Assessment of Treatment Outcomes in the Management of Club foot using the Ponseti Technique: A cross-sectional study.

BACKGROUND: The Ponseti technique remains the preferred method for club foot treatment. Although measures of treatment outcomes have been well documented, there is no consensus on the determinants of those outcomes. This study aims to assess treatment outcomes and the factors which can influence treatment outcomes. MATERIALS AND METHODS: This is a cross-sectional study. A total of 472 children representing 748 feet in total were recruited. Patient characteristics such as age at presentation, gender, tenotomy, walking with or without deformity, parental educational status and occupation were documented. Outcomes of care were assessed using indictors such as parents' satisfaction with the outcome of treatment and the patients' ambulation without deformity. The relationships between the determinant factors and these outcomes were explored using multivariable binary logistic regression. RESULTS: Most of the children (69.1%) were aged below 2 years. Brace compliance was very high (89.9%). The pre-treatment average Pirani scores were 3.9 ± 1.8 and 4.3 ± 1.8 for the right and left feet, respectively. Majority (88.3%) of the children achieved ambulation without deformity, whereas most (87%) of the parents were satisfied with the treatment outcomes. In total, parental satisfaction with child's treatment outcomes was lower in parents who were not formally educated odds ratio (OR) = 0.19 (95% confidence interval [CI] 0.08-0.43), but parental satisfaction was lower if the child had higher Pirani score OR = 0.77 (95% CI 0.62-0.96). Children who had more casts applied to the affected foot were more likely to walk without deformity OR = 1.24 (95% CI 1.01-1.52). CONCLUSIONS: This study revealed that treatment outcomes in children with club foot can be determined by some sociodemographic and treatment-related factors.

Monolateral external fixation versus internal fixation of Gustilo IIIB open tibial fractures: a multicenter comparative study.

PURPOSE: Gustilo IIIB open tibial fractures are associated with significant risks of complications particularly nonunion and fracture-related infections (FRI) due to the severity of the injuries. The commonly adopted viewpoint is that a Gustilo IIIB open tibial fracture is a relative contraindication for internal fixation. However, this study aims to assess the veracity of this viewpoint. The objective of this study was to evaluate the impact of the definitive fixation technique on fracture nonunion and FRI rates in Gustilo IIIB open tibial fractures. In this study, we compared the rates of nonunion and FRI rates in grade IIIB open tibial fractures managed definitively with either mono-lateral external fixation or internal fixation. METHODS: The study was a multicenter retrospective comparative study undertaken in seven Nigerian tertiary hospitals. Following ethical approval, medical records of patients diagnosed with Gustilo IIIB open tibial fractures (between 2019 and 2021) were retrieved, patients who had a minimum of nine months of follow-up period and were found eligible had their relevant data entered into an online data collection form. Data obtained was analysed with SPSS version 23, and chi-square test was used to determine the statistical significance of differences observed between the two groups with regard to nonunion and FRI rates. P values less than 0.05 were considered statistically significant. RESULTS: Out of a total of 47 eligible patients, 25 patients were managed definitively with mono-lateral external fixation whilst 22 patients were managed with internal fixation. Five of the 25 patients (20%) managed with external fixation had nonunion whilst two cases of nonunion were recorded amongst the 22 patients (9.1%) treated with internal fixation. The difference between the two techniques with regard to nonunion rates was not statistically significant (P = 0.295). 12 out of 25 patients (48%) in the external fixation group had FRIs whilst 6 out of 22 patients (27.3%) in the internal fixation group had FRIs. The rates of FRIs of the two groups were not significantly different (P = 0.145). CONCLUSION: Our findings suggest that mono-lateral external fixation and internal fixation do not differ significantly with respect to rates of nonunion and fracture-related infections in Gustilo IIIB open tibial fractures.

Experience with accelerated ponseti technique for treatment of idiopathic clubfoot in a regional orthopaedic hospital in Nigeria.

Introduction: Idiopathic talipes equinovarus (ITEV) 'aka clubfoot' is the most common foot deformity in children. Ponseti technique had been accepted as a standard method for correction. The traditional Ponseti technique for correction is well known. Accelerated Ponseti technique is said to offer some advantages over the standard technique. The aim of this study was to determine and document the efficiency and success rate of accelerated Ponseti technique. Methods: This was a prospective interventional study which lasted 26 months from February 2017 to April 2019. Twenty-eight patients with 42 feets who met the inclusion criteria were recruited. They had serial manipulation and casting twice every week till percutaneous tenotomy was done as indicated. Final cast usually applied after tenotomy and left for 3weeks. Each patient was followed up for a year corresponding to 9 months after the commencement of night bracing. Data were analysed using SPSS version 20. Results: The mean age was 8.1 months with a range of 1-36 months. The mean Pirani score recorded was 4.4, while the mean number of casting sessions was 3.6 and the mean duration of treatment was 12.4 days. The tenotomy rate recorded was 42.9%. Pre-bracing assessment of Pirani score, passive ankle dorsiflexion and foot abduction done and repeated after a year revealed optimal correction. The relapsed rate at 1 year was 4.8%. The only complication observed was pressure sore in a patient. Conclusion: The accelerated Ponseti technique is an efficient method of treatment of ITEV in a much shorter time with a higher success rate. It facilitates compliance with treatment.

Analysis of risk factors for wound infection after extremity fracture caused by machete cut in a resource-limited setting.

Background: Machete cut fracture is a unique subset of open fracture. The sharp force of a wielded machete that cleanly divides soft tissue envelope with minimal or no contusion results in an open fracture wound that is relatively less prone to infection. However, in resource-limited settings, the wound infection rate after machete cut fracture is relatively high. This study aimed to determine the risk factors for wound infection after extremity machete cut fractures in a Nigerian setting. Methods: We undertook a retrospective analysis of the patients who were seen in the Emergency room of two tertiary hospitals in Nigeria with a machete cut extremity fracture from 2009 to 2018. The association of wound infection with population and wound characteristics as well as intervention related factors were evaluated. Statistical significant factors for wound infection in the Univariable analysis were entered into a Multivariable regression analysis to evaluate the risk of each factor when adjusted to other factors. Results: There were 113 machete-cut fractured bones in 67 eligible patients and wound infection was a complication in 45 (39.8%) of the cases (95%CI 30.3 - 49.7%).The factors significantly associated with high wound infection rate were smoking, haematocrit < 30%, fractures sustained outdoors, lower extremity fractures, a wound size of >5cm in length, injury-to-hospital arrival interval > 6hrs. Multivariable regression analysis identified wound size >5 cm (aOR 14.142, 95%CI (2.716 - 73.636); p = 0.002), injury-to- hospital arrival interval later than 6hrs (aOR 4.410, 95% CI (1.003-19.394); p = 0.050) and administration of antibiotics later than 3hrs of injury (aOR 5.736, 95%CI (aOR1.362 - 24.151; p = 0.017) as independent risk factors for wound infection. Conclusion: Wound infection after open fractures caused by machetecut is more likely to occur in patients that present later than six hours after injury, wounds more than 5cm in length and delayed antibiotic administration. Appropriate treatment protocols can be instituted with this knowledge.

Firearm Injury Among Children and Adolescents in Nigerian Civilian Trauma Setting: Prevalence, Pattern, and Implications for Prevention.

Firearm injury in children and adolescents and the morbidity associated with it is an appreciable burden in resource-limited settings, though it is under-reported. This study aimed to determine its prevalence and pattern in Nigerian civilian trauma setting. We undertook a retrospective study of all the patients with firearm injury aged 19 years or under who visited the Emergency Department (ED) of two tertiary hospitals in Nigeria over a period of 15 years. Of the 46,734 children and adolescents seen in the ED, firearm injury was the reason for the visit in 56 of them, giving a prevalence of 1.2 per 1000 ED attendance (95% CI: 0.9-1.6). The male-to-female ratio was 1.8:1, and the mean age was 13.98 ± 5.6 years. The preponderance of firearm injury was in the rural areas, during the dry season, at home, and in the daytime. Armed robbery (20, 35.7%) and communal clash (7, 12.5%) were the two topmost incidents leading to gunshot wounds. Armed robbery-related gunshot occurred mostly on the roads and at nighttime and involved predominantly 15-19-year-olds. Lower extremity was the topmost anatomical region involved. The majority (67%) had no pre-hospital care; the mean and median injury-hospital arrival interval respectively was 352 hrs and 4.2 hrs. Wound infection was the topmost complication. The mean hospital length of stay was 22.6 days. One (1.8%) of the patients died on the third day of hospital admission. Educational campaigns for prevention intensified during the dry season should highlight the risk of firearm injury to this age group and emphasize the importance of proper supervision and guidance of vulnerable children and adolescents. Improving the rates of pre-hospital care and early presentation of victims to the hospital should be considered in tertiary injury prevention strategies.

Analysis of machete cut fractures in Nigerian civilian trauma setting.

Machete cut fracture is an important component of morbidity associated with machete injuries although it is under reported. This was a retrospective study to assess machete cut fractures in patients seen in Federal Teaching Hospital Abakaliki and National Orthopaedic Hospital Enugu from 2009 to 2018. There were 91 patients with 154 fractures, male- to- female ratio was 10:1 and mean age was 31.6 ± 14.6 years. The aetiological factors were assault (57, 62.6%), armed robbery (29, 31.9%) and accidental injury (5, 5.5%). The three top bones involved were ulna, metacarpal and finger-phalanx. Fracture was communited in (17, 11.0%), and Gustilo Anderson grade IIIC in (22, 14.3%). Injury to hospital arrival interval later than 6 h was common and correlated with prolonged length of hospital stay (p < 0.001). Anaemia, wound infection and hemorrhagic shock were the three top complications. Nine (5.8%) fractures ended in extremity amputation. Eleven (12.1%) patients left against medical advice, and 5 (5.5%) were transferred. Normal union in 98.3% of the fractures treated and followed up for a minimum of one year. Case fatality rate was 2.2%; none of the patient that died had pre hospital care, and hemorrhagic shock accounted for all the mortality. These call for appropriate injury preventive mechanisms, and improved rates of early presentation of patients to hospital, and pre hospital care.

Prophylactic surgical drainage is associated with increased infection following intramedullary nailing of diaphyseal long bone fractures: A prospective cohort study in Nigeria.

INTRODUCTION: Prophylactic surgical drains are commonly used in Nigeria following intramedullary nailing (IMN) of long bone diaphyseal fractures. However, evidence in the literature suggests that drains do not confer any benefit and predispose clean wounds to infection. This study compares outcomes between patients treated with and without prophylactic surgical drainage following diaphyseal long bone fractures treated with IMN. METHODS: A prospective cohort study with randomization was conducted at a tertiary referral center in Enugu, Nigeria. Investigators included skeletally mature patients with diaphyseal long bone (femur, tibia, humerus) fractures treated with SIGN IMN. Patients followed-up at 5, 14, and 30 days post-operatively. The primary outcome was surgical site infection (SSI) rate. Secondary outcomes included post-operative pain at 6 and 12 h, need for blood transfusion, wound characteristics (swelling, ecchymosis, and gaping), need for dressing changes, and length of hospital stay. RESULTS: Of the enrolled patients, 76 (96%) of 79 completed 30-day follow-up. SSI rate was associated with patients who received a prophylactic drain versus those who did not (23.7% vs. 10.5%, p = 0.007). There were no significant differences in transfusion need (p = 0.22), wound swelling (p = 0.74), wound ecchymosis (p = 1.00), wound gaping (p = 1.00), dressing change need (p = 0.31), post-operative pain at 6 h (p = 0.25) or 12 h (p = 0.57), or length of stay (p = 0.95). DISCUSSION: Surgical drain placement following IMN of diaphyseal long bone fractures is associated with a significantly higher risk of SSI. Reducing surgical drain use following orthopaedic injuries in lower resource settings may translate to reduced infection rates.