. The indication for surgery was single level, unilateral sciatic pain not relieved by conservative treatment, with supportive evidence of disc herniation in MRI . Surgery was carried out in the lateral position. After localising the disc space by x-ray, two 5 mm portals were made, one for the arthroscope and the other for working instruments. The spinal canal was entered through the inter laminar route and under direct vision the herniated disc was removed. The duration of study is from February 1998 to July 1999 with an average follow up of 13.58 months. There were 31 herniated, 9 extruded and 10 sequestrated discs. All patients were mobilised the same day and 42 were discharged the next day. Modified McNab criteria were used to measure the outcome of this surgical technique. 40 patients (80%) had a v! ery good outcome (i.e. fully functional with occasional discomfort). We conclude that this technique is a minimally invasive procedure with results comparable to conventional disc surgery. The advantages to the surgeon are the excellent illumination, magnification and visualisation .The advantages to the patient are minimal surgical trauma and speedy recovery. A video on the technique will be presented.

This is a study on the results of fifty consecutive patients who underwent endoscopic removal of herniated lumbar disc by interlaminar extra-dural approach. The indication for surgery was single level, unilateral sciatic pain not relieved by conservative treatment, with supportive evidence of disc herniation in MRI . Surgery was carried out in the lateral position. After localising the disc space by x-ray, two 5 mm portals were made, one for the arthroscope and the other for working instruments. The spinal canal was entered through the inter laminar route and under direct vision the herniated disc was removed. The duration of study is from February 1998 to July 1999 with an average follow up of 13.58 months. There were 31 herniated, 9 extruded and 10 sequestrated discs. All patients were mobilised the same day and 42 were discharged the next day. Modified McNab criteria were used to measure the outcome of this surgical technique. 40 patients (80%) had a v! ery good outcome (i.e. fully functional with occasional discomfort). We conclude that this technique is a minimally invasive procedure with results comparable to conventional disc surgery. The advantages to the surgeon are the excellent illumination, magnification and visualisation .The advantages to the patient are minimal surgical trauma and speedy recovery. A video on the technique will be presented.

SADIQ A.AL-MUKHTAR

UNIVERSITY OF BAGHDAD-AL-KINDY MEDICAL COLLEGE - IRAQ

In this prospective study " The correlation between clinical and operative finding in Disc herniation at lumbosacral region" 107 patients were evaluated according to a special Scoring system, to select patients with Low-back pain and sciatica for lumber discectomy.

This study revealed that ,this patient-evaluation system Is accurate, Easy to use, with no risk to patients.

Of those 107 patients, 100 patients had disc herniation at lumbosacral region, which was proved surgically; therefore different aspects concerning clinical presentation and physical examination were studied .

Depending on physical examination, prediction of the location of the lesion, horizontal site, size of the disc and types of herniation, can be judged .

ZIAD M. AL ZOUBI

PRESIDENT OF PAN ARAB SPINE SOCIETY - AMMAN JORDAN

Spondylolisthesis is a known problem of lumbar spine, it may result in instability of the spine with or without neurological deficit.

24 cases has been treated by fusion posteriorly by pedicle screws and plates, rods or rod plate system.

Reduction was not always one of the operation targets, indications of surgery procedures & results will be discussed.

H.FOURATI,M.ELLOUMI,N.AYADI,M.B.SALEM,M.H.ELLEUCH , S.BAKLOUTI

SERVICE OF RHEUMATOLOGY CHU SFAX - TUNISIA

The authors carried out a study of the effectiveness of their diagnostic strategy in thirty eight consecutively seen patients who had vertebral metastases of unknown origin. The diagnostic strategy consisted of the recording of the medical history, physical examination routin laboratory analysis, plain radiography of the spine and the chest and ultra sonography of the abdomen . Computed tomography of the chest, abdomen and pelvis was carried out in case of negativity of the previous tests. After his evaluation, a biopsy of the most accessible lesion was done. The history and physical examination revealed the occult primary site of the malignant tumour in eight patients (21 %). Plain radiographs of the chest established the diagnosis of carcinoma of the lung in five patients (13 %), computed tomography of the chest identified an additional two primary carcinomas of the lung. Ultrasonography of the abdomen identified the primary site of the tumour in f! ive patients (13%). The routin laboratory analysis were non-specific in all patients. Examination of the biopsy tissue established the diagnosis in only two additional patients and confirmed it in sixteen others. This simple diagnostic strategy was successful for identification of a primary carcinoma in twenty eight patients (74 %).

LUAY FAKHRI. TAPPONI M.B..KAHTAN RATHWAN

MOSUL TEACHING HOSPITAL. DEPARTMENT OF ORTHOPAEDIC. MOSUL - IRAQ

Multiple Myeloma is a primary malignant bone tumour believed to arise from plasma cell at the bone narrow. In the spine various presentations were noted ranged from mild backache, osteoporosis. To spinal fractures or cord compression.

Fifty Four patients with multiple myeloma of the spine were treated at the Mosul Teaching Hospital from January 1, l989 to January 1.1999.

31 patients were males with a mean age of 57. 8 years ranging from 4O-79 years. Twenty three patients were females with a mean age 58.7 years ranging from 4 1-73 years. The diagnosis depends on laboratory tests (High E.S.R., Bence Jonce protein eclectrophoresis) and on surgical procedures (bone marrow biopsy).

We studied the various modalities of treatment with a comparison of the results and statistical analysis of the results.

TAREK ABDALLA EL-GAMMAL

DEPARTMENT OF ORTHOPEDICS, HAND AND RECONSTRUCTIVE MICROSURGERY UNIT ASSIUT UNIVERSITY SCHOOL OF MEDICINE - EGYPT

Between 1993 and 1997, 32 male patients, injuries were surgically treated at the Department of Orthopedics and Traumatology, Assiut University Hospitals. 15 patients had complete paralysis. .Average dennervation time was 4 months. 18 interfascicular grafting and 72 extraplexual neurotization procedures were performed separately or in combination . Donor nerves were the intercostals , spinal accessory , phrenic, Contralateral C7, and cervical plexus, In order of frequency .

Patients were followed for a minimum of 24 (average 35) months. Partial lesions had significantly better outcome (P<O. 05). Young age (<40) and short denervation time were associated , but not significantly with better outcome. Biceps function was best following grafting the musculocutaneotis nerve itself ,or neurotization with the phrenic nerve (100% grade IV) followed by neurotization with the intercostals (89. 5% grade III or more), and lastly grafting the C5 root or upper trunk (grade III in one out of three patients). Phrenic to suprascapular neurotization produced the best results of shoulder abduction (40-90 degrees) followed by combined neurotization of spinal accessory to suprascapular and phrenic to axillary (20-90 degrees) Sensory recovery over the lateral forearm and palm varied fromS2 to S3+ according to method of reconstruction.

S.AL-KHAIDHIAIRE

IRAQ

We report on 20 patients presented as resistant tennis elbow having clinical features of radial tunnel syndrome in whom surgical release of thickened fibrous arcade of Frohse of supinator muscle and freeing the underlying posterior interosseous nerve have relieved their symptoms. A related cadaveric anatomical study of 1 0 cadavers demonstrated the presence of such fibrous structure at the free edge of superficial part of supinator muscle in about 30% of the specimens dissected. Passive pronation of the forearm caused marked tightening of arcade of Frohse.

TAREK ABDALLA EI-GAMMAL, AMR EI-SAYED

DEPARTMENT OF ORTHOPEDICS, HAND AND RECONSTRUCTIVE MICROSURGERY UNIT ASSIUT UNIVERSITY SCHOOL OF MEDICINE - EGYPT

Replantation surgery has become a routine practice. The definition of a successful replantation has changed considerably from a surviving limb to a functioning and sensate limb. As a rule, each case should be evaluated individually before attempting replantation. In this presentation clinical cases are shown of wrist replantation , thumb replantation at different levels, distal digit replantation, multiple digit replantation _, replantation in children and multiple level replantation.

MARDINI ISSAM - HUSSAIN AL REDHA

RASHID HOSPITAL- TRAUMA UNIT- DUBAI

One of the major challenges that faces the management of hand injuries in Dubai is the severity of the trauma and the fact that been managed in many cases by the most junior surgeons or not given the appropriate attention like underestimating or post-pounding the treatment of the hand to later sessions to treat other injured part of skeleton.. Loss of the soft tissue of the hand represents specific problems regarding their depth and surface area especially the Palmer surface due to its particularity and functional importance. The aim of the treatment is to ensure the viability of the involved part and to get a functional hand. The delay in reconstruction lead to badly impaired function . Most open hand injuries require secondary procedure and clean cut Injuries . in this talk we will show some of our modest experience trying to focus on the soft tissue covering and on some therapeutic principles which outline our strategy to get the most reasonable fun! ctional results and to keep the patient away from the long stay in the hospital as well as to enable him to resume his work as soon as possible with least disability possible.

MOHAMED ALI F. AL BAYATI

HAMAAD SHIHAB HOSPITAL BAGHDAD IRAQ

TAREK ABDALLA EI-GAMMAI, AMR EI-SAYED

DEPARTMENT OF ORTHOPCDICS, HAND AND RECONSTRUCTIVE MICROSURGERY UNIT, ASSIUT UNIVERSITY SCHOOL OF MEDICINE - EGYPT

Free muscle transplantation is indicated either for coverage of extensive tissue defects or restoration of function of the upper limb (Free Functioning Muscle soft Transfer). FFMT for biceps reconstruction is indicated in old cases of brachial plexus injury, crushing injuries and poliomyelitis. indicated in Volkmann ’s ischeamic contractures.

In this report we present our experience with more than 20 cases of free muscle transplantation in a variety of indications. Is mainly The muscle used for coverage was the Latissimus dorsi and rectus abdominis.

The muscle used for functional restoration was the gracilis.

16 h 30 - 18 h 30

SADDAM TEACHING HOSPITAL-DIWANYA-IRAQ

From 1994 -1998 62 displaced forearm fractures were managed by K-wire fixation . All were unilateral . The age groups ranged 3-12 years . 51 were males and 11 females.

Forearm fractures are extremely common in children, most fracture at any level usually treated by closed methods The management of severely displaced fragments with soft tissues interposition or unstable fractures is controversial and operative treatment is required only when several attempts at closed reduction have failed.

The aim of this study is to evaluate the advantage of this method in comparism with plate fixation.

Simple technique of K-wire fixation through short longitudinal incision we followed. The k wire removed at average of 3 weeks, bone union occurred in all cases at an average of 6 weeks . No complications were identified except superficial skin infection in 5 cases (8%) . It is a single safe operation with minimal complication and small scare . In comparism with extensive approach needed for plate fixation with poor cosmetic result , in addition a second operation is needed to remove the plate.

In conclusion : this method is a best alternative to plate fixation of forearm fractures in children, it allows bone union with minimal complications and scarring of the implant removal.

IMAD SARSARN

BAGHDAD MEDICAL COLLEGE – IRAQ

The effect of the anatomical and the mechanical change which are the cause or a result of a dislocated hip in influencing it' s treatment were studied.

The content of this paper was based on observation and studies made on two hundred and ten hips with an average follow up of fifteen year’s.

It was found that tow forms of dislocation were encountered . In one the hip was malaligned although it's parts are normal, in the other the dislocation is due to an abnormal parts of the hip .

Five different procedures are needed to correct these error’s, which should be described in this presentation

WALEED A. AL DOORI

SADDAM CENTER FOR RECONSTRUCTIVE SURGERY- IRAQ

23 Cases of D.D.H. with 33 hips were presented with acetabular dysplasia prospectively in Saddam center for reconstructive surgery from July 1997 to June 2000

The dislocated hips were classified according to Tonnis grading and the acetabular angles were measured pre operatively . 19 hips treated by open reduction and 14 hips were treated by the open reduction and salter Innominate osteotomy (in one stage ) all of these cases had derotation osteotomy 6 weeks later . The cases were followed and evaluated according to Barrete clinical and severins radiological rating system The AVN were classified according to kalamchi and Maceween gradings . We have 72 % excellent and good results. With 2 cases of AVN grade and The acetabular development was faster and the hips were more stable after salter Innominate osteotomy. with more than 30% correction of their acetabular angles consequently there was less cases of subluxation or redislocation after resuming weight bearing

HAKAM ALTIKRITY

SADDAM COLLEGE OF MEDICINE BAGHDAD – IRAQ

Fracture of femoral shaft are common in children in our country.

The study includes a total of 146 consecutive cases seen between 1988-1998, retrospectively, evaluated age of the patients was between 4-10.

Our analysis concludes that femoral shaft fracture in children up to 10 years treated by continuous skin traction for 2 - 3 weeks and spica cast is more suitable and easy method of treatment with less complication.

The affected limb may grow faster than the controlateral limb (range of overgrowth 9 - 15 mm).

The advantage over surgical treatment are, lower risk of infection and injury to the epiphysis, and no scar ; with elimination of second surgery for removal.

MOHAMED A. S. AKRAWI M.B.CH.B. MD.

SURGICAL DEPT. - MEDICAL COLLEGE - UNIVERSITY OF MOSUL - IRAQ

Sixteen patients with congenital pseudoarthrosis of the tibia were treated by bone sliding technique since 1978 . The follow up period ranged from 4 to 20 years , the average was 12 years .

Four patients were treated after complete bone growth. Six patients suffered from neurofibromatosis. All patients required surgery because of failure of previous surgical interventions .

Twelve patients were treated by epiphyseal distraction and the rest by bone sliding following upper tibial osteotomy . The success of this bone sliding technique merits its superiority over the

conventional methods of treatment for this drastic pathology , taking into consideration that it is applicable in older children.

R. ATIA – A.G. MENADI

DEPARTEMENT OF ORTHOPEDICS AND TRAUMATOLOGY IBN ROCHD HOSPITAL ANNABA ALGERIA

The finding out of antibiotics and the change of the way of living, especially the close contact of countries to the big cities are regarded as a crucial component in the decreasing osteoarticulary infections.

Writers bring a series of cases of osteoarthritis hematogene of a child who is taken into change between child. Both of sexes are liable to the initial clinical panel is the one of septicemia and seldom the patient is oriented from the ouset to the orthopaedy emergency, but rather to podiatry where he/she is transferred during 24h/48h.

Frequently, the patient has already been treated by antibiotics in private medical offices.

The medical test of locomotor apparatus finds generally a sole localisation osteoarticulary .The hip is the one that is concerned of two thirds of cases, coming after the shoulder, the knee, the elbow and the ankle. The articulation occurrence of spine, sacro-iliac, pubic articulation remain exceptional.

The wrist and the articulations of both hands and feet are rarely touched. So does for acromio- claviculary and stern claviculary.

The diagnosis is revealed by the clinical test and ultrasonography that find articulary overflow. The treatment remains the pions evacuation through puncture or essentially via arthrotomy. The antibiotics treatment and the immobilisation are the rule.

The increase is marked by the deterioration of the articulation ending to ankylosis.

The articulary recuperation has a direct relation with the delay of treatment.

Room A:

T.A. HAMDAN

MEDICAL COLLEGE, BASRAH IRAQ

150 patients with malignant bone tumours were admitted from July 1980 to December 1999. 52 patients were admitted in the last five years.

Histopathological examination reveals osteogenic sarcoma in 93 , Ewing sarcoma in 30, chondrosarcoma in 25 , fibrosarcoma in 13 , Giant cell tumours in 12 ,malignant fibrous histiocytoma in 6, multiple myeloma in 8 , lymphoma in 3, squamous cell carcinoma in 3, solitary myeloma in 2 , and in 5 patients no clear cut diagnosis was achieved . Histopathological results were not in agreement with the operative findings in 23 patients. In 5 patients the tumours arise from a pre-malignant lesion.

Age ranged between 7-65 years, 80 were male and 70 were female. The tumour sites were lower end of femur in 30, upper end tibia in 36, upper end humerus in 20, pelvis in 12 , mid-shaft femur in 10, lower end radius in 12 upper end femur in 8, mid-shaft tibia in 5 mid-shaft humerus in 5 , lower end tibia in 2, lower end humerus in 3, mid-shaft radius in 2, scapula in 3 and the spine was involved in 2 patients .

132 patients presented with pain, 96 presented with swelling , fungation and ulceration was noticed in 9 patients. Only one patient with Ewing sarcoma presented with pathological fracture. Late presentation was the major problem: it ranges between 9-18 months, another problem was refusal to surgery in the early stages of the disease. 129 patients end up with amputation, while 12 had wide local resection and 9 cases were inoperable. 3 patients had their tumour close to site of a retained metal. 120 patients were socio-economically disadvantaged with malnutrition, long standing stressful life, poor sanatorium, and they depend on carbohydrate and fat rich diet. In addition to the wide spread contamination with depleted uranium the above factors may explain the increasing incidence and the change in the clinical pattern in the last five years.

The tow years survival rate was 92%. this is probably the outcome of late presentation and refusal of aggressive surgery in the early stage of the tumours.

JAWAD H. TWAIJ

DEAN OF AL-MUSTANSRIA MEDICAL COLLEGE , BAGHDAD - IRAQ

Primary malignant bone tumours are still uncommon in comparison with other parts of the body. In the Orthopaedic Department of AL Yarmouk Teaching Hospital in Baghdad the usual number and presentation of patients suffering from primary malignant bone tumours have been admitted and managed.

However, the author studied some additional cases with odd presentations of these tumours during the last ten years, In regard to the age of the patients, sites of the lesions, pattern changes, aggressiveness behaviour, response to treatment modalities, survival rate and clinical features.

This study includes: 5 cases of Ewing's sarcoma presented in atypical presentations in regard to age and sites, this includes 4 cases of Ewing' s sarcoma presented in the metacarpal bones and metatarsal bones . All these cases presented in children and one case affect the neck, head of the femur and part of the pelvis in a lady 23 years old presented with pain in the knee only.

All these cases died in a matter of 6 months inspite of all surgical , radiotherapy and chemotherapy methods of treatment, In addition the author observed cases of osteosarcorna diagnosed accidentally by radiological examinations and the patients were presented with little pain in the knee joint, all these cases behaved in a very aggressive way later on.

The study includes also a case of giant cell tumour and myeloma with special interest.

KAMAL AL TAHAN

RED CRESCENT HOSPITAL , BAGHDAD - IRAK

This study is discussing whether the form of the patellofemoral joint has a real effect on developing osteoarthritic changes. After a short review of the theories of the degenerative changes, we discuss the different Wiberg and modified types of the Patella.

According to that we investigated one hundred German, and one hundred Iraqi patients in similar condition clinically and radiologically, and classified them due to the wiberg types of the patella, their jobs, sex, age and the degree of the osteoarthritic changes.

We had an interesting comparison.

D.S. ALOBIDI -M.T. ALSABTI.

Injury of ACL is getting more common by the days and treatment of patients with deficient ACL knees is a bit difficult problem. In this study 32 patients were managed for deficient ACL by reconstruction of the ACL by using modified Jones procedure using the middle third of the quadriceps tendon, middle third of the patella and the middle third of the liga. patellae. This study is a prospective one in which the results of the surgery including the complications were registered_.

All patients were followed up for an average of 18 months .It was found that the results of surgery were quite satisfactory and the complications encountered were few.

L.NOUISRI - T.B. CHAABANE - M.HAMDI - A.BOUGHOUFA - S.KCHALFI -F.BELKHIRIA - A. KHELIL

DEPT OF ORTHOPAEDIC SURGERY - MILITARY HOSPITAL - TUNIS

Instability of the anterior cruciate ligament (ACL), either isolated or combined with other capsuloligamentous and menisci injuries is frequent.

This strong ligament is a key stabiliser : loss of its function combined with peripherial menisci tears Leeds to joint overload in the sagittal and frontal planes and eventually to osteoarthritis.

Attempts to reconstruct the ACL , have been difficult and frustrating, but the incidence of functionally and anatomically stable knees after surgery is now improving.

The purpose of this retrospective study (1995 -1999) is to evaluate our experience using free antogenous central one third patellar tendon (9-12 mm) with attached patellar and tibial bone blocks for ACL arthroscopic reconstruction in 140 patients (131 men , 9 women , middle age 27 years) who were available for clinical review at a mean follow up of 19 months.

Early results demonstrate excellent stability and symmetrical ranges of knee motion for 80 % of them.

CLAUDE ABI SAFI, ROGER JAWISH

Background : The aim of this study is to evaluate prospectively the effect of intra-articular Tenoxicam on postoperative effusion after arthroscopy.

Methods: 1OO patients underwent Knee arthroscopy on a day-case basis .There mean age was 35 years. There were 64 male and 36 female .Normal saline was used for irrigation. At the end of the operation, the irrigation fluid was removed from the Knee joint and 20m1 Tenoxicam diluted to 20ml of 0.9% normal Saline were administered into the Knee 10 minutes before limb tourniquet was deflated . The mean duration of the operation was 25 minutes. The patients were seen systematically two weeks after the operation and were examined by the same surgeon for Knee effusion . During this period, it was allowed to take Only paracetamol for pain relief.

Results : No side effects of the N.S.A.I.D. have been observed . The effusion was specially developed in Meniscus lesions and osteoarthritis . It was estimated severe in 3% and mild to moderate in 12% of the patients. It happened in 18% of male and 8.3% of female.

Conclusion : Intra-articular injection of Tenoxicam is not only effective in providing Knee analgesia but also in reducing Knee effusion after arthroscopy without inducing the side effects of the N.S.A.I.D

SHAKIR M. AL- AINACHI.

HAMMAD SHIHAB MILITARY HOSPITAL, BAGHDAD- IRAQ

32 Cases with Poliomyelitis presented as fixed flexion deformity of the knee, all complaining of abnormal gait in the form of HAND-KNEE GAIT. All the 32 cases (15 males and 17 females) were treated by supracondylar extension osteotomy of the Femur in the period between January 1993 to January 2000.

The angle of fixed flexion was 25 degrees or more, the age ranged between 14 -45 years.

The selection of patients for surgery, the surgical procedure, results and complications are discussed in this paper.

This type of surgery can greatly improve the quality of gait in those who require pushing their knees backwards by their hands during stance phase of walking (HAND - KNEE GAIT).

NASSER TURKEI F.I SUBAEL , NASSER M.G. , ABDEL GAWAD , AYMAN EL SAYD

QATAR

Initially of the patients in need for knee joint replacement were used to be sending outside the country for surgery. In addition to the cost effect, such patients were lacking proper control and supervision by a constant treating team. The patients were subjected to treatment in different places, by different surgeons, with different implant designs and through different techniques. The postoperative program of rehabilitation was frequently deficient. Late postoperative complications although infrequent, sometimes need urgent intervention, makes with this polymorphism, great difficulty to be managed . All these factors made the decision of establishing national knee arthroplasty team a necessity. The aim was to have the capability to treat the denovo cases meanwhile able to deal with the revision potential for the already present knee arthroplasty . The local surgical procedure of total knee replacement was started on the beginning of 1995. In this artic! le , a prospective study of short-term result of 44 cases with total knee replacement was evaluated. The preoperative assessment, operative technique and postoperative rehabilitation program was discussed. The results after a minimum of three years were collected and analysed. The Knee society rating and scoring system was used to evaluate each case. The subjective and the objective results were quite encouraging to expand the program and to establish the technique.

RYSAVY M. DZUPA V , ZIDKA M. , NASSER TURKI AL SUBAIE, MOHAMMAD AL KHAYARIN

ORTHOPAEDIC CLINIC, 3^RD MEDICAL FACULTY, CHARLES UNIVERSITY, PRAGUE, CZECH REPUBLIC ORTHOPAEDIC DEPARTMENT, HAMAD GENERAL HOSPITAL, DOHA, QATAR

Limb length discrepancy could appear as a result of congenital deformity, inflammatory diseases, post traumatic conditions, osteomyelitis. Distraction osteogenesis is widely used for leg lengthening, but often requires a long period of external fixation which carries risks of pin-tract sepsis malalignement, stiffness of the joints and late fracture of the immature regenerate.

In an attempt to reduce the rate of complications a combination of an external fixation and intramedullary nailing was introduced. We present the results of 7 cases in which a lengthening of a femur over an intramedullary nail was used.

The mean preoperative shortening was 6 cm, mean age in time of operation was 18 years.

The mean gain in length was 4,5 cm, the mean time of external fixation was 13,5 days per centimetre gain in length. All distracted segments healed spontaneously. There was one case of superficial pin tract infect and one case of failure of the intramedullary nail, in which was performed reosteosynthesis by interlocking nail.

The method allows early rehabilitation, with a rapid return of joint movement. There is a lower rate of complications than in case when external fixation is used on its own.

The procedure is technically demanding and requires cooperative patient.

KSIBI H., SELLAMI M, KAMMOUN L. , KALLEL S_. ,BEN AMOR H., ZOUARI M.,

KARRAY S., LITAIEM T., DOUIK M.

KASSAB INSTITUTE TUNISIA

The shelf operation is an intervention of which the goal is the improvement of the cover of the femoral head that protecting the hip from the early osteoarthrosis. The goal of this work is to specify the place of the shelf operation in the preserving processing of the osteoarthrosis .

We report a retrospective study of 19 shelf operation, realised at 17 patients (13 women and 4 men). The average age was 22 years and the total functional mean score according to the classification of Merle d'Aubigne was of the 14,5/18. All hips were painful but with preserved mobility.

At the time of the intervention, the arthrosis was beginner in 80% of the cases to the

average retreat 10 years, 80 % of the hips were painless or not very painful.

With an average profit of 2,3 points on the total score.

Radiologically 84 % of the patients were stabilised or having better result.

However the best indication of the shelf operation is the pure acetabular dysplasia, subject less than 40 years, and early hip osteoarthritis. The femoral osteotomy is associate to the shelf operation when it exist a mixed dysplasia with a good centring of the femoral head on the dynamic radiography.

S. KAMOUN – M. FATHALLAH – S. TRIGUI –S. KALLEL – M. ZOUARI – S. KARRAY M. DOUIK -T. LITAIEM

INSTITUT M. KASSAB - TUNISIA

Hip osteoarthritis is an invalidating affection whose repercussion is judged in term of pain and functional invalidity.

The therapeutic management depends on age and the evolutionary stage of osteoarthritis

The purpose of this study is to specify the place of the proximal femoral osteotomy in the therapeutic arsenal of the hip osteoarthritis.

We bring back a retrospective study of 27 proximal femoral osteotomies of valgisation and varisation carried out at 24 patients (14 women and 10 men).

The average age was of 41 years and half and the average total functional score according to the Merle d’Aubigné grading was 13/18.

All the hips were painful but of practically preserved mobility. At the time of the osteotomy osteoarthritis was rather advanced.

The patients were reviewed with an average retreat of 11 years and 4 months , 3/4 of the hips are painless or far from painful, with an average profit of points on the global functional score.

Radiographic improvement is obtained in more than half of the hips

The proximal femoral osteotomy represents one of the essential conservative procedures in the treatment of hip osteoarthritis especially in young subjects when the clinical, anatomic and radiographic conditions are favourable with its realisation. The goal is to delay the expiry of total hip arthroplasty, not deprived form hazards.

NIGROU K. -CHEBIL M. -BEN DALI N. -KANOUN ML.-KHORBI A. -HADDAD N.-HACHEM A.

AZIZA OTHMANA HOSPITAL SERVICE OF PR.HACHEM 1008 - LA KASBA – TUNISIA

Surgical treatment of hallux valgus contains several techniques . those techniques can correct the distortion by soft tissues procedures or by osteotomies. If the indications of those tao methods are admitted by all, the type of osteotomy remains a subject of discussion, and many surgeons perform the technique that dominate.

Introduced in Tunisia few years since, scarf osteotomy constitutes the main technique employed for treatment of hallux valgus in the most orthopedic services.

We report a retrospective study of 33 cases of scarf osteotomy performed between 1993 and 1999; follow up of tao years, our results confirm the efficacity of this technique to correct a mild and severe hallux valgus. However, some factors such as a long first ray or a great distal articular metatarsal angle should be always corrected, because these factors expose to undercorrection and recurrence of distortion.

ESSADAM H. – TRABELSI M. - CHERIF M.R. – MBAREK M. – BELHASSINE H. – JAMOUSSI M.

AZIZA OTHMANA HOSPITAL – TUNISIA

Empirically A lot of factors determine the prognosis of bone’s fracture.

Among these factors we find the radiological shape of fractures.

The authors find :

And they try to explain these differences in the lesion of soft tissues (osteoperiosteum and medullary).

STAKUB KAGHADE

POLICE HOSPITAL – MINISTRY OF INTERIOR – DAMASCUS - SYRIA

The trauma is consider the great cause of deaths for people especially the young group (20-35 yr) which involve the most active and productive period of human life and this lead to the lost of great number of potential productive years (YPLL)

Multiple traumas accompanied by high rate of morbidity & mortality even in the developed countries.

Objective, evaluation of emergency system in management of MTRA and to demonstrate the mistakes (scene - hospital) materiel and method; retrospective study of 131 M. tra cases was followed in 4 hospitalin Damascus (almowassat damascus – douma – police)

Results : males : 78 % - females : 22 % - children : 27 % - youngs : 40 % - adulthood 7 % - adults 20 % - aged persons 6 %

The case of accident : traffic 99 cases – high falling 25 gunshot 5

Forms of injuries : limbs 55 % - skull fractures 14 % - concussion 23 % - dislocations 5 % - pelvis 8 % - Abdomen 8 % - thorax 4 % - spine 5 % - vascular 0,5 %

Recommendations: Multiple trauma management needs high qualified emergency team starting in the a scene and follow the patient in the hospital.

M. TRAFEH M.RAHMI Y. NAJEB D. COHEN

MAROCCO

Humeral shaft fracture represent 2 % of the fractures. The usual bone healing of this bird of fracture is know, but the managing of this injury is not unanimous.

The aim of this study is :

• Evaluation of the surgical management of this fracture.

• The indication of each type of Osteosynthesis.

This study is a retrospective are, about 42 fractures of the humeral shaft. The use of a sell plate in 29 cases. It procure the best results in this study.

In this study 2 cases of sepsis, 2 cases of radical false, 2 cases of no union and 4 cases of malunion are noted.

Surgical treatment of humeral shaft fracture is indicated in cases of no reduction, or in case of fracture complication or in case of post-traumatic radical palsy.

The use of plate or wailing by kirshner wise are the two common method used.

The plate have air preference because of a anatomy reduction and stability allowing immediate rehabilitation.

AMR EL SAYED , MD , HATEM G.ZAKI , MD

DEPARTMENT OF ORTHOPEDICS, ASSIUT UNIVERSITY SCHOOL OF MEDICINE EGYPT

We present 8 cases of different types of fractures of femoral diaphysis treated with standard AO plates and screws with adjuvant looking nuts. The age range is from 18-45 years old. This has resulted in bone union in I.5 months on the average, with full return of function. The locking nuts elevate the plate off the bone and lock the screws to the plate, thus acting as an internal fixator; and improve the mechanical and biological behaviour of the standard AO plate, without the need for special types of plates and screws.

The locked plate system may present an alternative to locked intramedullary nailing when there are contraindications or technical difficulties, with lower irradiation exposure, embolic complications and at the same time shows comparable results.

M.HAMDI , S .KHELFI ,S.KAMMOUN , F.BELKHIRIA ,T. BEN CHAABANE,L.NOUISRI, KHELIL

DEPARTMENT OF ORTHOPEDIC SURGERY –MILITARY HOSPITAL - TUNISIA

Fracture of the distal radius is the most frequent traumatic lesion .Whose wrong benign reputation is actually revealed, due to the important anatomic and functional after affects reported in the literature.

The Kapandji's intrafocal pinning is an interesting therapeutic contribution since it allows good stability and earlier mobilisation .

One hundred and fifty fractures of the distal radius were treated by Kapandji 's technique during the period between 1986 - 1999 ( lO5 men, 55 women age: 45 years)

According to Kapandji’s classification, 75 % of these fractures were extrarticular essentially type I and II . At 7 years follow up (10 months -14 years) few complications were reported , good results were Obtained in 90% of cases and functional recovery was rapid , indicating that this method represents undoubted progress when compared to other therapies .

HAMDI. MF – OTHMANI.L -ABID. F - SAIDI. S - ZITOUN .Y-SASSI . N

DEPARTEMENT OF ORTHOPEDIC SURGERY HOSPITAL OF MAHDIA - TUNISIA

The management of the comminuted fractures of distal radius using the principle of ligamentotaxis through external fixation has undergone a recent evolution.

Twenty cases of unstable fracture of the distal end of the radius were treated by distraction and fixation , using a Hoffmann external fixator. The most of these fractures were comminuted ,unstable and intraarticular.

The average age was 44 years with a sex ratio :2.3. All patients were followed up for between four months - five years ,the results were evaluated by active motion of the wrist, grip strength , pain , and radiographic analysis.16 patients had satisfactory results and 4 had a bad results.

The severe algodystrophies were observed

MASSAAD RAYMOND

LIBAN, BEKAA, HOSPITAL AL RAHMEH

Derived from Ender nailing, this technique is based upon the biomechanic principal of the coxo-femoral segment, which is the grue was properly studied. This grue of Pauwels, characterised by all the mechanical elements, accordingly twenty two patients were operated in two series.

Ostéosynthesis by the under nail (6 patients)

Introducing two Ender nail from the superior metaphys is to come out at the internal half of the femoral head. One nail is left on the external side of the greater trochanter. The upper ends of the nails are locked together by two spongious screws.

1. Osteosynthesis by Blade-Nail –Locked (16 patients)

One intramedullary nail is introduced into the external face of the greater trochanter,

blade sliding sup on the superior end of the nail, traverse horizontally the cervico-cephalic massif. The blade and the nail are locked together bay a screw, which traverses the femoral neck.

The osteosynthesis by Blade-Nail –Locked, provides a technique, which is stable, solid, elastic, little invasive, with small skin incision, minimal blood lost, shorter hospital stay, and ensuring rapid recovery of the patient, and minimal economic cost to the patient as well as to the society.

(The principal and the results of this study will be explained in details through out my presentation.)

R. ATIA - A.G. CHORFA - A. YAHIA

DEPARTEMENT OF ORTHOPEDICS AND TRAUMATOLOGY IBN ROCHD HOSPITAL ANNABA ALGERIA

The whole breakings of tibial pestle annoys the bimalleolary-clip and have a great impact on the ankle function.

Writers bring a series of 67 cases. It is concerned mainly with young patients aged from 21 to 38 years, belonging to male sex in which 85 % of the cases are victims of a hard traumatism on a blocked foot.

The skin opening is the main associated.

The pathological anatomy finds a lesion touching the inferior tibio splin bone articulation and the … in the and posterior anterior edge rarely both

The treatment has been surgical : an osteosynthesis by plak associated to free screws, an additional treatment through cast and precocious training have been prescribed. No additional bone implant has been done.

The result was appreciated on the ankle’s movings, on the quality of walking according to the patient’s state and the functional troubles : aches and crawing.

The complications are marked by the sore toughness and the infection in the two cases in which we preconise of the arthrodese of the ankle.

SABAH MENDI ALJANBI

SADDAM TEACHING HOSPITAL -DIWANIA A-IRAQ

56 Patients with open comminuted tibial shaft Fractures were treated by external device in Saddam teaching hospital. The common Cause of the injury was road traffic accident (50%). Skeletal and extraskeletal injuries were present in (46%) of the cases . The commonest age group was 0-15 years (46.4%). Males (46%) affected side more than females (10). Left side(32) affected more than the right side (20). The commonest type of fracture was type III (50%). The average period of fellow Up was 12 months. The average time for wound healing was 18.3 days. The average time for bone healing was 19.5 weeks. The commonest complication pin tract infection (16 cases- 28.5%). Primary closure have been done in 34 cases (60%).

The results were very good in 28.5% ,good in 50% , fair in 10.75 % , poor in 10.75 %.The high incidence of good and very good results was due to proper management of bone and soft tissues and to high percentage of younger age cases (26 cases below 15 years) . The causes of the fair severity of poor results were due to the severity of infection .

The aim of this study was to evaluate the using of the external fixature device and primary closure in the management of open comminuted tibial shaft fracture.

HAZEM ABDELADHIM

EGYPT

Between January 1995 and January 2000, 84 acetabular fractures in 82 patients were operated upon with open reduction and internal fixation. 20 acetabular fractures were referred to us after the elapse of time ranging from 4 weeks to 8 months.

The youngest patient was 12 years of age at the beginning of the study and the oldest was 70 years old. There were 15 female patients and 67 males.

Our patients were followed up and assessed both radio logically and clinically.

Radiological assessment was done according to the Matta’s criteria. Reduction less and more than 3 mm are non satisfactory. In this series, there were 28 anatomical reductions, 23 satisfactory, 7 secondary congruent reductions, 21 non-satisfactory and 5 failures , 10 reconstruct where 5 arthroplasties had to be carried out.

The patients were followed up for a minimum of 12 months and a maximum of 60 months. At the end of the last assessment clinical grading was done according to the Merle d’Aubigné and Postel scale where pain, range of motion and ambulation were assessed. A total out of 18 points were assigned to the functional result of the patient.

The results were 15 excellent, 20 very good, 30 good, 9 faire . 4 poor and 6 failures where arthroplasties had been carried out (one additional joint replacement had been carried out at the end of the study). This gave a total of 65 satisfactory results (77,38 %) and 19 non-satisfactory results (22,62 %).

T.A. HAMDAN

MEDICAL COLLEGE, BASRAH - IRAQ

Vast experience was gained after handling 1000 war wounded and civilian injured by missiles. The injurious agents were fragments of shell in 71.3%, bullets and accidents in 6.8%, mines in 4.3%, and flame burn in 6.19%.

Three types of injuries were distinguished: primary, secondary and latter two types were due to flying debris set in motion or body propulsion .

Considerable therapeutic, medical care and repeated physical examinations are mandatory. 36 lesions were missed at the initial physical examination . Compound fractures were the dominant injuries and it was noticed in 73.69%,12.3 end up with limb amputation, while 8.6% had only soft tissue injury.

The author advocates removal of the retained missile at the time of initial wound

excision, because the missile track can be traced easily, some retained missiles may be ignored because the hazards of removal is probably more than that of retention.

A system of staged debridment and wound management is presented which has contributed to reducing infection, morbidity and mortality.

The initial wound excision is the cornerstone in the management of war wound, primary closure may be performed in some special cases.

The experience of managing 45 patients with compound fractures and bone loss is presented, the bone defects were minor in 33 patients and major in 12 patients , associated nerve injuries were seen in 16 patients while associated vascular  were seen in 10patients.

The application of external fixation has revolutionised the management of missile injuries. Early definitive fracture care employing external fixation will reduce the incidence of amputation and improve the functional result to a great extent.

At the time of heavy casualties, a special organisation is must to reduce the complications that may arise from rush sending of the patients to the radiology department.

Disabilities are expected in some cases, but it can be reduced or even abolished if proper and ideal measures were used in the management starting at the scene.

Disabilities may be classified into avoidable and unavoidable.