Malignant change in chronic irritation: a case series.

BACKGROUND: Chronic irritation is a known cause of malignant change in humans. It is believed that at least a minimum of five years is needed for the evolution of the illness. OBJECTIVE: To present cases of consecutive squamous cell malignant change in patients with various irritations, and to highlight that these cases are not too uncommon in our environment. METHODS: Case reports of patients with definitive treatments offered. Patients had amputation done after incisional biopsies were done to determine the mitotic status of the lesions. RESULTS: The three patients presented late. All had lower limb affectation. Conservatism was difficult, all of them ending up with amputation of the affected limbs. One of them had inguinal lymph node metastasis after the amputation, signifying advanced disease, but unfortunately had to leave hospital because she could not cope with the financial demands of treatment. CONCLUSION: Malignant change from chronic irritations can occur under five years. Education might help early presentation and improved outcome. Our hospitals should provide for the treatment of these group of patients despite their financial status.

Poliomyelitis: Pattern and Treatment Outcome in Niger Delta; Nigeria

Background: Poliovirus is an enterovirus in the family of Picornaviridae and consists of three antigenic types; 1; 2; and 3. All three types cause paralysis. It is a major cause of musculoskeletal deformity in many African communities including Nigeria. The deformities include muscle weakness; contractures; grotesque foot deformities and angular deformities around the knee; amongst others. Aim: To highlight 20 children with musculoskeletal deformities due to poliomyelitis treated in a private hospital in Port Harcourt. Methods: Twenty children with musculoskeletal deformities due to poliomyelitis were retrospectively studied. Results: The patients' ages ranged from1 to 16 years; with 95of them under 15 years of age. More than 50of the study group had poor immunisation status as 6 of them were unimmunised (30) and 5 (25) of them were incompletely immunised. Even though all school strata were represented; most of them were not schooling. The commonest deformity was contracture of the knees (100) and muscle wasting in the affected limbs. All of them had loss of muscle power in the lower limbs. Surgical correction was achieved by soft tissue release in 95of them and osteotomy in 5. The outcome was good; as acceptable extension of the knee was achieved post operatively. Conclusion: The musculoskeletal abnormalities of poliomyelitis contribute highly to physical disability. All patients affected by paralytic poliomyelitis become disabled to some extent and this increases the disease burden in Nigeria

Rotation of spinal curvatures of patients with structural scoliosis.

BACKGROUND: Scoliosis has obscure aetiopathogenesis and is underreported in our environment. OBJECTIVE: To examine the pattern, magnitude, direction and extent of rotation of 42 structural curves in scoliotic patients. METHODS: Plain radiographs of the spine in patients with scoliotic deformities were randomly selected from the film libraries of four Nigerian tertiary institutions.These were then assessed radiologically for the indices above, including the use of Cobbs method and the pedicle technique of Moe. RESULTS: In all, 14 thoracic and 28 thoracolumbar curves were evaluated. A double curve was identified in only one patient. Average age (range) of affected males was 31 (3-78) years and for females (n=25), it was 19.4 (3-40) years. Mean Cobb angle was 23.6 degrees (10 degrees-70 degrees) in males and 40.1 degrees (10 degrees-89 degrees) in females. In 29 (69%) of curves, angle magnitude was d" 30 degrees. Direction of spinal curvature was right convexity in 33 (78.6%) of evaluated curves while most curves 35 (84.4%) exhibited +1 vertebral rotation. CONCLUSION: Females present earlier than the males with a higher Cobb angles. Progression of curves appears to be a higher challenge in females. There is need for scoliosis surveillance programme for early diagnosis.

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.

A report of two cases of uncemented total hip replacement in patients with sickle cell disease.

This is a report of two sickle cell patients (HbSS) with advanced osteoarthritis of the right hip. The patients were in Ficat and Arlet's stage 3 and 4 respectively. Both were females aged 23 and 46 years and they had uncemented hydroxyapatite coated omnifit (Stryker Howmedica Osteonics) total hip prosthetic replacement. The results so far have been quite encouraging. The procedure is technically demanding, fraught with risks and expensive but very useful. This is the first of such reports in Nigeria.

Epidemiology of open Tibial Fractures in a Teaching Hospital

) were males and the majority had at least a secondary education (86.7) and were single (95.1). Most of them (82.2) were aware of sexually transmitted infections; and 77.9were aware that condoms prevent transmission of HIV. Seventy-one percent of the young persons were sexually experienced (i.e. previously had sex); 12.9admitted they had previously had sex in exchange for money; and 63.4reported ever using a condom. Median age of sexual debut (sexarche) was 15.7 years. Most (82.1) of the sexually experienced were currently sexually active reporting sexual intercourse within the 6 months preceding survey. Nearly half (47.1) of these had sex with a casual and/or commercial sex worker without a condom.Conclusion: Young people are adopting sexual practices that are essentially high-risk; with severe implications for regional and national socio- economic development. This underscores the fact that they know only little and lack skills to protect themselves from being infected with HIV infections; even when they are sexually active. There is therefore need to advocate for and support initiatives that address reproductive health needs of young people in the Niger Delta region

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.

Gunshot injuries in the Niger Delta region of Nigeria

Background: Violent trauma especially by gunshot injuries appears to be on the increase worldwide. There is inadequate data from many centres in Nigeria to support this observation. Aim: To determine the pattern of gunshot injuries in the University of Port Harcourt Teaching Hospital (UPTH). Methods: This was a prospective study covering a period of three years (January 2002-December 2004). A standard proforma was used to record all cases of gunshot injuries reporting to the UPTH. Details sought were age, gender, occupation, gun type, anatomic region of the body involved and treatment given. Other information recorded were time of injury, duration of hospital stay, injury time before presentation, assailant and outcome. Information was obtained directly from victims, relations, the police or those accompanying the victim. Where surgical operations were done or patients were admitted to the wards, relevant information or findings were then retrieved from theatre and ward records. Results: There were 135 patients (120 males and 15 females) between the ages of 1½ -67 years. Students and civil servants constituted the largest number. Seventy-one injuries were due to high velocity missiles while 64 were low velocity. Armed robbery and attacks by "unknown assailants" were the commonest modes of attack with 47 and 41 victims respectively. The lower limbs, abdomen and chest were the most frequent anatomic regions involved recording 38, 28 and 27 cases respectively. There were 9 cases in which multiple anatomic sites were affected. The majority of patients (56) presented within 12-18 hours after injury; only 9 cases presented within 6 hours. Twenty-nine patients underwent laparotomy while 14 had thoracostomies. Forty-nine patients were treated and discharged. Minor surgery (like wound debridement) was the commonest treatment in 43 patients. All cases of fracture among these were subsequently referred to the trauma unit for appropriate treatment. Thirty patients died giving a mortality rate of 22.2%. Conclusion: Gunshot injuries constitute a major cause of violent trauma in the Niger Delta Region of Nigeria with a high and disturbing level of morbidity and mortality

Pattern and management approach of diabetic foot disease in a developing country.

BACKGROUND: Diabetes mellitus is a common endocrine illness in our environment. Diabetic foot gangrene is its commonest surgical complication and is a health burden in Niger Delta region of Nigeria. The aim of the study was to highlight the demography, bacterial incidence, time frame to development of diabetic foot, reaction to ablative surgery and the use of San Antonio wound classification system forthe treatment decision. METHODS: We retrospectively reviewed 46 diabetic feet in 41 diabetics over a 5 year period, January 1999 to December 2003, using the San Antonio classification system. The case notes of all patients seen in the University of Port Harcourt Teaching Hospital were included in the study. RESULTS: There were 32 males and 9 females with a male female ratio of 3.6:1. The age range was 34 to 90 years with a mean of 56 +/- 12 years. The mean duration between diagnoses of diabetes mellitus and development of foot disease was 13 +/- 5 years. Twenty four patients (59.5%) with stages A or B irrespective of the grade had a chance of limb salvage using appropriate antibiotic, serial wound debridement, regular dressing and skin grafting where necessary. Of the 24, 3 absconded, 5 died and 16 healed and were discharged. The remaining 17 patients (40.5%) were stages C and D and were offered ablative surgery irrespective of the grade. Nine discharged against medical advice, 5 died and 3 were discharged in good condition. CONCLUSION: This is a disease of the older population. Delay in accepting ablative surgery affects prognosis. Outcome in management of diabetic foot disease can be improved by education, early presentation, funding for establishment of specialized diabetic foot clinics and early decisive definitive management.

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.

Proposal for lateral malleolar reconstruction in fibula loss proximal to the syndesmosis.

BACKGROUND: High energy ankle injury can be devastating. Fibula loss proximal to the syndesmosis is a management challenge. The aim of this paper is to show that simple fusion of the floating lateral malleolus to the tibial plafond can restore the ankle mortice integrity. METHOD: A case report of a patient that had spontaneous fusion of the lateral malleolus to the lateral tibial plafond after a high energy injury and subsequent sepsis. RESULT: Uneventful union of the lateral malleolus to the lateral tibial plafond. CONCLUSION: Ankle fusion, bone lengthening procedures are time consuming and costly. A simple fusion of the lateral malleolus to the tibial plafond will restore stability to the ankle joint.

Mortality patterns in the accident and emergency department of an urban hospital in Nigeria.

OBJECTIVE: The accident and emergency (A & E) department of any hospital provides an insight to the quality of care available in the institution. The University of Port Harcourt Teaching Hospital (UPTH) is a foremost institution in the South-South geopolitical region of Nigeria, servicing a core population of about 5 million people. The aim of this review was to highlight the demographic patterns of mortality, time spent before death in the emergency room. METHODS: A 3 year retrospective review, covering April 2000 - March 2003, of patients attended to in the Accident & Emergency department of University of Port Harcourt Teaching Hospital was carried out. Casualty records including attendance registers, Nurses' report books and death certificates were used to extract demographic indices, causes of death and time from arrival to death in the Accident and Emergency Unit. Multiway frequency tables were used for analysis. RESULTS: Of the 22,791 patients seen during the study period, 446 died, giving a crude mortality rate of 2 percent. The male to female ratio was 1.5:1; the trauma subset and the non-traumatic subset being 4.6:1 and 1.2:1 respectively. Most of the cases were of non-traumatic origin (79.8%), with the 20-49 age group being the most affected when all the cases were taken into consideration. However, the overall mean age was 33+/-9.4 years. The peak age in trauma deaths was 20-29 year, while that in non-traumatic deaths was 40-49 years. Some of the deaths (3.4%) could not be traced to any cause. Probably due to incomplete records or ignorance to the cause of death. Road traffic accidents and assaults were the commonest causes of traumatic death, accounting for 57.8% and 11.1% respectively. Bulk of the non traumatic deaths (25.2%) was from cardiovascular diseases. Most of the patients (70.9%) died within six hours of arrival in the accident and emergency, while 3.6% (16) were dead on arrival. The average time in the casualty before death was about 22.0 hours. Contributing factors to theses deaths might include poor infrastructures on ground, inadequate transportation to hospital, delay in presentation and inadequate clinical exposure by the first line physicians in the accident and emergency department. CONCLUSION: Improvement in management techniques might unravel the mysteries of death of unknown origin. Management of medical emergencies should be emphasized in the training of accident and emergency workers.

Paediatric accidental deaths in Port Harcourt, Nigeria: a 10-year retrospective study.

BACKGROUND: Some studies on medicolegal autopsies have been conducted in Nigeria. This study was carried out to highlight the causes, peculiarities and possible factors responsible for paediatric accidental deaths in Port Harcourt, Nigeria. METHODS: All 3058 medicolegal autopsies referred to the coroner and performed in the department of Anatomical Pathology University of Port Harcourt Teaching Hospital, over a 10 year period covering January 1986 to December 1995 were analyzed. The accidental death subset was specially analyzed with respect to the paediatric age group of 0-16 years. RESULTS: A total of 3084 coroners autopsies were carried out during the study period. Of these 356 (11.5%) were paediatric accidental deaths. The commonest cause of death was road traffic accidents constituting 84.3% (n=300). The male:female ratio was about the same. The head was the commonest body region affected (n=90). Cars and buses were the commonest vehicles involved. Pedestrians were most at risk constituting 66 percent. Bulk of the cases occurred over the weekends. Drowning, electrocution and burns accounted for 8.7%, 2.8% and 4.2% respectively. CONCLUSION: Most of the deaths are avoidable. Parental monitoring, control of movements, legislation and general concern of the adult population for children's welfare will reduce these largely preventable deaths.

Pedestrian deaths resulting from road traffic accidents seen at the University of Port Harcourt Teaching Hospital--six-year review.

BACKGROUND: Road traffic accidents form an increasing bulk of trauma deaths worldwide. The aim of this study was to highlight the pedestrian deaths in our hospital experience and to suggest ways of curbing the menace. METHODS: A six-year retrospective review of mediocolegal autopsy consultations at the University of Port Harcourt Teaching Hospital. Multiway frequency tables were used for analysis. RESULTS: Cars constituted the commonest cause of pedestrian deaths (51.2%). This was followed by motorcycles (39.5%), with heavy vehicular deaths contributing 9.3%. The male to female ratio was 1.5:1. The under 20 years age bracket constituted 32.6% while the under 30 years constituted 53.5%. Multiple injuries contributed to 48.8% of deaths followed by head/neck injuries (34.9%). CONCLUSION: The scourge of fatal road accidents does not spare the pedestrian. Preventive measures are advocated. Legislation, individual discretion and societal commitment will definitely reduce this scourge.

Domestic accidental deaths in the Niger Delta Region, Nigeria.

BACKGROUND: Domestic accidental deaths constitute a public health burden in the Niger Delta Region of Nigeria. This study is aimed at highlighting this public health burden. OBJECTIVE: This is study is aimed at highlighting this public health burden. DESIGN: A six year retrospective study using mortuary records. SETTING: University of Port Harcourt Teaching Hospital, Port Harcout, Nigeria. PATIENTS AND METHODS: Coroner's forms data were used from University of Port Harcout Teaching Hospital, Anatomical Pathology Department, which is the foremost health institution in the region serving a core population of about six million people. RESULTS: Eighty three domestic accidental deaths seen at the University of Port Harcourt Teaching Hospital in the Niger Delta Region of Nigeria between January 1995 and December 2001 were analysed. The 83 deaths occurred in 63 males and 20 females, giving a ratio of 3:1, between the ages of six months and 86 years. There was a bimodal age distribution, with 20 cases (24.1%) occurring in preschool age children, and 22 cases (26.5%) occurring in the elderly over 70 years. Fifty one deaths (61.4%) occurred in the urban areas, while 32 cases (36.8%) occurred in the rural areas. Seventeen cases (20.5%) occurred from falls from height or same level, thereby, constituting the commonest mechanism of injuries that lead to death in the elderly. In children, the commonest mechanism of injuries leading to death was poisoning. The yearly incidence of these deaths is decreasing with the peak of 26.5% in 1995, and 6.0% in 1999. CONCLUSION: Enforceable legislation by government coupled with public education to reduce occurrence should be encouraged. Safety at home must be taken very seriously.

The scope of extremity amputations in a private hospital in the south-south region of Nigeria.

BACKGROUND: The aim of the study was to review extremities amputation cases in a private medical establishment in Port Harcourt with a view to identifying the incidence, indications, and limb status at surgery. METHODS: Hospital records were reviewed on amputation cases from June 1998 to May 2003. Upper and lower limb amputations done elsewhere with stump reviews by us were included. RESULTS: Thirty-four cases were reviewed, with a male to female ratio of 2.1:1. The 2nd to 4th decade produced 67.6 percent of the victims. Trauma contributed 70.5 percent of the cases, with road trauma contributing 47 percent of the entire series. Gangrene as a result of injury complication was the commonest indication for surgery. Lower limb amputations were commoner (n = 24) than upper limb amputations (n = 10). Below knee amputation was the commonest procedure performed. The percentage of the patients who consulted the traditional bone setter before presentation in hospital was 33%. CONCLUSION: Complications of injuries arising from road traffic accidents are a major cause of limb loss in our environment. Ignorance and cultural beliefs expose innocent persons to quacks especially traditional bone setters. Education and strong legislation is advocated to prevent unwarranted limb loss.