Orthopaedic infuries in the elderly: Federal Medical Center, Umuahia experience

Background: The elderly constitute an important part of the general population. Worldwide the population of the elderly has increased over the years. This paper documents the pattern of orthopaedic injuries in the elderly in Umuahia; Nigeria. Methods: A retrospective study of all injuries in patients aged 60years and above seen at the Federal Medical Centre; Umuahia from 1st July; 1996 to 30th June; 1999 utilizing data from the patients' case notes; casualty and ward registers are well as the theatre registers. Extracted data was analyzed using descriptive statistics. Results: Of the 102 patients seen; only 62 patients' records were retrievable. There were 38 males and 24 females giving a male: female ratio of 1.6:1. Their average age was 68.7 years. Over 60were in the 60-69 years age bracket. Most of the injuries occurred in the rural setting. The most common aetiology was road traffic accidents(54.8) followed by falls (21.0). Most patients (69.4) presented within 7 days of injury with 27.4receiving some form of treatment before presentation. The most common body region affected was the lower limb followed by the upper limb. Fractures were the most common injury type. The most common comorbidity was hypertension followed by arthritis and diabetes mellitus. The average duration of hospital stay was 20.7 days. No mortality was recorded. While 45.2were discharged on recovery; 22.6discharged against medical advice. Conclusion: Trauma-related injuries in the elderly are not uncommon and road traffic accident was the most common aetiology. Efforts should be made to prevent these injuries

Prospective evaluation of the Bengezi and Al-Fallouji modified Alvarado score for presumptive accurate diagnosis of acute appendicitis in University of Port Harcourt Teaching Hospital, Port Harcourt.

BACKGROUND: The accurate diagnosis of acute appendicitis (AP) in a patient is valuable to the busy clinician. Decision making in cases of AP poses a clinical challenge especially in developing countries where advanced radiological investigations are not readily available and do not appear cost effective, clinical parameters remain the mainstay of diagnosis. Time and resources wasted on surgical intervention, with the added risks of surgery and anaesthesia, only to discover that this was unnecessary remains a big challenge. This prospective study was carried out to assess the accuracy of the Bengezi and Al-Fallouji modified Alvarado score in presumptive diagnosis of AP and its effect on the negative appendicectomy rate (NAR) at the University of Port Harcourt Teaching Hospital. METHODS: A retrospective study of the NAR of this hospital between June 2000 and May 2002 was carried out. All consecutive patients (128) who presented with presumptive diagnosis of AP between June 2003 and May 2004 were scored using the Bengezi and Al-Fallouji modified Alvarado scoring system and correlated with histological diagnosis. Patients discharged without surgery based on score, were reviewed in the outpatient's clinic for one month to ascertain that they did not need surgical intervention. The NAR for all appendicectomies performed by surgeons for presumptive diagnosis of AP without scoring between June 2004 and May 2005 was determined as control. Validity of the scoring system was assessed by calculating sensitivity, specificity, positive and negative predictive values. RESULTS: A total of 128 patients were scored. Forty patients with scores less than 4 after eight hours observations and re-evaluation at the Accident and Emergency were discharged without surgery. Eighty eight patients had appendicectomies as treatment for scores 5-10. There were 39 males and 49 females. In eighty patients, the appendix was histologically inflammed and 8 were normal, giving a NAR of 9.09%. High sensitivity of 92.93% and specificity of 92.93% were recorded in the study. The NAR of the retrospective study was 26.4% and 19.05% for the control group operated without scoring. CONCLUSION: The Bengezi and Al-Fallouji modified Alvarado score is a simple, safe and cost effective aid in diagnosis of acute appendicitis and decreases NAR.

Prospective Evaluation of the Bengezi and Al-Fallouji Modified Alvarado Score for Presumptive Accurate Diagnosis of Acute Appendicitis in University of Port Harcourt Teaching Hospital; Port Harcourt

Background: The accurate diagnosis of acute appendicitis (AP) in a patient is valuable to the busy clinician. Decision making in cases of AP poses a clinical challenge especially in developing countries where advanced radiological investigations are not readily available and do not appear cost effective; clinical parameters remain the mainstay of diagnosis. Time and resources wasted on surgical intervention; with the added risks of surgery and anaesthesia; only to discover that this was unnecessary remains a big challenge. This prospective study was carried out to assess the accuracy of the Bengezi and Al-Fallouji modified Alvarado score in presumptive diagnosis of AP and its effect on the negative appendicectomy rate (NAR) at the University of Port Harcourt Teaching Hospital. Methods: A retrospective study of the NAR of this hospital between June 2000 and May 2002 was carried out. All consecutive patients (128) who presented with presumptive diagnosis of AP between June 2003 and May 2004 were scored using the Bengezi and Al-Fallouji modified Alvarado scoring system and correlated with histological diagnosis. Patients discharged without surgery based on score; were reviewed in the outpatient's clinic for one month to ascertain that they did not need surgical intervention. The NAR for all appendicectomies performed by surgeons for presumptive diagnosis of AP without scoring between June 2004 and May 2005 was determined as control. Validity of the scoring system was assessed by calculating sensitivity; specificity; positiveand negative predictive values. Results: A total of 128 patients were scored. Forty patients with scores less than 4 after eight hours observations and re-evaluation at the Accident and Emergency were discharged without surgery. Eighty eight patients had appendicectomies as treatment for scores 5- 10. There were 39 males and 49 females. In eighty patients; the appendix was histologically inflammed and 8 were normal; giving a NAR of 9.09. High sensitivity of 92.93and specificity of 92.93were recorded in the study. The NAR of the retrospective study was 26.4and 19.05for the control group operated without scoring

Dual implant application in the treatment of aseptic femoral shaft nonunions--case series.

BACKGROUND: Femoral shaft nonunion is not uncommon in orthopaedic practice in the developing economy and it can pose a management challenge. There is no single standard method of treatment. OBJECTIVE: To report four patients with femoral shaft nonunion treated by dual implant application in a private Orthotrauma practice in Port Harcourt, Nigeria. CASE REPORTS: The first patient was a 50-year-old retroviral positive male with right femoral nonunion who had implant failure (Kuntscher nail breakage) after initial Kuntscher nailing. The second patient was a 38-year-old female who had Kuntscher nail migration following intramedullary nailing for left femoral fracture. Subsequently she had plate fixation which failed. The third patient was a 39-year-old male who was managed by traditional bone setters for a left femoral fracture. He had Kuntscher nailing but due to poor callus activity and shortening, he had a revision surgery. The fourth patient was a 26-year-old female who had left femoral shaft nonunion after initial Kuntscher nailing. She subsequently had an exchange nailing but did not achieve bony union. All the injuries were road accident related. All four patients had dual implant application (intramedullary nailing with plate and screw augmentation) and went on to bony union. CONCLUSION: Intramedullary nailing augmented with plate fixation is a useful and efficient method for treatment of femoral shaft nonunion. The technique is simple and does not require special instrumentation.

Spectrum of urological procedures in University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria.

AIM: To determine the relative frequencies of types of operations, age and gender distribution of the patients and the indications for operation in the Urology Unit over a 10-year period between 1989 and 1998. SETTING: The Urology Unit of the University of Port Harcourt Teaching Hospital. TYPE OF STUDY: Retrospective. METHODS: Patients' demographic data were collected from the Main Theatre registers of the Hospital, the Medical Records Department ward records patients' and case note. Those operations done in the Urology Unit were analysed. RESULTS: Urological operations (total 1875) formed 22.6% of all surgical operations in the hospital during the decade under review. There were 1847 males (98.5%) and 28 females (1.5%). The age distribution showed two peaks in the first decade and in the seventh decade. Frequencies of operations were least in the 4th decade and after the 9th decade. Circumcisions, surgery for prostate disease, procedures for urethral strictures, urological trauma and paediatric reconstruction formed the majority of operations. Endoscopic urological procedures were limited to the occasional cystoscopy. Some 67.6% of the operations were performed in the first half of the decade and 32.4% in the second half. A rapid decrease in the number of operations was noticed which compared with the same pattern in the Department of Surgery as a whole. CONCLUSION: We recommend the establishment and development of human and material resources for Urological service for basic procedures and endo-urological practice in keeping with contemporary trends and the allocation of more theatre space and out-patient Clinic time to the urology service.

Slow, gradual external fixator distraction in acquired ankle and foot contracture.

BACKGROUND: External fixators have been noted to have a place in the orthopaedic management of problems involving the ankle and foot. We here report a case of ankle and foot contracture managed by soft tissue release and slow, gradual external fixator distraction. METHOD: A case report of a patient with acquired ankle and foot contracture and discussion of relevant literature. RESULTS: A 9-year old female presented to our out-patient clinic with features of right ankle and foot contracture following treatment by traditional bone setters 6 years earlier. The contracture was fixed at 30 degrees. She had soft tissue release and slow, gradual external fixator distraction which corrected the foot to a plantigrade position. Subsequently she had skin grafting for the skin defect. After removal of the external fixator she was placed on a below knee cast and commenced weight bearing. The cast was removed after three weeks and the patient has continued to bear weight on a plantigrade foot. CONCLUSION: External fixators have a definite place in contracture release and should be widely utilized.

A simple lithotomy device for children.

BACKGROUND: The position of the patient is important for good access during surgery. The aim of this paper is to present a simple lithotomy device for children. METHOD: We present a simple easy-to-construct and affordable lithotomy device utilizing locally available materials for paediatricpatients. RESULTS: A simple, cheap and easy-to-construct lithotomy device for children has been used in our centre. It is also easy to sterilize and very durable. No complication has been noticed so far that is attributable to the lithotomy device. It has been used for Swenson's procedure for Hirschsprung's disease, and rectal biopsy. CONCLUSION: The affordability of the device will save hospital administrators and the country great cost while still being effective. The device is being recommended for use in developing countries where paediatric operating tables are not available.

Conservative management of tuberculous spondylitis in a developing country.

BACKGROUND: Tuberculous spondylitis is a significant health burden in the Third world. Tuberculosis and its complications are on the increase because of the HIV/AIDS challenge. The aim of this study was to review the patients managed for tuberculous spondylitis at the University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria. METHODS: This was a retrospective study of patients seen at the University of Port Harcourt Teaching Hospital between January 1999 and December 2002 with tuberculosis of the spine. Patients case notes were reviewed after collating out-and-in-patient records. Analysis was done using multiway frequency tables. RESULTS: There were 16 males and 18 females, with a ratio of 1:1.1. Their ages ranged from 3.3 to 82 years with an average of 31.1. Peak ages of occurrence were the 3rd and 4th decades. Eighteen patients (52.9%) presented within the first 6 months of symptoms. The most frequent presenting symptoms were back pain, weight loss, difficulty with walking, low grade fever, and night sweats. The most frequent signs were gibbus and lower limb paralysis. The most common association was pulmonary tuberculous (32.4%). The thoracic spine was mostly affected, followed by the lumbar spine. Wedge collapse of the vertebrae was the common radiological finding. Twenty two patients had multilevel affection. Twenty patients (71%) had a lymphocyte differential of more than 45%, 87% had erythrocyte sedimentation rate of over 20 mm/hr. Westergren, and Mantoux test was positive in 55 percent of the patients. Twelve patients had outpatient treatment and 22 had in-patient treatment. Duration of hospital stay ranged from 7 to 157 days with an average of 62.6 days. All the patients had standard combination antituberculosis therapy. No patient had surgery for tuberculous spondylitis. Outcome of treatment was good (68.2%). Follow up was poor with a high default rate. There were 3 mortalities (8.8%). CONCLUSION: Diagnostic delays partly due to lack of experience makes a high index of suspicion necessary to make a diagnosis. Outcome utilizing conservative methods of treatment is good.

Chronic pyonephrosis associated with renal neovascularisation.

The spectrum of renal tract infections is wide. When the kidney has been severely damaged, the radiological findings may suggest a malignancy. To report a case of chronic pyonephrosis, which even at exploration appeared to be a malignancy. The case record of the patient as well as the literature were reviewed and reported. A 25 year-old woman presented with a 5-year history of left lumbar pain, urinary frequency and intermittent total haematuria. The intravenous urography showed non-function in the left kidney harbouring a calculus. Treatment was delayed for poor finances. At laparotomy a huge renal mass invading the colonic mesentery and showing neovascularisation was removed. The final diagnosis was chronic pyonephrosis. She recovered from postoperative septicaemia. Neovascularisation is a feature of malignant disease mediated by angiogenesis factors. These factors are probably present in chronic inflammation. It is suggested that for nephrectomy, prophylactic antibiotics should be used. There is also a need for histopathological examination of every specimen removed at operation.

Renal cell carcinoma presenting as a scalp swelling.

BACKGROUND: Renal cell carcinoma occasionally presents in an unusual manner. AIM: To report the rare presentation of renal cell carcinoma as a scalp swelling. METHOD: The case record of a patient with renal cell carcinoma and the literature on the disease were reviewed. RESULT: A 42-year old woman presented with a scalp swelling. Haematuria was missed at the first visit until she volunteered it on a subsequent visit. Investigations suggested renal cell carcinoma. This was confirmed following a right nephrectomy. The scalp lesion was a metastasis extending through the skull into the intracranial compartment. She was not given any systemic drugs because none was available. She survived until she was lost to follow up. CONCLUSION: Haematuria remains an important symptom of renal cell cancer and should be elicited during systemic enquiry.

Nephrectomy at the University of Port Harcourt Teaching Hospital: a ten-year experience.

The case records of patients who had nephrectomy from 1989 to 1998 were retrieved. Data extracted for analysis included age, sex, clinical features, indications for nephrectomy, post-operative complications and histological findings. Thirty-four unilateral nephrectomies in 21 males and 13 females were done. The patients were aged between 1.5 to 75 years. The predominant presenting features were abdominal pain (76.5%), abdominal mass (70.6%), haematuria (61.8%) and weight loss (47.1%). Diagnostic investigations were intravenous urography and renal ultrasound scan. The major indications for renal exploration included non-functioning kidney and renal mass suspected to be carcinoma. The histopathological findings included renal malignancy 23 (67.6%), hydronephrosis 6 (17.6%) and renal infections 3 (8.8%). The male/female ratio in nephrectomy for malignancy was 1:1.09. Renal trauma was the indication in only one patient. Non-functioning kidneys on intravenous urography (IVU) occurred in both malignant and infective lesions. Hypertension was found in 9 patients preoperatively. It resolved in 7 patients after operation. The histological finding in one kidney differed from what was assumed at operation. Follow-up USS showed compensatory hypertrophy in the remaining kidneys. Post-operative sepsis occurred in 4 patients. One of these was a retroperitoneal abscess. Two patients with huge tumours died on the operating table. Two died from sepsis. Four patients died from metastatic disease within two years after operation. Malignancies constituted the commonest indication for and commonest cause of mortality in nephrectomy. Antibiotics prophylaxis is advocated. All nephrectomy specimens should be subjected to histopathological examination.

Fournier's gangrene in Nigeria: a review of 21 consecutive patients.

A review of 21 consecutive cases of Fournier's gangrene seen at the University of Port Harcourt Teaching Hospital (UPTH) in the period 1994-1998 is presented. All the patients were males with an average age of 43.4 years. Most of the patients had a predisposing factor. There was a low incidence of pre-existing medical conditions. The commonest organisms isolated were of the enterobacteria group. All the patients were treated with antibiotics, surgical debridement and frequent wound dressings with hypertonic saline, hydrogen peroxide and Eusol. In 71.4% of the cases, the wounds healed by secondary intention. The mortality was 9.5%. The deaths occurred in the older age group. We recommend surgical debridement of necrotic tissues as they present and suggest that the surgical procedures be minimal as scrotal wounds heal satisfactorily.