Segmental endoprosthesis replacement in a resource-constrained setting.

PURPOSE: Indications for the use of endoprosthesis have continued to expand over the years, especially as an alternative to ablative surgery. This mode of treatment which was initially limited to orthopaedic oncology is now being applied in complex trauma with significant bone loss and end-stage arthroplasty. However, use of endoprosthesis in a resource-constrained setting such as sub-Saharan Africa is limited by various factors. These factors include high cost of endoprosthesis, restricted availability of appropriate equipment and the requisite trained specialists in the field. METHODS: Twelve patients who had segmental endoprosthetic replacement for various aetiologies were studied in this case series. Resection lengths, complications and functional outcomes were noted. RESULTS: The resection length varied between 12 and 27 cm. Using the Henderson classification system, one patient (8.3%) had a Type 1A complication, one had a Type 3A complication (8.3%), and two patients had Type 4A complications (16.6%). Functional outcomes were graded using the MusculoSkeletal Tumour Society scoring system, and scores were good to excellent in ten patients, moderate in one and poor in one patient. CONCLUSION: Early results indicate fair outcomes; however, factors limiting the use of endoprosthesis still persist. These include high cost of endoprosthesis, restricted availability of appropriate equipment and the requisite trained specialists in the field.

Endoprosthetic replacement of distal femoral tumors in Nigeria: A case series.

In this observational study, three consecutive patients who were treated for distal femur tumours using endoprosthetic replacement between June 2013 and June 2014 were studied. The patients were within the ages of 28-47 years at the time of surgery. All three patients had modular endoprosthesis fixation and were evaluated using the Musculoskeletal Tumour Society (MSTS) Scoring System. Numerical values from 0 to 5 points were assigned for each of the following 6 categories: pain, function, emotional acceptance, use of supports, walking ability and gait. These values were added and the functional score was presented as a percentage of the maximum possible score. The results for each patient were graded according to the following scale: Excellent - 75-100%; good - 70-74%; moderate - 60-69%; fair - 50-59% and poor - <50%. Of the 3 patients evaluated, 2 had a diagnosis of Giant Cell Tumour (GCT) of the distal femur; the third patient was diagnosed to have plasmacytoma. All underwent wide local resection with modular endoprosthetic distal femur reconstruction. The MSTS functional scores calculated were 70%, 78%, and 52% respectively. Complications noted included wound dehiscence in two patients and thrombosis of the Pulmonary artery needing an arterial embolectomy in one of these two patients. The same patient also had a post-operative loss of motor and sensory function below the level of the ankle.

Perioperative considerations in orthopaedic patients with diabetes mellitus: a review.

Patients with diabetes mellitus are predisposed to a host of orthopaedic problems which may require surgery and many patients with orthopaedic conditions may have unrecognised hyperglycaemia presenting for the first time at surgery. This group of patients are also prone to adverse surgical outcomes like post-operative infections and poor wound healing. The control of hyperglycaemia in orthopaedic patients with diabetes mellitus is the key in optimising surgical outcome in these patients. Peri-operative insulin is the main antihyperglycaemic agent of use. The risk of hypoglycaemia with tighter peri-operative glucose control outweighs its potential benefits. Blood glucose control with insulin infusion is better than sliding scale insulin. Control of infections and promotion of wound healing are necessary adjuncts in the management to optimise surgical outcome.

Deep calf cavernous haemangioma in a 10 year- old girl: a case report.

Haemangiomas are abnormal proliferation of blood vessels in any vascularised tissue. They can be capillary or cavernous varieties. Cavernous are either of cutaneous or deep types. Cavernous when compared with the capillary haemangioma is rare. Rarer still is the deep type of cavernous haemangioma. This is a report of a 10 year old Nigerian girl who presented with a right posterior leg swelling of 8 year duration, size initially was that of a peanut but increased to fill the entire calf region causing pain to the patient as well as cosmetic and anxiety concern to the parents. No preceding history of trauma, no associated systematic symptoms. She had exploratory laparatomy at 1 year of age at a private hospital for an abdominal mass which was excised. Pre-operative plain radiograph, Magnetic Resonance Imaging(MRI), Abdominopelvic ultrasound scan (USS) were done, fine needle aspiration cytology (FNAC) though done was not helpful. Histo-pathology result of excised leg mass confirmed diagnosis; there was a free margin of excision. Post-operatively, clinical improvement was marked.

A review of obesity and orthopaedic surgery: the critical issues.

Obesity is a growing concern in the health community because of the morbidities associated with it. There is a higher occurrence of many orthopaedic conditions among obese individuals than their non-obese counter parts. Obesity also worsens the progression of many of these orthopaedic conditions. Studies have shown that obesity may have negative impact on bone metabolism and may be implicated in the pathophysiology of some orthopaedic conditions like osteoporosis, fractures, osteoarthritis and many soft tissue ailments by both reduction in bone mass and elaboration of proinflammatory cytokines. These contribute to preponderance of musculoskeletal co-morbidities among obese patients. Critical peri-operative issues which include increased cardiopulmonary risks, issues of special equipment, instrumentation, surgical approach, patients' positioning and adjustments in medication should be acknowledged and meticulously addressed in operative management of orthopaedic conditions in obese patients. Surgeries in obese patients are fraught with operative challenges and post-operative complications than in the non-obese and a good knowledge of the critical issues in surgical management of obese patients is necessary to facilitate decision making as well as rendering of effective and efficient orthopaedic care.

Surgical consideration for benign bone tumors.

BACKGROUND: The surgical management of symptomatic benign bone tumor has been described in various manners in medical literature. However, there are few published reports on the presentation and surgical management of benign bone tumors in black African patients. OBJECTIVES: To determine the pattern of presentation of benign bone tumors and evaluate the common indications for surgery in a Nigerian Orthopedic Center. MATERIALS AND METHODS: This is a prospective study of 67 patients, surgically treated for benign bone tumors, over a three-year period, at the National Orthopedic Hospital, Lagos, Nigeria. RESULTS: The common histological types include, osteochondroma, giant cell tumor, and the simple bone cyst. These tumors have varying anatomic locations, but are more commonly located around the knee joint. In this series, most of the patients have presented with an active or aggressive stage of the disease. The most common indication for surgery is painful swelling; other indications include a pathological fracture, restricted range of movement, and peripheral nerve compression. The surgical procedures performed are simple excision, curettage, and stabilization; and 1-stage and 2-stage wide resection with reconstruction. Patients with significant bone defects have autologous bone grafting or methylmethacrylate cement application. Further stabilization is achieved with intramedullary or compression plate and screw fixation. Amputation has only been necessary in one patient with a huge aneurysmal bone cyst. At the average follow-up period of 28.6 months, five patients showed recurrence. All were with a histological diagnosis of giant cell tumor. CONCLUSIONS: The mode of presentation of benign bone tumors in this group of black African patients is heterogenous, demanding various surgical options. Limb sparing is a largely feasible option, but the recurrence rate is particularly higher for giant cell tumors. Increase in the number of patients presenting with giant cell tumors raises the possibility of an increase in the incidence of this condition in the black African population. Larger multicenter studies in the black African population may shed more light on the actual incidence of giant cell tumors and other bone tumors in this group of patients.

Multicentre study of bone tumours.

BACKGROUND: Bone tumours are associated with high morbidity and mortality, especially in Lagos where late presentation, lack of diagnostic and therapeutic facilities as well as cultural and religious beliefs/practices constitute a formidable challenge to appropriate management. OBJECTIVE: To study the clinico-pathologic pattern of primary bone tumours in Lagos. METHODS: A 2.5 decade retrospective review of cases of primary bone tumours at National Orthopaedic Hospital, Lagos (NOH), Lagos University Teaching Hospital (LUTH), and Havana Specialist Hospital (HSH) was done. Data such as age, gender, tumour type were extracted from the medical records and analysed. RESULTS: Six hundred and ninety-eight (698) cases were reviewed. 364 cases were from NOH, 242 from LUTH and 92 from HSH. There were 10 cases in 1981, 13 in 1985, 19 in 1990, 30 in 1995, 38 in 2000 and 46 in 2005. The age range of cases was 6 to 85 years with a mean of 25.8 years and peak frequency in the 11-20 year age group. 423 patients (60.6%) were males and 275(39.4%) were females giving a male to female ratio of 1.5: 1. Three hundred and fifty-six (51.0%) were of benign while 342 (49.0%) were malignant. The commonest types were osteosarcoma 197 cases (28.2%), osteochondroma 106 cases (15.2%) and osteoclastoma 78 cases (11.2%) CONCLUSION: Primary bone tumours presenting to hospitals in Lagos are on the rise. They are common amongst males and teenagers. Majority are benign and comprise osteochondroma, osteosarcoma, osteoclastoma, aneurysmal bone cysts and chondrosarcoma.

Clinico-pathologic patterns of extremity liposarcoma.

BACKGROUND: Liposarcoma is a tumour derived from primitive cells that undergo adipose differentiation. OBJECTIVE: To describe the clinico-pathological pattern of extremity liposarcoma in Lagos, Nigeria. METHODS: This is a descriptive study of patients with histologically established liposarcoma affecting the extremities seen at the Oncology unit of the National Orthopaedic Hospital, Lagos Nigeria. Demographic and clinical data ( including age, gender, presenting complaints anatomic location of lesions ), histologic type, clinical stage and treatment outcome were collected using a prepared proforma and analysed. RESULTS: Liposarcoma accounted for 6 [27.3%] of 22 cases of soft tissue sarcomas seen within the study period. All 6 were males with a M:F of 6:0. The age range was 36- 59 years. Lesions were mostly located in the thigh 5/6 (83.3%). The most common histologic type was myxoid seen in 3/6 [50%]. All presented at stage T2bNoMo. Five (83.3%) had limb salvage surgery with adjuvant radiotherapy while one had ablative surgery. Survival and recurrent rates could not be determined as all patients were lost to follow-up soon after surgery. CONCLUSION: Liposarcoma is the commonest extremity soft tissue sarcoma seen in our centre, the myxoid type being the commonest histologic subtype.

Challenges in the diagnosis and management of musculoskeletal tumours in Nigeria.

The management of musculoskeletal tumours is important because of the high mortality rates associated with the available treatment modalities. A 5-year prospective study of bone and soft-tissue tumours is presented, along with the difficulties encountered in diagnosis and treatment. There were 71 patients (male:female ratio of 1.7:1, age range 5-85 years, mean age 32 years) with an average duration of 24.7 weeks (range 1 day to 34 years) before presentation. No patient had computed tomography (CT) scanning or magnetic resonance imaging (MRI) due to financial constraints, 95% had biopsies and X-rays, 15% could afford chemotherapy/ror chemotherapy is a sad consequence. 50% agreed to amputation. In the soft-tissue sarcoma group, only one of three patients could pay for limb-sparing surgery. In the benign group, 65% had limb-sparing surgeries and 15% had amputation. Fifty percent (50%) of patients were lost to follow up within 3 months and 39% of the malignant group died within the same period. Musculoskeletal tumours are a reality in our environment and a significant portion of our population have financial limitations. Ignorance and cultural beliefs promote late presentation to our hospitals, which are poorly equipped to give optimal care, despite the presence of trained personnel.

Concerns, attitudes, and practices of orthopaedic surgeons towards management of patients with HIV/AIDS in Nigeria.

The increasing number of people living with HIV/AIDS is causing concern among surgeons over risk of occupationally acquired HIV infection. This may influence their attitude to such patients. The purpose of this study was to develop a cross-sectional survey of orthopaedic surgeons to assess their concerns, attitudes, and practices towards management of HIV-positive patients in Nigeria. All respondents were males, 55 (73.3%) of them indicated concern over the risk of occupational acquisition of HIV infection and 37 (49.3%) had examined or operated on at least one HIV/AIDS patient. Sixty (79.9%) were willing to be tested for HIV and 51 (67.9%) were previously tested. Fifty-seven (75.9%) would order preoperative HIV screening of high risk patients, and 67 (89.3%) would operate on HIV-positive patients. Most orthopaedic surgeons in Nigeria would operate on HIV-positive patients.

Indications for ablative surgery in extremity musculoskeletal tumours.

BACKGROUND: Surgical options for treatment of extremity musculoskeletal tumours include excision [limb sparing] surgery or amputation [limb ablation]. Ablative surgery is for advanced extremity musculoskeletal tumours when limb salvage surgery is not feasible. OBJECTIVE: To determine the indications for ablative surgery in extremity musculoskeletal tumours in our centre. METHOD: This is a 6 year prospective study of patients presenting with extremity musculoskeletal tumours at National Orthopaedic Hospital Lagos. Data such as age, gender, presenting complaints, anatomic location of the tumour, clinical stage, type of ablative surgery and adjuvant treatment offered, histologic type of tumour, and treatment outcome were documented. RESULTS: Nineteen patients had ablative surgery as a mode of treatment. 11 were male while 8 were female with a M:F of 1.3:1. The age range was 3 - 69 years. Seven patients [6 males and 1 female] refused ablative surgery and voluntarily discontinued treatment. Most tumours were located in the lower limb and all patients that had ablative treatment presented with stage 3 or 4 disease. Osteogenic sarcoma was the most common diagnosis, accounting for 4 cases [21.1%]. Six patients [31.6%] with non-malignant tumours had ablative surgery due to either late presentation or inaccurate preoperative diagnosis. Trans-femoral amputation was the most common level of amputation and this was done in 9 patients [47.4%]. Adjuvant chemotherapy was prescribed for all patients. The recurrence and survival rates could not be determined for each tumour as the patients were lost to follow-up soon after surgery with average post operative follow up of 5.5 months. CONCLUSION: Late presentation with locally advanced disease remains the dominant indication for ablative surgery in extremity musculoskeletal tumours.

Bone cement in the management of cystic tumour defects of bone at National Orthopaedic Hospital, Igbobi, Lagos.

BACKGROUND: Cystic bony defects are characteristics of bone tumours especially benign ones e.g. Giant cell tumours of bone [GCT] and some metastatic tumours to bone. These patients present late with significant cystic cavities at a time the cost and availability of prosthetic implants to replace these defects sometimes precludes resection. The objective of this study is to evaluate the outcome of filling these defects with bone cement augmented with plate and screw for stability. METHOD: A seven year prospective study was carried out in patients presenting with large cystic bony defects secondary to bone tumours at the oncology unit of the National Orthopaedic Hospital, Igbobi, Lagos. Data such as age, sex, anatomic location of lesions, histological type of tumours, x-ray findings, operation performed with the number of packets of bone cement used to fill the resultant bony defects were retrieved from prepared proforma. The average follow-up was 36 months. RESULT: The proximal tibia and distal femur accounted for 42.9% and 28.6% respectively of the 14 patients studied. Giant cell tumour was the most common histological diagnosis 78.6%. Bone cement was effective in meeting the local requirements of limb salvage, early functional recovery and as a temporising measure until the patients can avail themselves of better options. The complication encountered was that of anaphylactic reaction in 2 scrub nurses. CONCLUSION: Bone cement augmented with appropriate implants has proven valuable as a stop gap in filling large cystic bony defects resulting from tumours.

Pattern of osteochondromas in Lagos, Nigeria.

Osteochondromas are the most common benign tumours of bone. It is a problem of rapidly growing skeleton. Most of them are asymptomatic. The most common reason for presentation being perception of the lesion as a cosmetic blemish. This study aims to study the epidemiology of osteochondromas at National Orthopaedic Hospital, Igbobi (NOHI), Lagos, Nigeria. This is a five year prospective study of osteochondromas that presented at NOHI, Lagos, Nigeria. NOHI is the largest orthopaedic reference centre in Nigeria. This study was necessitated by the paucity of epidemiological data on the subject in Nigeria and the sudden increase in the number of cases presenting to us. Sixty eight patients with histologically established osteochondromas were studied. Clear majority (42) were males. Forty two patients (61.8%) were aged 20 years or less. An overwhelming majority were pedunculated (88.2%) and solitary (97.1%). The commonest reason for presentation and request for treatment by patients was the lesion being a cosmetic blemish (85.3%). They all had excision and 2 patients (2.9%) had recurrence with malignant transformation. The study showed that osteochondromas were preponderant in Nigerian males in the second decade of life. Excision was the treatment of choice.

Day-case surgery for inguinal hernia: a multi-specialist private hospital experience in Nigeria.

BACKGROUND: The growing popularity of day-case surgery derives mainly from its twin benefits of convenience and cost-effectiveness. It is particularly useful in treating inguinal hernia which remains one of the most common presenting surgical problems. OBJECTIVE: To evaluate the results of inguinal herniotomy or herniorrhaphy done as a day-case. METHODS: A cross-sectional study of 72 cases of inguinal hernia treated by day-case herniotomy or herniorrhaphy at Havana Specialist Hospital, Lagos, Nigeria between July 2002 and June 2004. Post-operative follow up ranged from 2 to 4 years. Patients with concurrent systemic illness that needed admission as well as those who preferred admission were excluded. Data including age, gender, hernia characteristics, type of anaesthesia, complications and outcomes were collected and analysed. RESULTS: A total of 72 cases were studied. Only 4 were females, the remaining 68 were males. Ages 6 months to 60 years were affected with a mean age of 26.7 years and a peak incidence in the 21-30 years age group. The commonest complication was pain felt post-operatively by 62.5% of the study population. However, wound infection (seen in 11.2%) was the most significant complication. Other complications were wound and scrotal haematoma (8.3%), hemia recurrence (1.4%) and hypertrophic scar (1.4%). No mortality was recorded. CONCLUSION: The study showed that post-operative pain is the commonest complication of day-case inguinal hemiotomy and herniorrhaphy. Wound infection was however the most common significant complication. The overall outcome was good.

Locked intramedullary nailing for the treatment of femoral shaft fractures: experience and result in 19 cases.

BACKGROUND: Fractures in the proximal or distal third of the femoral shaft or those with severe comminution are known to be less suitable for intramedullary nailing with Kuntscher nail. With the introduction of interlocking intramedullary nailing the problems of rotational malalignment and shortening that accompany such fractures are now less common. At the National Orthopaedic Hospital Igbobi, Interlocking Intramedullary Nailing was introduced as a form of surgical treatment for fractures of the femur, our initial experience in this type of intramedullary nailing form the basis of this report. METHOD: This is a retrospective study of all cases of fractured femur that were treated with locked intramedullary nailing between March 2002 and September 2003. RESULTS: During a 19-month period, 19 patients with 19 fractures were treated for fracture of the femoral shaft with locked intramedullary nailing using the Russell-Taylor (18 fractures) and Grosse-Kempf (1 fracture) nails. Thirteen fractures (68.5%) had comminution of the Winquist-Hansen type III and IV 12 of which were statically locked. There were three intra-operative technical problems including the case of a subtrochanteric fracture, where the nail missed the medullary canal of the proximal segment. There were 2 cases of superficial wound infection, which responded to local wound care and antibiotics. Although limb length discrepancy and rotational mal-alignment were not assessed routinely during the follow-up of patients, no symptomatic malrotation was recorded. Sixteen out of the 19 patients were available for follow-up for an average period of 11 months. All these cases progressed to union, without the need for dynamization in statically locked fixations. CONCLUSION: In spite of the initial problems encountered with this relatively new procedure in our centre, we were able to achieve a reasonably good result in addition to supporting the notion that dynamization of a statically locked nail is not always necessary for healing of fractures.

Pathological study of bone tumours at the National Orthopaedic Hospital, Lagos, Nigeria.

BACKGROUND: Although primary bone tumours are relatively uncommon, they constitute the most important tumours in patients under 20 years. OBJECTIVE: To update the literature on the relative frequency and clinico-pathologic characteristics of bone tumours in this environment. MATERIALS AND METHODS: The clinical and histopathological records of patients presenting with diagnosis of bone tumours between 1999 and 2004 and managed at the National Orthopaedic Hospital, Igbobi, (NOHI) Lagos, Nigeria were review and where necessary, new ones were prepared from the paraffin blocks and stained with routine haematoxylin and eosin stain. The clinical data such as the age, sex, presenting signs and symptoms, site distribution of lesions, radiological finding as well as the record of other investigation and management were extracted from the clinical case notes of patients. RESULTS: Seventy-seven cases were recorded; 61 (79.2%) benign and 16 (15.6%) malignant. The male:female ratio for all tumours was 2:1. The commonest benign bone tumours were osteochondroma and giant cell tumour accounting for 52 (67%) of all cases with > 60% in males. The most common primary malignant bone tumour was osteosarcoma, all in males. The peak incidence was in the second and third decades and commonest sites were the distal femur and proximal tibia. Four (5.2%) cases of metastatic bone tumours located commonly in the proximal femur and humerus were also recorded. CONCLUSION: Osteochondroma and giant cell tumours are the commonest benign tumours while osteosarcoma is the most common primary bone tumour all occurring in the first two decades of life. The age and sex distribution and morphology are similar to those already established in the African and international literature.

Management of Giant Cell Tumour : a Nigerian Experience

Giant cell tumours (GCT) are the commonest bone tumours worldwide. It is rarely malignant but when it does it progresses to fibrosarcoma with high mortality. Otherwise it causes poor cosmesis; disability and pathological fractures. A total of 19 cases of histologically established Giant cell tumour of the bone were reviewed prospectively in a 5 year study. 14 cases were benign; 4 malignant and one was a malignant transformation. Lesions around the knee accounted for 42.2of the cases; but the radius was the commonest single bone affected with 26.3. Eleven patients had curettage; five of them had autogenous bone grafting while the remaining six had bone grafting and plate augmentation. One patient had fore-quarter amputation while seven had tumour resection. There was no recurrence recorded among those that had currretage and autogenous bone grafting. 33of those that had curettage and bone cementing as well as 16.6of those that had resection presented with recurrence. One patient died within 3 months of surgery due to metastasis to the lungs; liver and spleen. Mean follow up was 9.2 months (range of 2 to 60 months). With early presentation; curretage and bone grafting is often effective; late presentation however has an increased risk of recurrence due to soft tissue involvement; dearth of investigative tools and financial constraints