Does the Proximal Femur Geometry Predict Early Functional Outcome after Plate Fixation of Geriatric Pertrochanteric Fractures?

BACKGROUND: The proximal femur geometry determines the hip force distribution. The femoral neck axis length (FNAL), the hip axis length (HAL), the femoral head diameter, and the femoral neck-shaft angle (FNSA) could influence the risk and outcome of pertrochanteric fractures. Restoring these parameters to their prefracture values could predict early hip function. AIM: To determine if the postoperative proximal femur geometry of geriatric patients with plating for pertrochanteric fractures predicts the early functional outcome. MATERIALS AND METHODS: The study was a prospective study carried out at the National Orthopaedic Hospital Enugu for 18 months. Geriatric patients who had Proximal Femoral Locking fixation for pertrochanteric fractures were recruited. Radiological parameters of the proximal femur in the unaffected and fixed hips were measured and compared. The functional outcomes of the patients were measured at 3 months postoperative period using the Harris hip score (HHS). Multiple linear regression was conducted on the parameters to determine the HHS. RESULTS: Thirty patients participated in the study, with a significant difference (P < 0.001) in the mean FNSA between unaffected (M = 128.69, standard deviation (SD) =2.93) and operated hips (M = 121.81, SD = 8.86). The FNSA was the only significant predictor of hip function, with a 1-degree increase improving the HHS by 1.30. CONCLUSION: There is a significant difference in the FNSA between the unaffected and the operated hips. The FNSA significantly predicts the early hip function and should be reconstructed to within normal range during surgery.

Discharge against Medical Advice in Eight Tertiary Hospitals in Nigeria: A Prospective Study.

BACKGROUND: Discharge against medical advice (DAMA) is when a patient decides to leave the hospital without the consent of the treating physician. It poses serious clinical, ethical, and legal challenges to the individual physician as well as the hospital. AIM: To determine the prevalence and reasons for DAMA in orthopedic departments of eight tertiary hospitals in Nigeria. MATERIALS AND METHODS: This was a prospective multi-center descriptive study undertaken in eight tertiary Nigerian hospitals. Consecutive patients who requested for DAMA within 1 year of the study and who consented to participate in the study had face-to-face interviews. Data obtained were documented in a questionnaire and analyzed with SPSS version 20. RESULTS: The total number of patients studied was 373 with a mean age 34.7 ± 17.5 years. About a quarter of them (25.5%) were between 31 and 40 years. A prevalence rate of 1.9% was found with financial constraint being the predominant reason for DAMA (40.8%). Other reasons include family preference for unorthodox treatment (18.8%) and treatment dissatisfaction (7.0%) among others. CONCLUSION: The study findings indicate a low DAMA rate when compared to previous studies in this region. It also indicates that financial constraints, family preference for unorthodox care, and low educational status are major drivers of DAMA. Deepened health insurance and other measures that can reduce the prevalence of DAMA should be prioritized to improve treatment outcomes.

Assessment of handgrip strength in healthy african subjects: Establishing age and gender stratified reference values.

Background: The handgrip strength assesses hand function in traumatic and non-traumatic upper extremity conditions. It is also a surrogate marker for other systemic diseases unrelated to the upper limb. Various reference values have been established in different world regions, with few studies in our population. Aim: To determine the average handgrip strength by gender and age categories among healthy subjects in Nigeria. Materials and Methods: It was a cross-sectional study assessing handgrip strength by age category (ten-year bin width), gender, and handedness in 210 healthy persons aged 10 to 79 in Nigeria. Its relationship with age, height, weight, mid-arm circumference, triceps skinfold thickness, and mid-arm muscle area was evaluated using multiple linear regression. Results: The mean handgrip strength in the dominant and non-dominant hands was 31.09 kg and 28.45 kg, respectively, P < 0.001. Males have higher values than females in all age categories. The grip strength peaked in the 30-39-year age group in both genders and declined afterward. Age exhibited a nonlinear pattern but had an overall negative relationship, while height was positively related to grip strength in both genders. In contrast, mid-arm circumference and mid-arm muscle area predicted handgrip strength only in males. Triceps skinfold thickness was excluded from the model because of multicollinearity with the mid-arm muscle area, while weight did not predict grip strength in either gender. Conclusion: The handgrip strength in this study is less than that in western literature. Hence, test interpretation should reference the values from this study.

Preliminary outcome of use of parenterally administered tranexamic acid during primary total knee replacement.

Background: Perioperative blood loss and the need for blood transfusion following total knee arthroplasty (TKA) has been a source of concern for many arthroplasty surgeons and patients over the years. Tranexamic acid (TXA) is increasingly being used by surgeons in limiting perioperative blood loss and the subsequent need for transfusion during TKA. Aim: This study aims to determine the efficacy of TXA in preventing perioperative blood loss, transfusion needs of patients that underwent TKA, complications, and its financial implications of its use in our institution. Patients and Methods: The study was a clinical comparative audit of perioperative blood loss and transfusion needs in primary TKA patients. The study population was divided into two groups of equal numbers (n = 40). Group A, who did not receive perioperative TXA, had TKA prior to the adoption of TXA in our institution, whereas group B, who received TXA, had TKA after TXA was adopted. Results: The mean postoperative hemoglobin was 9.49 g/dl for group A and 10.15 g/dl for group B (P = 0.021). The mean postoperative blood drainage was 888.25 ml for group A and 821.67 ml for group B (P = 0.397). The number of patients transfused in group A was 17 (42.5%) against 7 (17.5%) in group B. The mean postoperative transfusion volume was 270 ml and 101.25 ml for group A and B, respectively (P = 0.014). The mean total transfusion volume was 450 ml and 277 ml in group A and B, respectively (P = 0.063). Conclusions: The use of TXA in TKA was shown to be beneficial in our study as it resulted in a statistically significant reduction in the postoperative transfusion volumes and higher postoperative hemoglobin levels.

The Efficacy of Local Infiltration Analgesia in the Control of Post-Operative Pain after Total Joint Replacement Surgeries.

BACKGROUND: Total joint replacement surgeries can produce severe pain in the post-operative period that can prolong the duration of hospital stay. The aim of the study, was to determine the efficacy of Local Infiltration Analgesia in the management of post-operative pain after total joint replacement. METHOD: This was a prospective study with patients recruited for the study divided into group A and B. Group A received intra-operative analgesic cocktail while those in group B (control group) received an equal volume of normal saline. Both groups received the same post-operative pain management protocol. Pain assessment in the post-operative period was done using the visual analogue scale, at 4 hours, 8 hours, 24 hours and 48 hours post surgery. Time to achieving assisted ambulation, occurrence of adverse events, and the number of times analgesic was administered for breakthrough pain were assessed. RESULTS: A total number of 50 patients who had either total joint arthroplasty (25 in each group) were recruited for the study. The Normal saline group had significantly higher VAS scores in the first 8 hours after surgery (p values 0.016 at 4 hours and 0.037 at 8 hours post-operation) while both groups had similar pain scores thereafter. Mobilization times were not significantly different between both groups and adverse events occurred with almost equal frequency in both groups. CONCLUSION: Periarticular local infiltration analgesia as part of multimodal pain control protocol is effective in the control of early post-operative pain after total joint replacement.

CONTEXTE: Les chirurgies de remplacement total de l'articulation peuvent produire une douleur intense pendant la période postopératoire qui peut prolonger la durée du séjour à l'hôpital. Le but de l'étude était de déterminer l'efficacité de l'analgésie locale par infiltration dans la gestion de la douleur postopératoire après une arthroplastie totale. MÉTHODES: Il s'agissait d'une étude prospective avec des patients recrutés pour l'étude ont été divisés en groupes A et B. Le groupe A a reçu un cocktail analgésique intra-op¼ratoire. tandis que les patients du groupe B (groupe témoin ont reçu un volume égal de solution saline normale. Les deux groupes ont reçu le même protocole de gestion de la douleur post-opératoire. L'évaluation de la douleur dans la période postopératoire a été réalisée à l'aide de l'échelle visuelle analogique, à 4 heures, 8 heures, 24 heures et 48 heures après l'opération après l'opération. Le temps nécessaire à l'obtention d'une l'ambulance assistée, la survenue d'événements indésirables et le nombre de fois où un analgésique a été administré en cas de percée de la évalués. RÉSULTATS: 50 patients ayant subi une arthroplastie totale (25 dans chaque groupe) ont été recrutés pour l'étude. Le groupe recevant du sérum physiologique présentait des scores VAS significativement plus élevés dans les 8 heures après l'opération (valeurs p de 0,016 à 4 heures et 0,037 à 8 heures après l'opération), alors que les deux groupes avaient des scores de douleur similaires par la suite. Les temps de mobilisation n'étaient pas significativement différents entre les deux groupes et les événements indésirables sont survenus à une fréquence presque égale dans les deux groupes. CONCLUSION: L'analgésie périarticulaire par infiltration locale dansle cadre d'un d'un protocole multimodal de contrôle de la douleur est efficace dans le contrôle de la douleur postopératoire précoce après une arthroplastie totale. Mots clés: Analgésie par infiltration locale; arthroplastie totale; arthroplastie; douleur postopératoire.

Predictors of early elbow function following paediatric humeral supracondylar fractures: A retrospective analysis.

BACKGROUND: Supracondylar fracture usually occurs as a result of fall on an outstretched hand. Prompt management is essential to prevent complications. Functional outcome after management of this fracture may be predicted by some factors. AIMS: The study aimed to review the management of supracondylar fractures and determine what factors have an impact on the functional outcome of the elbow using MEPS score in the early post-operative period. PATIENTS AND METHODS: This study was a retrospective study of all patients with supracondylar fractures that presented at the accident and emergency department of a tertiary institution over a 2-year period. Their relevant data were retrieved from their folders and analysis done using SPSS 20. The MEPS score at 6 months was calculated. Multiple linear regressions were used to determine factors that can predict early elbow function using the MEPS score at 6 months. RESULTS: In the study, 61.4% (35) patients were males and 38.6% (22) females. The commonest mechanism of injury was fall on the outstretched hand (FOOSH), 70.2%. The mean duration of presentation to the hospital was 38 h (SD = 56.9). Among treatment offered to the patients, a higher number had open reduction with pinning. The mean postoperative Mayo elbow score was 87.6. Age of patients, Gartland type and the duration of cast immobilization were significant predictors of the MEPS at 6 months after treatment. CONCLUSION: The Gartland type and duration of cast immobilization are the most important predictors of the MEPS score at 6 months in this study.

Job satisfaction among health professionals in a federal tertiary hospital in Nigeria.

BACKGROUND: Job satisfaction of health workers is essential in building up employee motivation and efficiency. The objective of this study is to ascertain the level of job satisfaction among health professionals in a federal tertiary health institution in Nigeria. METHODOLOGY: This study was done at the National Orthopedic Hospital, Enugu (NOHE), in south-east Nigeria. Two hundred and thirty-six health workers were recruited from the various clinical departments via a systematic sampling technique. A questionnaire documenting relevant sociodemographic data and assessing the level of satisfaction with the financial remunerations, working conditions, infrastructure and equipment, learning and academic sponsorships, welfare packages, and performance appraisal systems was administered to them. RESULTS: The findings revealed a relatively low level of job satisfaction among the staff of NOHE especially with regards to financial remuneration, working conditions, tools and infrastructure, learning and training opportunities/sponsorship, leadership style, and welfare packages with increasing dissatisfaction in that order. However, the average staff is satisfied with the performance appraisal system as regards promotion. CONCLUSION: The majority of the clinical staff have a low level of job satisfaction. A review of the salary structure of health professionals as well as improving the working conditions, tools, and infrastructures in the hospital is needed.

Total hip replacement in sickle cell disorder: A preliminary report of challenges and early outcome of 21 consecutive patients.

OBJECTIVE: The aim of this study is to describe the pattern of presentation osteoarthritic patients with sickle cell disorder (SCD) in our environment, determine the implant sizes taking the peculiar nature of the pathology and our operating environment into consideration, highlight the challenges and technical difficulties encountered during the procedure, measure the functional outcome and observe complications of treatment, recommend ways of improving outcome. PATIENTS AND METHODS: Between November 2008 and November 2012, 29 consecutive primary total hip replacements (THRs) were performed on 21 patients with avascular necrosis of the head of femur secondary to SCD. Patients' evaluation was performed at two different times of follow-up (1 and 5 years, respectively). RESULTS: Twenty-one patients were available at 1 year as well as 5-year follow-up. The mean preoperative Harris Hip Score was 20.17 ± 11. The mean postoperative Harris Hip Score was 92.25 ± 13 (P < 0.001) at 1 year and 88.75 ± 10 (P < 0.001) at 5 years. Eighteen patients had regional anesthesia while three had general anesthesia. The average cup size used was 49.43 with a range of 46-54. The average liner size was 49.43 with a range of 46-54. The head size used in all patients was 28. The average stem size was 6.57 with a range of 6-8. The offset used in all the patients was standard All the patients had 1-2 screw fixation of the acetabular shell. Four patients had complications as follows: periprosthetic fracture 1, superficial wound infection 1, pulmonary complication 1, and abdominal crisis 1. CONCLUSION:: THR is a veritable means of treatment of patients with avascular necrosis of the femoral head arising from SCDs. The challenges encountered during the surgery are related to the quality of bone of the affected patient. Arthroplasty Surgeons in our environment must be fully prepared for the challenges by ensuring a preoperative plan that will take care of the technical problems such as recreating femoral canals, wiring of intraoperative fractures as well as treatment of acetabular defects. A detailed planned total hip arthroplasty can be performed in patients with SCD in younger patients with good clinical benefits.

Total knee replacement in a resource constrained environment: A preliminary report.

INTRODUCTION: Total knee replacement surgery is relatively new in Nigeria and available in few centres only. It has been evolving at a slow pace because of the lack of facilities, structures and adequate surgical expertise alongside patient ignorance and poverty. OBJECTIVE: The aim of this article is to review the cases done in a resource constrained institution in Nigeria and report the short term outcomes. METHODOLOGY: All the patients that were booked for Total knee replacement, using same prosthesis over a 40 month period, were recruited into the study. Using a prepared data tool, information on personal biological information, clinical presentation, peri-operative management, and outcome of management were obtained after an informed verbal consent. All the patients were further followed up for at least one year. RESULTS: 45 knees were replaced in 38 patients. The age range of the patients was 41-85 years with a mean age of 62.6. The male to female ratio was 1: 4.4. The indications for surgery were a combination of pain and deformity. All the patients came with varying forms and degrees of angular deformities. Eight knees had bone defects that required bone grafting while 5 knees had tibia extension rods. The commonest complication, which was recorded, was drop foot (8.9%). Knee society pain scores in the patients improved from the average of 21.35 to 83. CONCLUSION: Despite the challenges inherent in health care in developing countries, with proper institutional planning and team work, the short term outcome of arthroplasty in our resource constrained environment is good.

Pattern of femoral fractures and associated injuries in a Nigerian tertiary trauma centre.

BACKGROUND: The femur is the strongest and largest bone in the human body. It therefore requires high-energy trauma for it to fracture unless there is an ongoing pathology that weakens the bone. Femoral fractures are thus associated with significant pain, deformities, bleeding and varying degrees of injuries. The aim of this study is to determine the pattern of femoral fractures and the associated injuries in our region while recommending possible means of averting these injuries. MATERIALS AND METHODS: A 10-year retrospective study was done in National Orthopedic Hospital Enugu from 1994 to 2003. The demographic data, etiology, the part of femur affected and associated injuries were collated from the hospital records/folders. The analysis was performed using descriptive statistics in Microsoft Excel 2007. RESULTS: A total of 562 cases were reviewed, 63.7% of all the patients were males and the most common etiological factor was road traffic accidents. The site of fracture varied with age and etiology with 26.5% occurring at the mid-shaft with an average age of 27.2 years and 16% occurring at the neck of femur, more in the elderly, with 55.6% following minor falls and trips. The most common associated injury was soft tissue injuries requiring secondary wound closure. CONCLUSION: Femoral fractures are common and the pattern varies with age and the mechanism of injury. They are associated with other injuries that may be life-threatening.

The impact of water mattresses on incidence of PUs in patients with spinal cord injuries in Nigeria.

OBJECTIVE: To evaluate the impact of water mattresses on the incidence of pressure ulcers and length of hospitalisation in patients with spinal cord injuries in Nigeria. METHOD: A retrospective review was conducted of all patients who presented and were managed for complete traumatic spinal cord injury between January 2005 and December 2008. This period included 2 years prior to, and 2 years following, the introduction of water mattresses to the ward; patients from these periods were grouped as A and B, respectively. Information collated from the medical records included demographic data, wound aetiology, time to presentation, level of injury, complications, treatment, and duration of hospitalisation and follow-up. Outcome measures were presence or absence of pressure ulcers and length of hospital stay. RESULTS: In total, 201 patients were treated within the study period. Of these, 99 patients met the inclusion criteria; 35 patients (19 paraplegics and 16 tetraplegics) were managed between 2005 and 2006 (group A), while 64 patients (28 paraplegics and 36 tetraplegics) were managed in 2007 and 2008 (group B). The age range of the included patients was 9-76 years (39.0 ± 4.6 years and 41.5 ± 3.2 years for groups A and B, respectively) and all were male. Patient characteristics were similar for the two groups; however, there was a significant difference between the two groups in terms of presence of pressure ulcers, deteriorating of existing ulcers and condition of the patient on discharge (p < 0.05). CONCLUSION: The majority of pressure ulcers are preventable and a simple support surface, such as water mattresses, can reduce the incidence and magnitude of pressure ulceration, thus reducing hospital stay. DECLARATION OF INTEREST: The authors do not have any financial relationship with any organisation that manufactures water mattresses, either locally or overseas. There were no external sources of funding for this study.

Surgical Resident Doctor's Perspective of their Training in the Southeast Region of Nigeria

There are several problems militating against satisfactory residency training in Nigeria. These problems may not be effectively identified and resolved if the opinion of the trainee doctors is ignored. Objectives: To review surgical residents' perspectives of their training program in South-eastern Nigeria; with the aim of suggesting evidence-based innovative changes to enable the programs meet global trends and standards. Materials and Methods: A total of 90 semi-structured and pre-tested questionnaires were evenly distributed (30 per hospital) to the surgical residents at three tertiary healthcare facilities in South-eastern Nigeria. Information sought included sociodemographic variables; level in the residency training; rating of program and different aspects; learning environments/opportunities; and suggestions on ways to improve either part or overall program. Results: Analysis of 56 properly completed questionnaires (response rate=62.2) shows that the respondents were aged 29 to 53 years [mean(SD) = 35.3(1.7)]; mostly males (91.1) and junior residents (75). A significant majority of residents (47 or 83.8) rated the surgical residency training in their respective centers as inadequate. Grand rounds were roundly criticized as having misplaced objectives and tending toward fault-finding by Consultants. Suggested interventions for improvement included enhanced supervision/mentoring/teaching by senior colleagues; inclusion of didactic lecture sessions; research trainings; and foreign postings. Conclusion: There exist gaps between expectations of surgical residents and the training offered. These create needed support for an evidenced-based review of surgical residency training program to enable it meet the aspirations of trainees and the ever-changing trend in Medicine. More studies on surgical residents covering other regions of Nigeria; and including the trainers (Consultants); will be of immense value

Iatrogenic pyogenic spondylodiscitis: a case report and a review of literature.

BACKGROUND: Iatrogenic Pyogenic Spondylodicitis is a disease not commonly reported probably because of the way it is acquired, from the health practitioner. METHOD: The case of a 62 year old man that presented in our outpatient department with features of spondylodiscitis after several attempts at spinal anaesthesia at a rural hospital was reported and the literature reviewed. RESULT: The patient showed remarkable improvement few days with parenteral antibiotics and made complete recovery subsequently. CONCLUSIONS: Adequate asepsis is required for spinal anaesthesia and parenteral antibiotics given presumptively following numerous attempts at spinals.

Outcome of management of chronic osteomyelitis at National Orthopaedic Hospital, Enugu.

INTRODUCTION: Chronic osteomyelitis remains challenging to treat despite advances in antibiotics and new operative techniques. The associated morbidity and difficulty in eradicating the infection has posed a problem for the surgeon. The objective of the study is to evaluate the management of chronic osteomyelitis using the National Orthopaedic Hospital Enugu experience and recommend some modification of the treatment protocol in antibiotic usage. METHOD: A retrospective study was carried out. Records of fifty patients presenting with chronic osteomyelitis over a ten year period from 1997 to 2006 were analyzed. Patients with incomplete records were excluded. RESULTS: The young active age group was more involved. Majority of the patients presented quite late, more than 6 months from onset of symptoms. Saucerization, curettage and sequestrectomy were the commonest surgical intervention done; as types III and IV [Cierny Mader] chronic osteomyelitis prevailed over the others. The duration of parenteral (intravenous) antibiotics usage was within 72 hours in most of the patients; with oral antibiotic continued for about 48 weeks in most of the patients. Most of the patients had stopped discharging at 12 weeks of follow-up and showed clinical evidence of arrest of the infection. CONCLUSION: Following adequate surgical debridement in chronic osteomyelitis, short term sensitivity based intravenous antibiotics for 48-72 hours and subsequent oral antibiotics for a variable period of 48 weeks is adequate treatment for chronic osteomyelitis in a non-immuno compromised patient.

Effects of cyclooxygenase inhibitors on bone and cartilage metabolism--a review.

BACKGROUND: In this era of increeasing use of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) for treatment of painful/inflammatory disorders, it is necessary to review the effect of these drugs on bone and cartilage metabolism. Inflammation is an essential component of the healing process in bone, and cyclooxygenase (cox-1 and cox-2) enzymes play important roles in fracture repair. Therefore, there is concern that NSAIDs, which have anti-inflammatory and analgesic properties that are mediated by inhibition of cox-1 and cox-2 may delay the healing of bone injuries. Also as newer drugs, selective cox-2 inhibitors are being developed to avert the gastrointestinal symptoms of the non-specific NSAIDs, it is imperative that these substances are studied for any deleterious effect on bone and cartilage metabolism. METHODS: Literature on the subject was reviewed using manual library search, articles in journals and internet search. The search words were: NSAIDs and bone metabolism, cyclooxygenase inhibitors and bone metabolism. The search was done using medscape, ortolink and pubmed search engines. The search covered a period of 35 years (1970-2005). RESULTS: NSAIDs can either reversibly or irreversibly block the cyclooxygenase pathway thereby inhibiting prostaglandin synthesis. These cox inhibitors especially the cox-2 have been found to inhibit the production of prostaglandins which are necessary in bone healing. Prostaglandins play a role in both osteoblastogenesis and bone resorption, and so, cox inhibitors suppress these functions. CONCLUSION: NSAIDs especially the cox-2 inhibitors should be avoided following fractures or implant surgery. They should be reserved for other painful inflammatory disorders in which bone resorption and formation mediated by prostaglandins are not required.