Traitement chirurgical du Mal de Pott et de ses séquelles au Centre Hospitalier de l'Ordre de Malte Dakar / Surgical treatm ent of Pott's diseaseand its sequelae at the Hospital of the Order of Malta/Daka

Introduction. Evaluer les résultats du traitement chirurgical du Mal de Pott et de ses séquelles au Centre hospitalier de l'ordre de Malte de Dakar. Patients et méthodes. Nous présentons les résultats préliminaires d'une série consécutive de 23 patients (13 hommes et 10 femmes) d'âge moyen de 32,35 ans [6 ­70 ans] présentant des Maux de Pott ou de leurs séquelles nécessitant un traitement chirurgical. L'échelle d'incapacité d'Oswestry, l'échelle visuelle analogique et le score ASIA ont été utilisés pour l'évaluation clinique. Les radiographies pré opératoires, post opératoires et au recul ont été utilisés pour les résultats anatomiques. Tous ces patients ont été opérés selon trois stratégies opératoires sur une période de 67 mois (Avril 2014- Novembre 2019). Nous avons réalisé une laminectomie arthrodèse postérieure dans 52,2% ; une laminectomie plus OTP et arthrodèse postérieure dans 43,5% ; une discectomie et hémicorporectomie avec arthrodèse antérieure par plaque vissée de Roy Camille à l'étage cervical dans 4,3%. Résultats. La symptomatologie était dominée par la douleur rachidienne, la cyphose et les troubles neurologiques. La cyphose post opératoire était significativement améliorée (la moyenne passe de 48,52° en pré opératoire à 17,09° en post opératoire). On a obtenu 100% de fusion vertébrale. On note une nette amélioration de la douleur rachidienne (avec une baisse au recul de 55,44 points pour l'OID et de 5,66 pour l'EVA) ; 78,3% des patients étaient très satisfaits, 17,4% satisfaits et 4,3% mécontents. Conclusion. Le traitement chirurgical du Mal de Pott et de ses séquelles a fortement amélioré les rachis au Centre hospitalier de l'Ordre de Malte.

Introduction. To evaluate the results of the surgical treatment of Pott's disease and its sequelae at the Hospital Center of the Order of Malta in Dakar. Patients and methods. We present the preliminary results of a consecutive series of 23 patients (13 men and 10 women) with an average age of 32.35 years [6-70 years] presenting with Pott's disease or its sequelae requiring treatment. surgical treatment. Oswestry Disability Scale, Visual Analogue Scale and ASIA score were used for clinical assessment. Preoperative, postoperative and followup radiographs were used for anatomical results. All these patients were operated according to three operating strategies over a period of 67 months (April 2014- November 2019). We performed posterior laminectomy-arthrodesis in 52.2%; laminectomy plus OTP and posterior arthrodesis in 43.5%; discectomy and hemicorpectomy with anterior arthrodesis by Roy Camille screwed plate at the cervical level in 4.3%. Results. The symptomatology was dominated by spinal pain, kyphosis and neurological disorders. Postoperative kyphosis was significantly improved (the average goes from 48.52° preoperatively to 17.09° postoperatively). We got 100% spinal fusion. There is a clear improvement in spinal pain (with a drop at follow-up of 55.44 points for the OID and 5.66 for the EVA); 78.3% of patients were very satisfied, 17.4% satisfied and 4.3% dissatisfied. Conclusion. The surgical treatment of Pott's disease and its sequelae greatly improved the spines at the Hospital Center of the Order of Malta.

[Pulmonary Metastase of a Knee Mycetoma in Senegal]. / Métastase pulmonaire d'un mycétome du genou au Sénégal.

Mycetoma is transmitted by thorns infected. The commonest site for mycetoma is the foot. The primary pulmonary are rare and usually secondary to other primary site. We report a case of pulmonary fungal mycetoma secondary to primary site in the knee. We do a review of the literature and we discuss the way of dissemination.

Le mycétome se transmet principalement par piqures d'épines d'arbustes infectés. Les localisations primitives au niveau du pied sont les plus fréquentes. Les localisations pulmonaires sont exceptionnelles et secondaires à des localisations périphériques primitives. Nous rapportons un cas de localisation pulmonaire d'un mycétome fongique secondaire à une localisation au niveau du genou, puis nous faisons une revue de la littérature et nous discutons de la voie de dissémination.

[Recidives of Mycetoma after Amputation in Dakar (Senegal)]. / Récidives de mycétome après amputation à Dakar (Sénégal).

The treatment of fungal mycetoma is essentially surgical. This carcinological-like surgery consists of amputation in case of bone involvement. The recurrences after amputation are rare and address the problem of the operative indication. We report 5 cases of recurrence of fungal black-grain mycetoma after amputation of leg or thigh. Case 1: a 52-year-old patient with a mycetoma of the knee evolving for 8 years. There is no history of surgery. A thigh amputation with ganglion dissection is performed. One year after the surgical procedure, the patient presents a recurrence on the amputation stump and on the lymph node dissection site. An indication of hip disarticulation is made and performed 17 months after amputation. Case 2: a 25-year-old patient who has a black-grain mycetoma of the foot with osteitis evolving since 10 years. A leg amputation was performed. The patient had a recurrence at the popliteal level at 15 months postoperatively. An indication of amputation of the thigh is posed and refused by the patient. Case 3: a30-year-old woman with black-grain mycetoma of the knee with bone involvement for more than 10 years. A thigh amputation was performed and at nine months postoperativeshe presented a recurrence in the amputation stump. She was lost of sight despite the decision of surgical revision. Case 4: a 43-year-old patient operated on his foot and leg mycetoma at least 5 timesbefore amputation in 2000. The recurrence occurred one year after amputation. 18 years after amputation, a new surgical procedure was difficult due to extension of the lesions in the pelvis. Case 5: a 50-year-old female patient operated in Mauritania in 2012 (thigh amputation for mycetoma of the knee). She presented a recurrence on the amputation stump in 2018. An indication of disarticulation of the hip was posed and refused by the patient. These recurrences were testified by to the persistence of grains on the preserved segment. They pose the problem of the level of amputation and therefore of preoperative planning. Good preoperative planning allows optimization of the surgical procedure and avoids certain recurrences.

La chirurgie constitue le temps essentiel du traitement des mycétomes fongiques. Elle consiste en une amputation en cas d'atteinte osseuse. Nous avons observé 5 cas de récidives après amputation pour mycétome. Il s'agit dans tous les cas de patients présentant des mycétomes à grain noir avec atteintes osseuses. Les récidives sont survenues à moins de 18 mois de l'amputation faisant parler de reprise évolutive et posant le problème du niveau de l'amputation.

Surgical Treatment of Angular Pott's Kyphosis with Posterior Approach, Pedicular Wedge Osteotomy and Canal Widening.

BACKGROUND: It has been observed that the correction of severe posttuberculous angular kyphosis is still a challenge, mainly because of the neurologic risk. METHODS: Nine patients were reviewed after surgery (mean follow-up 18 months). There were 2 thoracic, 4 thoraco-lumbar and 3 lumbar kyphosis. The mean age at surgery was 23. Clinical results were evaluated by the Oswestry Disability Index (ODI) and by the neurologic evaluation. Preoperative, postoperative and final follow-up X-rays were assessed. The surgery included a posterior approach with cord release and correction by transpedicular wedge osteotomy and widening of the spinal canal. RESULTS: Average kyphotic angulation was 72° before surgery, 10° after surgery and 12° at follow-up. Three out of four patients with neural deficit showed improvement. Neurologic complications included a transitory quadriceps paralysis, likely by foraminal compression of the root. CONCLUSION: A posterior transpedicular wedge osteotomy allows a substantial correction of the kyphosis, more by deflexion than by elongation, with limited neurologic risks. However it is mandatory to widely enlarge the spinal canal on the levels adjacent to the osteotomy, in order to allow the dura to expand backwards.

Modified Dunn osteotomy using an anterior approach used to treat 26 cases of SCFE.

INTRODUCTION: Osteotomy performed below the femoral neck plays a leading role in the treatment of slipped capital femoral epiphysis (SCFE). It results in anatomical reduction. Several modifications have been made to Dunn's original osteotomy technique. We have developed another modification to this technique that uses an anterior surgical approach on a traction table with fluoroscopy control. HYPOTHESES: Will this technique help to reduce the number of complications? Will its results be superior to those achieved with the standard Dunn osteotomy procedure? MATERIAL AND METHODS: This was a retrospective single-center study of 26 cases in 24 patients (2 bilateral cases). Patients were positioned supine on a traction table with fluoroscopy control. An anterior surgical approach was used. A trapezoid-shaped osteotomy was performed below the femoral head. The head's reduction was checked on the fluoroscope and the fixation confirmed. The Postel Merle d'Aubigné (PMA) score was used for the clinical assessment. The radiographic assessment was based on Southwick's angle. RESULTS: The mean slip angle of the femoral head was 57°. A mean correction of 47° was achieved. Based on the PMA score, good and excellent results were achieved in 20 cases (77%) and poor results occurred in 6 cases (23%). The surgical treatment had a significant effect on the PMA score (P=0.0008). In terms of complications, there were five cases of chondrolysis and one case of necrosis associated with chondrolysis. DISCUSSION: The anterior approach provides direct access to the femoral neck, and thereby a cautious osteotomy at the site of the slip itself. Use of a traction table makes the external manipulations, reduction and fixation procedures easier to carry out. The results of this study were comparable to published results. LEVEL OF PROOF: IV, retrospective treatment study.

[Surgery in black grain mycetoma: about 44 patients treated at aristide le dantec hospital (Dakar, Senegal) from December 2008 to March 2013]. / Chirurgie des mycétomes fongiques à grain noir. À propos de 44 patients pris en charge à l'Hôpital Aristide le Dantec de Dakar (Sénégal) de décembre 2008 à mars 2013.

Black-grain mycetomas are fungal and cannot be healed by antifungals only.We conducted this study to determine the interest of carcinologic surgery only in the management of those black-grain mycetomas.We led a retrospective study concerning 44 patients over a period of 52 months. The mean age of patients was 32.5 years. The main location of mycetomas was the foot (21 cases), the ankle (10 cases), the knee (8 cases), the leg (3 cases), the chest, the back and the pulp of the fourth finger once each. The bone was affected in 21 cases. The surgery consisted in a carcinologic excision or amputation depending on the extension of the lesion and the degree of bony infringement, with ganglionic cleaning out in case of lymphadenopathy. In the average retrospect of 25.5 months, we noted 8 cases of recurrences among which 2 on the amputated patients and 6 on the patients treated by carcinologic excision. The surgery constitutes the main therapeutic issue of the fungal mycetomas.

Traitement des fractures ouvertes Gustilo IIIB du tiers distal de la jambe

Objectif: Déterminer les modalités thérapeutiques et préciser l'évolution du traitement des fractures ouvertes stade IIIB de Gustilo du tiers distal de la jambe. Patients et méthodes: Il s'agissait d'une étude rétrospective continue de patients opérés entre Janvier 2008 et Mai 2013. Treize patients totalisant 13 lésions stade IIIB de Gustilo du tiers distal de la jambe ont été concernés. La perte de substance exposant le tibia était contemporaine du traumatisme (n=7) et secondaire à une chute d'escarres (n=6). Le traitement réalisé a été étudié. L'évaluation des résultats était basée sur le délai et la qualité de la cicatrisation et de la consolidation osseuse. Résultats: Une antibiothérapie et une sérovaccination antitétanique ont été instituées pour tous les patients. Le délai moyen du traitement chirurgical était de 7heures. Le traitement consistait en un parage, une réduction de la fracture, et une ostéosynthèse par un fixateur externe. La couverture de la perte substance cutanée par un lambeau a été réalisée dans un délai moyen de 16 jours. La cicatrisation était obtenue chez tous les patients dans un délai moyen de 52 jours. La consolidation était effective chez 12 patients. Conclusion: Le traitement des fractures ouvertes IIIB de Gustilo du tiers distal de la jambe a reposé sur l'antibiothérapie, le parage, l'ostéosynthèse et la couverture cutanée par lambeau. Le fixateur externe était l'implant de choix. La cicatrisation a été obtenue chez tous les patients

[Thoracic tumor-like fungal mycetoma: interest of large surgery with terbinafine]. / Un mycétome fongique tumoral dorsal: intérêt de la chirurgie large associée à la terbinafine.

Fungal mycetoma are inflammatory pseudo-tumors of subcutaneous tissues and possibly bones due to exogenous fungi. They have a chronic course, often poly-fistulated with an emission of fungal grains. We report the case of a 65-year-old farmer with a thoracic fungal mycetoma discovered incidentally, associated with bone involvement. The diagnosis was confirmed by the positive culture to Madurella mycetomatis. The outcome was favorable with terbinafine 1g per day for 12 months associated with complete excision of oncologic type followed by a skin graft.

[Inclusion of hepatitis B vaccination in the Expanded Program of Immunization: feasibility study in the medical region of Kolda (Senegal)]. / Inclusion de la vaccination contre l'hépatite B dans le programme élargi de vaccination: étude de faisabilité dans la région médicale de Kolda (Sénégal).

Hepatitis B is highly endemic in Senegal. The prevalence of hepatitis B antigens in the population was estimated to be 10 to 12% in 1982. According to the WHO recommendations, a hepatitis B vaccination program (HBV) was launched in 10 medical centers in the Kolda medical region to assess the feasibility of including HBV in the EPI. The epidemiological impact of HBV was also investigated by comparison of the vaccinated zone (VZ) to a control non vaccinated zone (NVZ). HBV coverage had a pattern similar to that of DPT-IPV, but at a lower level: the overall coverage with HBV was only 37.5%, and the drop out rate for HBV1-3 was only 34.4%. In addition, the coverage of the under one year age group was insufficient: 45% for HBV3 as compared to 78% for DPT3 (p < 0.0001). Routine vaccination records in the medical centers in the VZ were consistent with the findings of cluster surveys. Hepatitis B markers were less prevalent among vaccinated that non vaccinated children (8 versus 18.5%, p < 0.001). HB antigenemia was significantly less frequent in the VZ than the NVZ (3.9 versus 10.9, p < 0.0001), and the difference was even larger for all hepatitis markers (7.4 versus 23.7%, p < 0.0001). This study therefore suggests that the inclusion of HBV in the EPI should be continued and strengthened in less accessible regions by an adapted social mobilization program. HBV could then be extended to the whole medical district of Kolda in association with regular epidemiological and serological surveillance.

[Evaluation of the financial participation of the users of 102 health services in 3 districts of Senegal]. / Evaluation de la participation financière des usagers dans 102 postes de santé de trois districts au Sénégal.

Primary Health Care (PHC) financing is today one of the major concern of public health system managers in developing countries. Their governments never allocated appropriate and sufficient resources to the sector of PHC. The external donors' funds are mostly allocated to short term PHC projects. They stop with the end of the projects. The undesirable consequences of that situation are well known. They are mainly related to a persistence of high rate of mortality and morbidity due to preventable diseases. To better address that situation the health ministers of the WHO african region adopted in September 1987 in Mali the Bamako alternative, to the country economical situation, for PHC services financing. It permitted to finance up to 80% of the recurrent costs of health system of Pikine department in 1980. In the three pilot districts where the Bamako initiative strategy has been tested: Podor, Matam and Bignona, all of the one hundred and two (102) health posts are self financed for their recurrent costs, since 1992.

[Attitude and behavior of the youth of Senegal toward drugs]. / Attitude et comportement des jeunes du Sénégal face aux drogues.

Formerly known as a dreadful calamity for industrialized countries, drug abuse now seems to have spread all over the world. In Senegal, it has been very difficult to gather reliable statistics on its extensiveness. To better define the problem in Senegal, UNESCO has launched an epidemiological study on young people drug abuse and alcoholism in schools and elsewhere. The authors analyse the results of this study and draw the following conclusions: all types of drug use are linked to religious practice, drug use by young people is due to curiosity or their ignorance of drug drawbacks and their lack of education, school, family, religious education and social repression play an important role in the fight against drug use.

Primary health care: from aspiration to achievement.

A review is presented of Senegal's response to the Bamako Initiative, aimed at strengthening primary health care. The experience gained is of broad interest since the basic principles involved are the same everywhere. Of particular importance are users' financial contributions and improved organization and management.

PIP: The 1987 Bamako Initiative tries to rectify the major gaps and inadequacies in implementing primary health care (PHC). In Senegal, people living near health units elect health committees which collect and manage health facilities and their income. Each patient contributes some money each time he/she uses a health service. The proportion of funding allocated to priority health care activities is very inadequate. Problems of public health services in Senegal range from chronic shortages of essential drugs to the people having lost faith and having abandoned public health services. Medical personnel in the public sector question the PHC strategy. So Senegal has developed a medium-term plan for social and health development for each health district and medical region. It has also redefined district and regional level management structures and their roles and responsibilities. Private pharmacies sell most of the 3000 medicines authorized to treat infectious diseases, deficiency diseases, and congenital diseases. They sell the more expensive brand name drugs. They controlled the sale of 13-14,000 million CFA francs worth of drugs out of the 15,000 million CFA francs worth of drugs sold in Senegal in 1991. An expert committee on essential drugs of the Ministry of Public Health and Social Action's Human Resources Development Project has revised essential drug lists to include generic names. It has distributed different lists to health huts, health posts, health centers, and regional hospitals. Another committee has determined the initial amount of money needed for essential drugs for each level of the health system. It has identified various sources of funding with Switzerland contributing enough money to cover drugs for health posts and health centers. Senegal has reorganized the supply and distribution system by decentralizing the National Supply Pharmacy. New management tools are registers of incomes and outgoings, stock cards, inventory cards, order books, and receipt books. Private pharmacists objected to full implementation of the Initiative. Physicians also resisted it.