INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES <p>International Journal of Allied Health Sciences, is a peer-reviewed, English-language scholarly online journal, published biannually by the Kulliyyah of Allied Health Sciences, International Islamic University Malaysia.</p> Kulliyyah of Allied Health Sciences, International Islamic University Malaysia en-US INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2600-8491 MANAGING SEVERE KYPHOSCOLIOSIS WITH HALO-PELVIC TRACTION: A CASE REPORT <p>This is an interesting case of a severe kyphoscoliosis patient that was managed using a halo pelvic traction (HPT) and posterior spinal instrumentation and fusion (PSIF). Our patient is a boy who was initially reviewed at our centre at the age of 3 for a spine deformity complaint and was unfortunately missing from follow up. He was referred back to us at the age of 13 due to a severe thoracolumbar kyphoscoliosis deformity with reduced effort tolerance. There were no neurocutaneous stigmata and his neurological examination was unremarkable. The apex of the deformity was at the level of T9 with the Cobb’s and kyphotic angles estimated at 152° and 144° respectively. CT and MRI scans showed no evidence of vertebral or spinal cord anomaly. Due to the severity of the deformity, the decision for a HPT was made prior to PSIF. Distraction was performed over 58 days, followed by a single stage PSIF from T2 to L3. At 1-year post- operative, patient had no active complaints, with no evidence of implant loosening. The usage of HPT for spinal deformity correction has been reported by O’Brien in 1973, but poor tolerance by patients and complex configuration of the fixator frame limited its regular use. With the combination of standard Ilizarov device and our new fixator components, construct of frame and application on to the patient would be easier. HPT allows surgeons to reduce the risk of neurological complications associated with acute correction of severe spinal deformities.</p> Muhammad Lutfi Abdul Rashid Chris Yin Wei Chan Mohammed Ziyad Albaker Kwan Mun Keong Saw Aik Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2293 2293 TIBIALIZATION OF FIBULA, CONQUERING TIBIA NONUNION WITH LARGE BONY DEFECT <p>We present a case of childhood non-union of tibia with fibula hypertrophy and equinus deformity of the right ankle. This is a case of a 47-year-old lady presenting with history of right tibia fracture that was complicated with osteomyelitis at the age of 3 years old. She had multiple debridement done resulting with bone loss during childhood. She had recent acute trauma to the right knee, and worsening bowing of the right leg which brought her to the attention of reconstructive orthopaedic surgery team. On examination, she is walking with a short limp gait. There are longitudinal scars over anteromedial and lateral aspect of the leg. The right knee is hyperextended at about 10 degrees with valgus deformity and multi ligamentous laxity. The right tibia is 10cm short. The right ankle is in fixed equinus. Radiographic examination revealed atrophic non-union of midshaft right tibia, hypertrophic right fibula, and anterolateral bowing of the fibula. An ipsilateral 7cm vascularised fibula graft was transposed onto the right tibia and stabilized using 2mm intramedullary Kirschner wire and Ilizarov external fixator, considering poor soft tissue condition. Bony union was expedite using iliac bone graft on another surgery. Union accomplished well within a year from first surgery. Achilles tendon release was also done to achieve plantigrade ankle. A better functional outcome could have been achieved following a limb lengthening procedure once union achieved, which patient refused. Ipsilateral fibula graft avoided morbidity to the contralateral limb. The utilization of hypertrophied vascularized fibular graft in conjunction with Kirschner wire and Ilizarov external fixator provides excellent mechanical and biological advantage. A good opportunity seized in managing a longstanding tibia non-union with large bony defect in adult patient.</p> <p><strong>Keyword: </strong>tibialization, nonunion, vascularised fibula graft</p> <p><strong>Acknowledgement: </strong>We would like to express special thanks to Plastic and Reconstructive Surgery team SASMEC for their contribution while managing this patient.</p> Noorhuda AM Mohd Hazrul Hazwan BH Shanmugapragash G Muhammad Luqman N Nazri Mohd Yusof Ahmad Fadzli S Akmal Azim AA Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2294 2294 MANAGEMENT OF PSEUDOARTHROSIS IN CHILDREN USING ILIZAROV EXTERNAL <p>Chronic osteomyelitis is an unfortunate condition that can lead to devastating complications among which are pathological fracture, non-union, and pseudoarthrosis. The management requires a long duration of antibiotic and follow-ups to gain skeletal consolidation.&nbsp;A two years eight months old girl presented with pseudoarthrosis of the right tibia after a history of pathological fracture secondary to chronic osteomyelitis. It initially started with a local abscess three months before chronic osteomyelitis changes. She failed conservative management with a full-length cast and was eventually treated with resection of the pseudoarthrosis, acute compression using peg technique and Ilizarov external fixator. After three months the fracture consolidated and Ilizarov external fixator was removed. However, she had an episode of fall leading to an undisplaced fracture of the tibia and was treated successfully with full length cast for two months.&nbsp;The management of pseudoarthrosis remains a challenge especially in dealing with bone and soft tissue defect and require meticulous planning before embarking on surgical intervention. It is proven widely that distraction osteogenesis through Ilizarov method stimulates the biosynthetic activity in tissues. Although the use of Ilizarov external fixator as skeletal stabilization in the management of chronic osteomyelitis is common in adult, it is uncommon in children. This is due to better healing potential in children and the fixator itself being bulky and require delicate care throughout its application.&nbsp;In conclusion, Ilizarov external fixator is an excellent option for skeletal stabilisation in the management of pseudoarthrosis in children.</p> <p><strong>Keywords:</strong> Chronic Osteomyelitis, Ilizarov external fixator</p> <p><strong>Acknowledgement:</strong> None of the authors has any financial, professional, or other conflicts to disclose.</p> Laila Maisarah A Rahman Nazri Mohd Yusof Ahmad Fadzli Sulong Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2295 2295 A RARE CASE OF SUPERFICIAL LEIOMYOSARCOMA. SOFT TISSUE RECONSTRUCTION OF LOWER LIMB FOLLOWING ONCOLOGY EXCISION <p>Superficial leiomyosarcoma is a rare, malignant smooth muscle tumour of the skin which most commonly affects the extremities. Surgical excision has been the standard of care for superficial leiomyosarcoma. With the combination of oncological surgery with reconstructive surgery, along with the introduction of radiotherapy, this has led towards better tumour control and preservation of limb function. Often enough, soft tissue tumour excision results in large anatomical soft tissue defects with exposure of vital structures, necessitating soft tissue reconstruction with vascularized tissue transfer. Free anterolateral thigh (ALT) flap is a reliable and versatile flap with broad clinical applications in soft tissue coverage. Here we report a case of a 58-year-old lady who presented with one year history of high grade leiomyosarcoma over right calf. Clinically, there is a fungating mass with central ulceration measuring 9 X 9 cm over the medial aspect of her right calf. She underwent multidisciplinary surgery which involved the orthopaedic oncology team and plastic and reconstructive surgery team. Wide local excision of right calf leiomyosarcoma with oncology margins was performed, leaving a defect size 18 x 19 cm over medial aspect of posterior right calf, exposing medial gastrocnemius muscle and tibia bone. Immediate soft tissue coverage was performed using free ALT flap. The flap is raised based on two perforators from the descending branch of the lateral circumflex femoral artery. Post operatively, patient had improved outcome and aesthetics. She was able to ambulate without support 2 months after she was discharged home. ALT flap is a versatile flap and is able to shape and provide large skin for soft tissue coverage for large defect.</p> <p><strong>Keywords:</strong> Leiomyosarcoma, lower limb, ALT flap, lower limb reconstruction</p> <p>&nbsp;</p> Adriana Sigang Langat Chai Siew Cheng Koh Khai Luen Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2296 2296 FREE FUNCTIONAL LATISSIMUS DORSI MUSCLE FLAP IN THE TRAUMATIC LOWER EXTREMITY: A CASE REPORT AND LITERATURE REVIEW <p>The reconstruction of the traumatic lower extremity remains a challenging task for both the orthopaedic and plastic surgeon. Various options of reconstruction are available with muscle flaps being one of the most reliable for soft tissue coverage. Nevertheless, there are limited reported cases in literature on the functional reconstruction potential as a neurovascularised muscle flap in the traumatic lower extremity. A free functional muscle transfer is used to restore critically damaged extremities, in addition to functional limb salvage. Here, we present a case of a 62 years old gentleman with an open fracture of the proximal left tibia and fibula with vascular injury (Gustilo classification grade 3C), complicated with soft tissue necrosis and exposed proximal tibia bone post revascularization of the left anterior tibial artery, in which a free functional latissimus dorsi muscle flap was used for simultaneous soft tissue coverage and functional reconstruction of the anterior compartment of the leg in the traumatic lower extremity. At 6 months postoperatively, he had satisfactory functional outcome wherein active dorsiflexion of his ankle joint was restored, with minimal donor site morbidity.</p> <p>&nbsp;</p> <p><strong>Keywords:</strong> free functional muscle transfer, extremity</p> Ragnild Redit Fatimah Mat Johar Johar Wan Azman Wan Sulaiman Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2297 2297 FUNCTIONAL RECONSTRUCTION OF A COMBINED TENDOCUTANEOUS DEFECT OF THE ACHILLES USING COMPOSITE FREE ANTEROLATERAL THIGH FASCIOCUTANEOUS FLAP WITH VASCULARIZED FASCIA LATA <p>Combined tendocutaneous defect of Achilles tendon remains a complex reconstructive challenge whereby both the soft tissue coverage and tendon reconstruction have to be considered to achieve a good functional and aesthetic outcome. Potential regional vascular compromise from previously injured leg and inability to provide tendon-like structures have rendered the non-suitability of loco-regional flap. Thereby, in this scenario, compound free flap with multiple tissue components represents a better solution, which has the advantage of incorporating vascularized tendon and skin coverage together. We described a 14-year-old boy who sustained an open right calcaneum fracture (Gustilo-Anderson IIIB) with transected Achilles tendon and huge skin defect from motorcycle wheel spoke injury. He initially underwent wound debridement, primary repair of Achilles tendon and external fixator application of right ankle. However, there was gapping at tendon repair site 3 weeks after primary repair due to poor healing. Subsequently, simultaneous soft tissue coverage and tendon defects reconstruction for a sizeable, combined Achilles tendon (6 cm long) and overlying skin defect (12 X 6 cm) using composite sensate free anterior lateral thigh (ALT) fasciocutaneous flap with vascularized fascia lata was performed at approximately 1 month from initial injury. The vascularized fascia lata was tabularised to wrap the native proximal stump of Achilles tendon and secured using modified Krakow suturing technique. The Distal end of tubularized fascia lata was then secured by drilling across right calcaneum bone and passing the suture transosseously. He led an uneventful post-operative recovery whereby he was able to ambulate with normal gait and lift his own weight against gravity without donor site complication at 1 year after surgery. The case report aims to present the application of this technique and its advantages over other flap choices in such huge combined tendocutaneous defect.</p> Raymond Yii Shi Liang1, Shi Liang Chai Siew Cheng Hamidah Binti Mohd Zainal2, Mohd Zainal Mohammad Ali bin Mat Zain Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2298 2298 SUCCESSFUL REPLANTATION OF A TRAUMATIC BILATERAL LOWER LIMB AMPUTATION IN MALAYSIA, A CASE REPORT <p>Bilateral replantation of the lower limbs following a traumatic total amputation are not commonly reported. We present a successful replantation of bilateral lower limbs following a traumatic total below knee amputation in a 30-year-old patient. The ischaemic time was more than six hours, and we only manage to fix the bone and perform neurovascular anastomosis and reconstruction with the help of bypass perfusion prior to the replantation. After the surgery, the right replanted limb had necrotizing fasciitis, which was debrided leaving huge soft tissue defect which was covered with a free myocutaneous Latissimus Dorsi flap. A year after the first operation, our patient can stand on his own and ambulate with support proving that our surgery can still provide functionality to the patient in terms of ambulation. In conclusion, with the advances of microsurgery and reconstructive field, limb salvage of amputated bilateral lower limb even with residual functionality should be attempted.</p> <p><strong>Keywords:</strong> Bilateral lower limb replantation, bilateral below knee traumatic amputation, extracorporeal membrane oxygenation, Latissimus dorsi flap.</p> Halimah Muhamad Siti Fatimah Noor Mat Johar Wan Sulaiman Wan Azman Nu’man Wan Ismail Wan Faisham Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2299 2299 WHEN GUSTILO III C AND MESS SCORE 9 TRAUMATIC LOWER LIMB MEETS REPLANTATION: A CASE REPORT OF LOWER LIMB REPLANTATION <p>Mangled Extremity Severity Score (MESS) has been used for more than twenty years to predict the limb salvageability following severe lower extremity trauma. MESS score of greater or equal to seven has hundred precent predictable value for amputation. Warm ischemic time of more than four to six hours in association with type III Gustilo fracture always end up with primary amputation due to unfavourable outcomes.&nbsp; We present a case of 24-year-old man with a near total amputation of right leg in a traumatic event. After thirteen hours of cold ischemic time with a MESS score of nine, the patient underwent leg replantation under the combined effort of orthopaedic and microsurgery team. The replanted limb survived after several surgical procedures. Functionally, he can ambulate with crutches with well-preserved plantar foot sensation. He is still under our rehabilitation program and follow up. We plan to do secondary operation to achieve better aesthetic and functional outcomes. With a dedicated team and good strategy, replantation for a limb of MESS score more than seven is still salvageable.</p> <p><strong>Keyworks:</strong> Replantation, Amputation, Trauma, Microsurgery, Mangled extremities</p> <p>&nbsp;<sup><br></sup></p> Lam Hui Yuan Siti Fatimah Noor Mat Johar Nu’man Wan Ismail Wan Faisham Wan Sulaiman Wan Azman Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2300 2300 NON-VASCULARIZED FIBULA GRAFT IN DEFORMITY CORRECTION OF A YOUNG CHILD <p>An eight years old child presented with a crush injury of her right leg, with open comminuted distal right tibia fracture and open right calcaneal fracture following an alleged motor vehicle accident in July 2019. This disastrous injury resulted in an extensive soft tissue damage which required multiple debridement and soft tissue surgery. Initially we performed debridement, external fixation; split and skin grafting. At this stage, complete healing and soft tissue coverage achieved, but her bone healing was impaired with non-union, varus deformity and shortening around 3 cm. Six months later, we discussed, counselled the parents and patient for autologous bone graft (non-vascularized fibular strut graft) and free flap procedure. Intraoperatively, large amount of fibrous tissues was removed, no signs of infection noted, and bone shortened until good bleeding sign seen. (Paprika sign). A 2 cm ipsilateral fibula strut graft harvested and inserted into the tibial intramedullary canal. It was stabilised with a 5-holes medial distal tibial locking plate. Our plastic surgery team further assisted with the closure employing a contralateral free anterolateral thigh (ALT) flap. With utilisation of this graft, we were able to avoid complications of taking alternative grafts such as iliac, and also assisted in her deformity correction by giving mobility during reduction. The tricortical nature of this graft also helped in maintaining the reduction and shown to be well integrated and united in the fracture site. Choice of ALT flap as wound closure seems beneficial for both soft tissue healing and bone healing. Serial plain radiographs shown good fracture healing and well aligned bone. The donor fibula site had also shown regrowth of the fibula, likely from the periosteum. This child was able to fully weight bear after 5 months with very minimal (1 cm) limb length discrepancy, which she compensated well while walking.</p> <p><strong>Keywords:</strong> crush injury, non-union, non-vascularised fibula graft</p> <p><strong>Acknowledgement:</strong> We would like to express special thanks to Plastic and Reconstructive Surgery team SASMEC for their contribution while managing this patient.</p> <p>&nbsp;</p> Mohd Hazrul Hazwan BH Shanmugapragash G Noorhuda AM Muhammad Luqman N Nazri Mohd Yusof Ahmad Fadzli S Akmal Azim AA Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2301 2301 THERE IS NO LEISURE IN TREATING ORTHOGERIATRIC INTERTROCHANTERIC FRACTURE-STABLE FIXATION AND EARLY AMBULATION <p>Fracture around hip is one of the most common fractures because of which elderly patients get admitted in an orthopaedics trauma ward. Early surgery became a priority in health systems, but early postoperative physiotherapy also plays a major role in prevention of mortality: independently from surgical timing, patients who did not walk again within 10 days from surgery showed mortality rates higher than those of patients who did. At our centre we aim surgery within 72 hours from time of admission. All patients that were referred to our unit will be operated by trained medical officer, specialist, and consultant. During surgery close manipulative reduction will be attempted, however in difficult cases open reduction and joystick reduction were performed. Aim of reduction is to get near perfect anteromedial cortex continuity. Patients are allowed to fully weight bear immediately after surgery as tolerated with walking frame ambulation. Early mobilization with full weight bearing boosts the confidence of the patients, which has a good overall effect on the well-being, morale and should be recommended following intertrochanteric fracture fixation. In our centre, we started with few cases which were performed by fellow with direct supervision of senior consultant. Now senior medical officer can perform the same with good reduction and are not scared to allow patient to fully weight bear post operatively. In conclusion quality of life will be increased and overall healthcare costs will be decreased in these patients. We would like to share few of the cases with video presentation.</p> <p><u></u> <sup><br></sup></p> Mohammed Harris A Shival Sasidaran Kunalan Fazir Mohamad Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2302 2302 AN IRREDUCIBLE VARIANT OF COMPLEX UNSTABLE INTERTROCHANTERIC FRACTURE-A TECHNIQUE FOR OPEN REDUCTION <p>The care of patients with intertrochanteric fractures has advanced dramatically since the advent of internal fixation. However, the differences in failure rates between stable and unstable intertrochanteric fracture patterns have recently been emphasized. The goal of management of any hip fractures in the elderly is to restore mobility safely, efficiently while minimizing the risk. Whilst reduction by closed manipulation and traction remains the gold standard, difficulty in achieving anatomic alignment with complex unstable fracture remain the obstacle during surgery. Open reduction in proximal femoral nail insertion to achieve good reduction, optimal positioning lag screws is an option for the proximal femoral nail procedure. This article reports a 79<strong>-</strong>year-old lady presented with pain over the left hip after slipped and fall. Upon examination, there was some ecchymosis on the left greater trochanteric region, tenderness, and inability to actively raise the left lower limb. Radiographic evaluation showed complex unstable intertrochanteric fracture of left femur. We treated this complex unstable fracture using proximal femoral nail with modified open reduction technique. Attempts at closed reduction were not possible by any manoeuvre of rotation necessitating open reduction. The approach for open reduction should expose only as much of the fracture zone as necessary to achieve reduction. Periosteum elevator, bone spike and bone hook can be used to obtain reduction. Good alignment and implant position were achieved under image intensifier guidance. In conclusion, if one encounters this fracture pattern in practice, do not spend time on repeated attempts for closed reduction. Draping the patient in situ, using percutaneous joystick or minimal open reduction is fairly adequate. Satisfactory reduction in complex unstable intertrochanteric fractures could be achieved using this simple technique.</p> Normughni F Mohammed harris Ahmad Shival Sasidaran Kunalan Fazir Mohamad Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2303 2303 COMMINUTED SUBTROCHANTERIC FEMUR FRACTURE WITH INTERTROCHANTERIC EXTENSION IN ABOVE KNEE AMPUTEE <p>Fractures around hip in the amputated limbs are rarely seen these days and countable numbers admitted in orthopaedic trauma wards. With the advent of prosthetics, an increasing number of amputees are still ambulant and functionally active. When hip fractures occur in this group of patients, surgical treatment aims to optimize mobility and restore function. An active Paralympic badminton athlete with history of traumatic above knee amputation presented with history of motor vehicle accident. He complained of right hip pain with clinical signs of tenderness, swelling, and limited range of motion. Plain radiograph shows right comminuted subtrochanteric femur fracture with intertrochanteric extension. The patient was treated by open reduction, dynamic condylar screw fixation augmented with screw fixation and cerclage wiring. Post operatively patient was advised on wheelchair ambulation with early rehabilitation session for range of motion and muscle strengthening exercises. By three months, fracture united and patient able to return to his Paralympic sport activities. Fewer studies shows that muscle atrophy could be another cause to increase risk of fracture over amputated limb even with minimal trauma. So, we would like to stress that better stability in terms of types of plate fixation and proper rehabilitations with the advent of prosthesis has shown promising outcomes in treating these types of fracture in above knee amputated limb. Comminuted subtrochanteric femur fracture with intertrochanteric extension in an above knee amputee poses a surgical challenge. Good surgical technique and choice of implant plays an important role in achieving good functional outcome.</p> Kesavan Ravindran Mohammed Harris Ahmed Shival Sasidaran Kunalan Fazir Mohamad Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2304 2304 FEMORAL NECK FRACTURES: THE BALANCING ACT BETWEEN FIXING OR REPLACING <p>Common consensus dictates that the best femoral head that a young patient can have been their own, native femoral head. Physiologic “age” is a somewhat a vague term that takes into account the general health and functional status of the patient. New data have shown that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF are able to preserve their own femoral head for a decade after the original insult. Variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant choice, and capsulotomy. Mrs R, a fifty-five-year-old lady presented with a history of fall at home. She complained of left hip pain and inability to weight bear. Clinically, there was pain overlying the anterior aspect of proximal thigh with limited range of motion of the left hip. Plain radiographs illustrated a left neck of femur fracture. The patient was subsequently treated operatively with a dynamic hip screw of the left hip augmented with a Pauwel screw into the postero-inferior aspect of the head. Posterior inferior comminution significantly affects torque to failure in vertically oriented femoral neck fracture. Post operatively, patient was able to partially weight bear with walking frame. Patient subsequently was walking without aid at 6 weeks and with no evidence of avascular aecrosis on plain radiographs. The author prefers anatomic reduction and subsequent stabilisation with a sliding hip screw and Pauwel screw. Attention to detail is crucial in obtaining anatomic reduction, which is the single, most important variable determining the outcome of these challenging injuries.</p> Shival T Mohammed Harris Ahmed Sasidaran Kunalan Fazir Mohamad Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2305 2305 INVAGINATED SKIN RELEASE OF DOCKING SITE UNDER WALANT; OBSTACLES DURING COVID-19 PANDEMIC <p>Soft-tissue invagination or soft tissue incarceration is a common complication during the late stage of bone transport. We report a case of soft tissue release under wide-awake local anesthesia no tourniquet (WALANT) where operating theater slot is limited in the era of Covid-19 pandemic. A 31-year-old man involved with an accident which resulted in open fracture of right tibia Grade IIIa with 9cm bone loss. Ilizarov external fixator and cortectomy for bone transport was performed to address bone and soft tissues defect. During the bone transport process, noted the transport segment was halted by a soft tissue invagination at distal third of the right leg. Patient underwent soft tissue release under WALANT amidst the pandemic using combination of 1% lidocaine, 1:100,000 epinephrine, and 10:1 8.4% sodium bicarbonate. The solution was infiltrated through field block at area of interest to a maximum safe dose of 40ml dilution. Either an H shape “French Door” release or square excision of skin tissue was performed. No further revision of docking site was performed until union and implant removal. Soft tissue release for skin invagination over the docking site is an effective way to eliminate soft tissue block in bone transport. Conventionally, is done under regional or general anesthesia. We attempted this procedure under WALANT which was previously done for hand and wrist surgeries to address the operating time issue during this pandemic. In conclusion, WALANT is a viable option for skin release and bone resurfacing as it achieved both adequate surgical release as well as patient tolerance with additional advantage of reducing hospital stay.</p> Hafiz MHM Zamri AR Saifudin O Norhaslinda B Ahmad AR Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2306 2306 MYSTERY OF ISOLATED GREATER TROCHANTER FRACTURES: IS THERE MORE THAN MEETS THE EYE? <p>Isolated greater trochanteric fractures are rare and often treated conservatively. With the newer imaging modalities, there is evidence that these fractures are often accompanied with extensions to the meta-diaphyseal region not seen on plain radiographs. An elderly lady presented with a history of fall. She complained of left hip pain and inability to weight bear. Clinically, there was point tenderness overlying Greater Trochanter and limited range of motion of left hip. Plain radiographs illustrated a Left avulsion greater trochanteric femur fracture. Subsequently, CT scan of the hip showed fracture line extending from the Greater Trochanter till lesser trochanter. The patient was treated with dynamic hip screw and tension band wiring of the greater trochanter. Post operatively, patient was fully weight bearing on day1. At 2months post-op patient was ambulating with normal gait and good hip function. Radiographically documented isolated greater trochanteric fractures have been thought to be uncommon. Because of their purported rarity, greater trochanteric fractures are hardly included conventional hip fracture classifications However, according Yunus et al, 31 out of 40 patients that seemingly had isolated greater trochanter fractures had incomplete inter-trochanteric extensions on MRI. Increasing incidence of occult fractures diagnosed on further imaging brings about our proposal that these fractures should be treated surgically like above. The procedure is short, cheap, safe and allows immediate weight bearing. The potential consequences of missing these occult fractures include fracture displacement, late weight bearing, longer immobilization. We recommend that patients with an isolated greater trochanter fracture on the plain radiographs should undergo CT/MRI examination and those with intertrochanteric extensions undergo surgery. The surgical methods of addressing isolated greater trochanter fractures merit further investigation</p> Shival T Mohammed Harris Sasidaran Kunalan Fazir Mohamad Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2307 2307 QUALITY OF LIFE & FUNCTIONAL OUTCOME OF OPEN TIBIAL FRACTURE MANAGED WITH ILIZAROV EXTERNAL FIXATOR AS DEFINITIVE MANAGEMENT <p>The Ilizarov method is a useful tool for the treatment of open tibial fracture. Many patients showed enormous resilience with this method of definitive fixation despite the devastating effects of their injuries. Our aim is to evaluate the value of IEF treatment for trauma patients with a focus on their quality of life as well as the functional outcome. A cross-sectional study was conducted across three years involving 109 patients with open tibial fracture who underwent early Ilizarov external fixation as definitive management. Their quality of life after treatment was measured with SF-36 health survey where else patient's functional and radiological outcomes were assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria. 88 (80.7%) of the participants had site of initial fracture over tibial shaft, 13 (11.9%) over distal tibia and 8 (7.3%) of the participants had fracture over proximal tibia. 87 (79.8%) of the participants had Gustillo IIIa tibia fracture and 22 (20.2%) had Gustillo IIIb fracture. Clinical outcome was excellent in 76 (69.7%) good in 26 (23.9%) fairs in 5 (4.6%) and poor in 2 (1.8%) of the participants. Bone results were excellent in 84 (77.1%) good in 15 (13.8%) fairs in 8(7.3%) and poor in 2 (1.8%) of the participants. 106 (97.2%) patients achieved bone union. The results of the SF-36 Health Survey showed a significant difference between the population norm and the mean of the study group in Physical Functioning and Role Limitation-Emotional Problem. Early application of the Ilizarov fixator constitutes an excellent management of open tibial fractures due to good functional and radiological results. The SF-36 Health Survey demonstrate that patients suffer mainly from physical and emotional sequel after these management nevertheless their general, mental, and social health is well preserved.</p> George Ezekiel Nazri Mohd Yusof Rohaman bin Tasarib Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2308 2308 ADVANCED TECHNIQUE OF BONE TRANSPORT TO SOLVE THE SEGMENTAL BONE DEFECT IN LONG BONE <p>Large segmental defect may occur in the long bone from various reasons including trauma, infection, and tumor. The critical sized bone defect of the long bone may be treated in several ways, including the use of autogenous iliac bone graft, vascularized fibular graft, and bone transport using Ilizarov external fixator. Induced membrane technique has shown a successful bone regeneration which needs a considerable amount of autogenous graft. But this technique requires a significant morbidity of donor site, and the time taken to incorporate the graft may be lengthy. Vascularized fibular graft is a technically demanding procedure, which needs a skillful vascular surgeon. Moreover, it often associates the high rate of stress fractures or nonunion until the complete healing. Bone transport using an external fixator has become a standard method to reconstruct e a large segmental defect of extremities. It has many advantages including the unlimited amount of bone regeneration, the capacity to correct the deformity, and the early weight bearing. Although distraction osteogenesis provides a highly satisfactory means of reconstructing segmental tibial defects, prolonged use of an external fixator is difficult for patients, and complications are almost inevitable, such as pin-tract infections, resulted deep infection, and joint contractures. To reduce the period of external fixation, hybrid bone transport techniques has been developed. Bone transport over the nail (BTON) reduces external fixation times because the fixator can be removed before the distraction callus has consolidated. However, it requires union of the docking site before the fixator is removed, regardless of the addition of bone graft or the use of compression osteosynthesis. Moreover, there is a risk of developing deep infection leading to failure of the treatment, which could result from the close contact between the nail and the pins and wires. The positioning of the external fixator pins or wires around an IM nail at the diaphysis is difficult, given the limited space available. BTOP (bone transport over the plate) is another hybrid technique, using a plate (BTLP) and external fixator. This new method is safe with low complication rate including the risk of re-infection. It may be used when the nail is not available in the pathologies of segmental bone defects. The indications may be the short proximal or distal segments in the long bone fractures, in which the nail fixation is not sufficient to stabilize or makes the additional deformity. Also, the segmental bone defect in upper extremities is another indication, as the nail is not easy to fix. Given that the time required for external fixation was significantly shorter, BTOP technique is a more attractive option than the BTON technique.</p> Chang-Wug Oh Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2276 2276 MANAGEMENT OF DISTAL HUMERUS FRACTURES WITH ILIZAROV <p><strong>Background: </strong>Distal humerus fractures either open or closed or intra-articular, full functional recovery is difficult to obtain. The treatment options are available: minimal internal fixation, open reduction-internal fixation, and external fixation.</p> <p><strong>Objective:</strong> To evaluate the functional outcome and union time in distal humerus fracture treated with Ilizarov.</p> <p><strong>Methodology:</strong> This prospective Qausi-experimental study was carried out from April 2016 to March 2019. Total 14 patients were included with a mean age of 40 years (range 30–55) with distal humerus fractures either closed and open with supra and intercondylar, were stabilized with an Ilizarov method. Functional outcome and bone union was assessed by ASAMI criteria. Patients were followed up to 15-18 months. SPSS-21.0 was used to calculate the descriptive statistics.</p> <p><strong>Results:</strong> According to Gustilo classification for open fractures, there were Grade IIIA 09(64.28%). According to AO classification for closed fractures, A type fractures were 3(21.42%), C type 2(14.28%). Based on ASAMI criteria for bone assessment; excellent results in 3(21.42%), good results in 7(50%) and fair results in 4(28.57%) and functional outcome was 5(35.71%) excellent, 8(57.14%) good and 2(14.28%) fair was obtained. Union was achieved in all 14 cases and Ilizarov was taken out in a mean period of 4.3 (3-6) months. This result was expected as an average time of union was 14.83.</p> <p><strong>Conclusion:</strong> Ilizarov is an effective method for the stabilization of distal humerus fractures and can be preferred an alternative treatment method because this method allows close reduction without extensive soft tissue damage and also permits early elbow movements for the comminuted intra-articular distal humerus fractures.</p> <p><strong>Keywords:</strong> Humerus fractures; Distal; Ilizarov external fixator</p> <p><strong>&nbsp;</strong></p> Asadullah Makhdoom Raheel Akbar Baloch Pir Abdul Latif Qureshi Khaleeque Ahmed Siddiqui Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2277 2277 DEFINITIVE TREATMENT FOR OPEN SUPRACONDYLAR FEMUR FRACTURE WITH ILIZAROV EXTERNAL FIXATOR: THE UNION OUTCOME <p><strong>Introduction: </strong>Supracondylar femur also part of distal femur. 10% of fracture occur at this region presented as a open fracture. The challenge of management in this open fracture, mainly regarding the severity of wound and the fracture comminution with intra-articular involvement.</p> <p><strong>Methods:</strong> Ilizarov circular external fixator was opted as a primary fixation for treatment open supracondylar femur fracture in Hospital Tuanku Jaafar, Seremban, Malaysia, from June 2018 till December 2019. Modified RUST scoring was calculated to interpret the union and fracture healing base on serial plain radiograph post operatively.</p> <p><strong>Results:</strong> 16 patients underwent primary fixation with Ilizarov circular external fixator. 9 patients showed union base on Modified RUST with minimum score of 11 and maximum score of 16 interpret as fracture healing but 7 patients was not. The fracture union and healing start achieved at 6 months to 12 months duration post operatively.</p> <p><strong>Discussion and Conclusion:</strong> Primary fixation with Ilizarov circular external fixator gave more stability to allow early ambulating and weight bearing. It can prevent recurrent deep infection, non-union and internal implant fixation failure. Studies used Modified RUST scoring system was found had sufficient to interpret the fracture healing. Ilizarov Circular external fixation was a good option for primary fixation in open Supracondylar femur fracture and Modified RUST in plain radiograph able to help to determine the fracture healing.</p> Norhaslinda Bahaudin Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2278 2278 MANAGEMENT OF DIABETIC FOOT ULCER (DFU) USING TIBIAL TRANSVERSE TECHNIQUE (TTT), BONE LENGTHENING; BANGLADESH EXPERIENCE <p>Diabetic foot ulcers (DFU) are typically chronic skin ulcers associated with deep tissue destruction around the foot and ankle region with varying degrees of lower extremity vasculopathy and neuropathy. DFU is associated with a high rate of morbidity, disability, mortality and psycho-social cost. We treated 38 cases of diabetic foot ulcers following Tibial Transverse Technique (TTT), Bone Lengthening. The TTT technique is based on Ilizarov's “law of tension-stress” for limb regeneration and functional reconstruction. The principle is that when appropriate tension is applied to living tissues, it promotes cell division and differentiation of adult stem cells like that in the fetal tissues development and lead to tissue regeneration. During and after TTT treatment, the patients reported immediate pain relief, a feeling of warmth in the diseased limb, and quantitative angiography confirmed the formation of rich neo-vascular networks in the diseased limb or ischemic areas. DO promotes capillary and vascular network regeneration and bone transport technique can significantly improve the microcirculation and soft tissue wound healing. In conclusion, TTT technique for DFU (Wagner III and above) have successfully conducted more than 38 cases. We performed TTT along with routine debridement and dressing change. TTT technique can significantly enhance diabetic ulcer healing, increase the limb salvage rate, and reduce the DFU recurrence rate.</p> Md. Mofakhkharul Bari A. M. Shayan R. Bari Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2279 2279 HOW GIMP SOFTWARE HELPS IN PREOPERATIVE DEFORMITY PLANNING <p>The GIMP is a free software available online for image/picture manipulation programme. GIMP has been modified by Dr Selvadurai to use for deformity planning. It is a very useful programme for those who are not routinely doing the deformity corrective procedure as no fees required to be paid compares to that paid software. It can draw the mechanical or anatomical axis line and measure the joint orientation angle. Furthermore, it can cut the image and rotate it at the CORA or ACA. All the step of the planning can be saved and exported to the .png or .jpeg files and copied to power point for presentation. The presentation will show how to use GIMP with the case example.</p> Norazira Yaacob Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2280 2280 CHIPPING TECHNIQUE FOR NON-UNIONS AND/OR DEFORMITY CORRECTION <p>My chipping technique was originally developed for treatment of non-unions. However, I have found that in many cases of non-unions with deformities, deformities have been corrected very well simultaneously when I apply chipping technique to treat non-unions. Therefore, I started to use this chipping technique to correct deformities without non-unions. Open or closed wedge osteotomy is widely used to correct angular deformities. Closed wedge osteotomy requires precise angular osteotomy and open wedge osteotomy requires bone graft. Using my chipping technique, any angular and/or rotational deformity can be corrected accurately without precise wedge osteotomy. Furthermore, bone healing is quick and sure, because the chipping technique was originally developed to treat non-unions. The chipping technique could be a better alternative to wedge osteotomy for deformity correction. Additionally, as lots of callus is formed at chipped site, the callus can be lengthened using Ilizarov technique in case of shortening deformities. Chipping and lengthening technique, which requires neither precise osteotomy nor bone grafting, can be a useful technique for any deformities including shortening.</p> Takashi Matsushita Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2281 2281 TIBIAL CONDYLAR VALGUS OSTEOTOMY (TCVO): SURGICAL TECHNIQUE AND CLINICAL RESULTS FOR KNEE OSTEOARTHRITIS WITH VARUS DEFORMITY <p>Tibial condylar valgus osteotomy (TCVO) is an intra-articular proximal tibial osteotomy developed in 1989 and has since been used for the treatment of knee osteoarthritis (OA) associated with genu varum. This article describes the surgical technique and clinical results of TCVO. TCVO can be used for all grades of varus knee OA in patients of any age. It is particularly relevant for patients in whom traditional high tibial osteotomy is contraindicated due to advanced OA, intra-articular deformity, and varus thrust during gait. The preoperative range of movement should be at least 90°. Preoperative screening showed varus-valgus instability due to an intra-articular deformity of the proximal tibia. Using intraoperative image intensification, a sagittally oriented “L”-shaped osteotomy is made from the medial to the tibial tuberosity to the centre of the tibial plateau between the medial and lateral tibial spines. The separation of the osteotomy using the lamina spreader is gradually increased using an image intensifier guidance until the articular surface of the lateral tibial plateau comes in contact with the articular surface of the lateral femoral condyle. Adequate correction is indicated by parallelism of the lateral tibial plateau and a line tangential to the distal convexity of the lateral femoral condyle on an anteroposterior (AP) image and the elimination of the valgus instability with the knee in extended position. A “T”-plate (locking or non-locking plate or circular external fixator) is used to fix the osteotomy in the corrected position. Synthetic or autologous bone grafts can be used. We used the Japanese Orthopaedic Association score to evaluate the patient’s function and also measured the %MA, medial plateau opening angle, medial plateau angle, and lateral plateau opening angle on an AP view of the long length roentgenogram of the lower limb (standing position). The JOA score, radiologically measured values, and instability of the knee joint remarkably improved. TCVO increases the contact area of the knee joint and therefore decreases the load pressure per unit area. Furthermore, intra-articular osteotomy stabilizes the knee joint by increasing the tension of the cruciate ligaments</p> <p>&nbsp;</p> Tsukasa Teramoto Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2282 2282 LENGTHENING OVER NAIL– HOW I DO IT <p>Bone Lengthening using an external fixator has become a standard method to treat LLD (Limb Length Discrepancy) due various causes including congenital or acquired such in trauma or infection of the extremities. Bone Lengthening has many advantages including the unlimited amount of bone regeneration, control distraction up to the desired length and the early weight bearing. Although distraction osteogenesis provides a highly satisfactory means of gaining bone length, prolonged use of an external fixator is always a challenge for patients and complications are almost inevitable, such as pin-tract infections, deep infection, and joint contractures. To reduce the period of external fixation, hybrid Bone Lengthening techniques has been developed. Bone Lengthening over the nail (BLON) reduces external fixation times because the fixator can be removed while the distraction callus is consolidating. However, there is a risk of developing deep infection leading to failure of the treatment, which could result from the close contact between the nail and the pins and wires. The positioning of the external fixator pins or wires around an IM nail at the diaphysis is difficult, given the limited space available. This short presentation will share how to perform BLON for such cases.</p> <p>&nbsp;</p> Basir Tawil Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2283 2283 MANAGING LOCAL ENVIRONMENT IN MANAGING OSTEOMYELITIS <p>Treatment of osteomyelitis includes improving the systemic and local factors that affect the body ability to fight infection and to repair the bone. Optimising the biological and mechanical environment are the 2 local factors that surgeon can perform to ensure the success of treatment. The ideal biological environment includes good blood supply, durable soft tissue coverage, and the absence of necrotic tissue and foreign material. The optimum mechanical environment includes stability of the bone, obliteration of dead space, barrier to the wound and continuous drainage from the wound. External fixators provide stability to the bone without communicating with the infected area. Vacuum assisted dressing provide barrier with the external environment and drainage of the excessive exudate. Dead space can be obliterated with antibiotic beads, acute shortening, bone transport or muscle flap. Flap is also effective in bringing blood supply to the affected bone and providing durable soft tissue coverage to the wound. The case examples elicit how debridement, vacuum dressing, external fixator, local antibiotics, Ilizarov bone transport and flaps are being used to treat osteomyelitis.</p> <p>&nbsp;</p> <p>Keyword: osteomyelitis, debridement, flaps, external fixator, local antibiotic</p> nazri Mohd Yusof Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2284 2284 ILIZAROV EXTERNAL FIXATOR: TREATMENT OF NON-UNION TIBIA BY ACCORDION MANEUVER <p>Background: Accordion is a mechanical technique in Ilizarov in which alternative compression and distraction induce neo-angiogenesis and activates osteoblasts for osteo-genesis in non-union site. Objective: To assess the outcome of accordion Maneuver with Ilizarov frame in non-union of tibia. Methods:&nbsp;All patients of aseptic non-union that underwent AM at Department of Orthopaedic Surgery &amp; traumatology, Liaquat University of Medical &amp; Health Sciences, Jamshoro Sindh Pakistan during 2016 to 2020 were included. A standard protocol of cycles in which weekly compression or distraction was followed to enhance the osteoblastic activity. Radiographs were done after every 4-weeks to assess the progress of callus formation.&nbsp; Results:&nbsp;Twenty-two patients were selected, there were 17 males and 5 females. The mean age was 35.4years (range 17-54 years).&nbsp; Out of 22, interlocking intramedullary nail was done in 10 patients, uniplanar external fixation in 3 patients, DCP in 1 patient and 8 were managed non-operatively by Cast by surgeon or potter. Three cycles were repeated in 13 patients, 4 cycles in 6 patients and cycles in 3 patients. The mean union time was 6&nbsp;±&nbsp;1.28 months. Conclusions:&nbsp;AM is a simple closed technique safer than open&nbsp;surgical technique with bone graft. There is no blood loss, risk of infection, donor site pain and also financial burden and psychosocial trauma. However, a selection of patient is important for desired results.</p> <p>&nbsp;</p> <p>Keywords: Nonunion Tibia, Accordion Maneuver, Ilizarov</p> Asadullah Makhdoom Raheel Akbar Baloch Jehanzab Hassan Muhammad Faraz jokhio Tahir Ahmed Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2285 2285 KNEE ARTHRODESIS USING ILIZAROV: WHEN TO USE? <p>The Illizarov method offers a comprehensive approach for dealing with chronic knee infection, traumatic bone loss and knee joint destruction by using knee compression arthrodesis with or without simultaneous bone lengthening with dynamic circular external fixation. It is a salvage procedure from limb amputation with correction indications and choice of patients as this is final and irreversible procedure in order to have good outcome.</p> Nazari Ahmad Tarmuzi Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2286 2286 TRIFOCAL BONE TRANSPORT <p>Bone Transport using Ilizarov External Fixator has been widely used as a method to reconstruct large segmental defect of extremities in various situation including trauma, infection, and tumour. Bone Transport has many advantages including the unlimited amount of bone regeneration, early physiotherapy and weight bearing. Although distraction osteogenesis provides a highly satisfactory means of reconstructing segmental bone defects, prolonged use of Ilizarov External Fixator will decrease the patient’s compliance and inviting many complications such as pin-tract infections, hypoplastic bone formation, muscle atrophy and joint contractures. To reduce the period of external fixation, Trifocal Bone Transport technique is one of the options to overcome these challenges.&nbsp; Trifocal Bone Transport reduces external fixation times as it offers faster docking contact, early docking union and faster as well as better bone consolidation at each segment of distraction. These advantages overweight the disadvantages such as more complex frame assembly, additional osteotomy site and additional operating time.</p> <p>&nbsp;</p> Basir Tawil Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2287 2287 HOW TO MANAGE THE DEFORMITY AND ULCER ON FOOT & ANKLE IN SPINAL BIFIDA <p>Objective: To analyse the characteristics of foot and ankle deformity with ulceration in patients with spina bifida to conclude experiences on management with improved Ilizarov method in one stage. Methods: 77 cases suffering foot and ankle deformity with ulceration of spina bifida were included from January2008 to June 2019, in which 30 male and 47 female, aged 6–46 years with an average age of 22.86 years. There were 10 cases on left, 14 on right and 53 on both. The improved Ilizarov method combined soft tissue surgery, bone osteotomy and Ilizarov technique in one stage, by which the ulcer was dressed aseptically and avoid weight bearing preoperatively, no special treatment, no debridement, no flap coverage and no bacterial culture. Antibiotics were given for 3 days routinely, and the dressing was removed 5 days later. If there was exudation, gauze could be used to wrap continually, if there was no swelling and exudation, no need further more caring. General appearance and radiological image of ulcer and deformity were observed during the period of evaluation and treatment, surgical method and complications, foot &amp; ankle function and overall function were evaluated using AOFAS scoring system and special table designed by authors. Results: 77 cases were followed up for 6–132 months with an average of 50.5 months. Achilles tendon subcutaneous lengthening was performed in 2 cases, posterior tibial tendon and Achilles tendon simultaneous released for 31cases, subtalar joint arthrodesis 25 cases, calcaneus osteotomy 5 cases, triple osteotomy 28 cases, ankle arthrodesis 19 cases, internal rotation osteotomy of tibia was performed in 1 case and 1 case in external rotation osteotomy. There were 67 cases using Ilizarov fixators and 10 cases using Hybrid fixators for immobilization and correction. Stable feet were obtained, and ulcers healed simultaneously when all deformities of foot and ankle had been corrected. The healing time of ulcer was average 26.5 days ranging 7–36 days, and there was no infection or delayed healing occurred in any case. Ankle ankylosis in 25 cases, 3 cases of pin tract infection, 2 wires were broken. The AOFAS score significantly increased from 70.5preoperative to 81.6postoperative; based special table evaluating, Excellent 28 cases, Good 42 cases, Fair7 cases. Conclusion: The patients with foot &amp; ankle deformity and ulceration suffered from spinal bifida can be treated by improved Ilizarov method in one stage, and the results are satisfactory with short treatment period and decreased complications.</p> Jiancheng Zang Sihe Qin Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2288 2288 OPINION FOR RECONSTRUCTION OF THE HEEL PAD <p>The heel pad plays an important role in supporting upright stance and in normal gait. The common causes of heel defect include trauma, infection, vascular disease, and tumour extirpation. The relative paucity of expendable surrounding tissues and the special functional requirements of the heel pad, make the reconstruction very challenging. A few locoregional flaps have been described for small to moderate-sized defect. Large-sized defect commonly necessitates the use of free flaps. In terms of overall function, the medial plantar artery flap gives the best result but is limited by its size.</p> Akmal Azim Ahmad Alawi Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2289 2289 VARIATION OF GASTROCNEMIUS FLAP AND THEIR APPLICATIONS <p>In Hospital Tengku Ampuan Afzan, Kuantan a total of 145 cases referred for lower limb reconstruction in 4 years duration and 22 cases the option of reconstruction is gastrocnemius flap. Gastrocnemius Flap is useful flap in lower limb reconstruction. It is reliable, relatively easy to raise and can be used by non-specialized reconstructive surgeon. The flap main application is for the upper part of the leg and knee region. The flap variations include either the use of medial or lateral head. Its component variations include muscle, musculocutaneous and inclusion of part of the tendon. All have its own advantages and useful in complex defect of the upper part of the leg and knee region. Complex wound, exposed implant, revision surgery and infected wound are among the indications for the usage of gastrocnemius flap. In conclusion gastrocnemius flap is the armamentarium flap in lower limb reconstruction. Its provide well vascularized coverage and with musculocutaneous variations it can be raised as large flap and avoid more complex reconstructive procedure.</p> Muhammad Firdaus Abas Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2290 2290 HOLISTIC REHABILITATION AFTER POLYTRAUMA; INTERDISCIPLINAY INTERVENTION TO ENHANCE PATIENT ENABLEMENT <p>Rehabilitation is the process of development of a person to his or her fullest physical, psychological, social, educational, and vocational potential, by eliminating or compensating for any anatomic impairment, activity limitation, or environmental barrier. In contrast to classic medical therapeutics, which emphasize diagnosis and focused treatment directed against the pathologic process, rehabilitation directs treatment against the pathologic process but also applies multiple simultaneous interventions addressing both the cause and secondary effects of injury and illness thru biopsychosocial model. Holistic Rehabilitation includes assessment of the individual’s personal capacities, role performance, and life aspirations.&nbsp; In other words, rehabilitation is the process of transforming a person with functional limitations to a person with “maximal ability” through the application of medical treatment, therapy, and adaptive equipment.</p> Nor Shahizan Mohd Redzuan Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2291 2291 ORTHOSIS USAGE IN ORTHOPAEDIC TRAUMA COMPLICATIONS <p>Orthoses and sometimes prostheses are an important consideration after the extensive injuries suffered in major trauma. An orthosis by definition is an appliance that provides support, protection and affords correction of deformity of a body part. In major trauma appropriate orthotic prescription in early till subacute phase of injury prevents deformities and aids tremendously in functional recovery. Prostheses replace the function a lost limb or appendage when amputations become a choice of management. Orthotic and prosthetic prescription can play a major role in trauma rehabilitation to improve quality of life.</p> Salmah Anim Abu Hassan Copyright (c) 2021 INTERNATIONAL JOURNAL OF ALLIED HEALTH SCIENCES 2021-09-14 2021-09-14 5 4 2292 2292