Perioperative considerations in orthopaedic patients with diabetes mellitus: a review.

Patients with diabetes mellitus are predisposed to a host of orthopaedic problems which may require surgery and many patients with orthopaedic conditions may have unrecognised hyperglycaemia presenting for the first time at surgery. This group of patients are also prone to adverse surgical outcomes like post-operative infections and poor wound healing. The control of hyperglycaemia in orthopaedic patients with diabetes mellitus is the key in optimising surgical outcome in these patients. Peri-operative insulin is the main antihyperglycaemic agent of use. The risk of hypoglycaemia with tighter peri-operative glucose control outweighs its potential benefits. Blood glucose control with insulin infusion is better than sliding scale insulin. Control of infections and promotion of wound healing are necessary adjuncts in the management to optimise surgical outcome.

A review of obesity and orthopaedic surgery: the critical issues.

Obesity is a growing concern in the health community because of the morbidities associated with it. There is a higher occurrence of many orthopaedic conditions among obese individuals than their non-obese counter parts. Obesity also worsens the progression of many of these orthopaedic conditions. Studies have shown that obesity may have negative impact on bone metabolism and may be implicated in the pathophysiology of some orthopaedic conditions like osteoporosis, fractures, osteoarthritis and many soft tissue ailments by both reduction in bone mass and elaboration of proinflammatory cytokines. These contribute to preponderance of musculoskeletal co-morbidities among obese patients. Critical peri-operative issues which include increased cardiopulmonary risks, issues of special equipment, instrumentation, surgical approach, patients' positioning and adjustments in medication should be acknowledged and meticulously addressed in operative management of orthopaedic conditions in obese patients. Surgeries in obese patients are fraught with operative challenges and post-operative complications than in the non-obese and a good knowledge of the critical issues in surgical management of obese patients is necessary to facilitate decision making as well as rendering of effective and efficient orthopaedic care.

Gross haematuria among adult Nigerians: current trend.

AIMS AND OBJECTIVES: To determine if there is any change in the common causes of gross haematuria among adults Nigerians and to determine what proportion of these aetiologies is due to urological malignancies. PATIENTS AND METHODS: Consecutive adults with presenting with gross haematuria seen in our centre were studied prospectively between February 2006 and January 2007. All patients had detailed clinical and diagnostic evaluation including urine cytology, flexible/rigid urethrocystoscopy, ultrasonography and intravenous urography to determine the causes of their haematuria. Other special investigations including CT scan and tissue biopsies were only used in selected patients as indicated. RESULTS: The cause of haematuria was determined in 74 patients (93.7%) while haematuria was of undetermined origin in 5 patients (6.3%). Fifteen different specific diagnoses were made as the causes of haematuria in this study. The three commonest individual causes of haematuria were benign prostatic hyperplasia (30.4%), bladder carcinoma (12.6 %) and carcinoma of the prostate (10.1%). Urological malignancies were diagnosed in 29.1 % of the patients. The Urological malignancies detected were bladder cancers (12.6 %), prostate cancers (10.1%), renal Cell Carcinoma (5.1%) and urethral Carcinoma (1.3%). The incidence of the cancers increased with age; 82.6% of the patients with malignancies were aged 50years and above while only 17.4% were below 50 years of age (P= 0.045). Urological malignancies were also more common in men (73.9 %) than in women (26.1 %) (P < 0.05). CONCLUSION: We conclude that there is changing trend in the aetiologies of gross haematuria among adult Nigerian patients with urological malignancies being now more prevalent than previously reported in our environment.

Usage of Complementary and Alternative Medicine (CAM) among osteoarthritis patients attending an urban multi-specialist hospital in Lagos, Nigeria.

BACKGROUND: Osteoarthritis (OA), a chronic degenerative disease of synovial joints is characterised by pain and stiffness. Aim of treatment is pain relief. Complementary and alternative medicine (CAM) refers to practices which are not an integral part of orthodox medicine. AIMS AND OBJECTIVES: To determine the pattern of usage of CAM among OA patients in Nigeria. PATIENTS AND METHODS: Consecutive patients with OA attending orthopaedic clinic of Havana Specialist Hospital, Lagos, Nigeria were interviewed over a 6- month period st st of 1 May to 31 October 2007 on usage of CAM. Structured and open-ended questions were used. Demographic data, duration of OA and treatment as well as compliance to orthodox medications were documented. RESULTS: One hundred and sixty four patients were studied.120 (73.25%) were females and 44(26.89%) were males. Respondents age range between 35-74 years. 66(40.2%) patients used CAM. 35(53.0%) had done so before presenting to the hospital. The most commonly used CAM were herbal products used by 50(75.8%) of CAM users. Among herbal product users, 74.0% used non- specific local products, 30.0% used ginger, 36.0% used garlic and 28.0% used Aloe Vera. Among CAM users, 35(53.0%) used local embrocation and massage, 10(15.2%) used spiritual methods. There was no significant difference in demographics, clinical characteristics and pain control among CAM users and non-users. CONCLUSION: Many OA patients receiving orthodox therapy also use CAM. Medical doctors need to keep a wary eye on CAM usage among patients and enquire about this health-seeking behaviour in order to educate them on possible drug interactions, adverse effects and long term complications.

Excision and end-to-end anastomotic urethroplasty in the management of post-traumatic urethral stricture disease: experience and challenges in a Nigerian teaching hospital.

AIMS AND OBJECTIVES: The study aims to assess the outcome of excision and end-to-end anastomotic urethroplasty in the management of post traumatic urethral stricture in at one of the teaching hospitals in Nigeria. MATERIALS AND METHODS: All cases of post traumatic urethral stricture disease managed by excision and end to end anastomosis between January 2000 and December 2006 were retrospectively studied. The data collected included the patients age, cause of stricture, location, length and the outcome of surgery. RESULTS: A total of 47 patients excision and end to end anastomotic urethroplasty were carried out during the period. Twenty patients (42.6%) had bulbar stricture and 27 (57.4%) had pelvic fracture urethral distraction stricture involving the posterior urethra. There was a 100% success rate in the 20 patients with bulbar urethral stricture at a minimum follow up of 1 year while the success rate for the 27 patients with posterior urethral stricture was 70.4%. Complications included one case each of perineal wound infection and of urethrocutaneous fistula which were managed conservatively. CONCLUSION: Excision and end to end anastomotic urethroplasty gives excellent results for the treatment of short segment post traumatic bulbar strictures and should be used as the primary treatment for such strictures.

Multicentre study of bone tumours.

BACKGROUND: Bone tumours are associated with high morbidity and mortality, especially in Lagos where late presentation, lack of diagnostic and therapeutic facilities as well as cultural and religious beliefs/practices constitute a formidable challenge to appropriate management. OBJECTIVE: To study the clinico-pathologic pattern of primary bone tumours in Lagos. METHODS: A 2.5 decade retrospective review of cases of primary bone tumours at National Orthopaedic Hospital, Lagos (NOH), Lagos University Teaching Hospital (LUTH), and Havana Specialist Hospital (HSH) was done. Data such as age, gender, tumour type were extracted from the medical records and analysed. RESULTS: Six hundred and ninety-eight (698) cases were reviewed. 364 cases were from NOH, 242 from LUTH and 92 from HSH. There were 10 cases in 1981, 13 in 1985, 19 in 1990, 30 in 1995, 38 in 2000 and 46 in 2005. The age range of cases was 6 to 85 years with a mean of 25.8 years and peak frequency in the 11-20 year age group. 423 patients (60.6%) were males and 275(39.4%) were females giving a male to female ratio of 1.5: 1. Three hundred and fifty-six (51.0%) were of benign while 342 (49.0%) were malignant. The commonest types were osteosarcoma 197 cases (28.2%), osteochondroma 106 cases (15.2%) and osteoclastoma 78 cases (11.2%) CONCLUSION: Primary bone tumours presenting to hospitals in Lagos are on the rise. They are common amongst males and teenagers. Majority are benign and comprise osteochondroma, osteosarcoma, osteoclastoma, aneurysmal bone cysts and chondrosarcoma.

Deep vein thrombosis: risk factors and prevention in surgical patients.

BACKGROUND: Deep vein thrombosis (DVT) is a cause of preventable morbidity and mortality in hospitalized surgical patients. The occurrence of the disease is related to presence of risk factors, which are related primarily to trauma, venous stasis and hyper-coagulability. DVT seems not to be taken seriously by many surgeons in Nigeria. This is despite comprehensive studies that show no real differences in racial demography of the disease. OBJECTIVE: To highlight the importance of physician awareness about DVT especially its risks and prevention methods. METHODS: A detailed literature search was completed to extrapolate articles that described DVT risks and prevention. This involved hand and online searches. Specific search terms used included DVT/risk factors/prevention. The searches generated 468 papers. Of these 57 papers were included in the review. RESULTS: Predominant risk factors for DVT include middle or old age, prolonged surgery, trauma, confinement, presence of malignancy and insertion of deep venous catheters. In women, contraceptive use, hormone replacement therapy, pregnancy and the puepernum are a additional risk factors. Prophylactic measures include those directed at eliminating venous stasis and those directed at changes in blood coagulability. CONCLUSION: Deep Venous Thrombosis is a common disease with fatal and serious long term burdensome complications. We must target primary and secondary prophylaxis to improve survival and reduce morbidity from this preventable disease.

The new pattern of urethral stricture disease in Lagos, Nigeria.

OBJECTIVES: The study is a follow up to two separate studies done in this centre 42 and 20 years ago on the changing pattern of urethral stricture disease(USD). It assesses the aetiology,the general pattern and treatment outcome in our centre. PATIENTS AND METHODS: This is an 8 year review of all cases of USD managed at the Lagos University Teaching Hospital between January 1998 to December 2005. Diagnosis was confirmed mainly by urethrographic studies and occasionally by endoscopy. Data collected included age, sex, aetiology, site and length of stricture, treatment and outcome. RESULTS: Eighty four patients (83 males and 1 female) with USD were seen within the period with a mean age of 43.1 years. Trauma was responsible for 60 (72.3%) cases, with road traffic accident topping the list with 29 (34.9%), with iatrogenic trauma now accounting for 17 (20.5%) of all cases of USD. Indwelling urethral catheter was responsible for 13 (76.5%) of iatrogenic cases. Purulent Urethritis was responsible for 22 (26.5%) of cases. Fifty (60.2%) cases were located in the anterior urethral while twenty three (39.8%) were in the posterior. Fifty seven patients had urethroplasty with a recurrence of 14% and 8 patients had urethral dilatation with 50% 1 year recurrence. CONCLUSION: Trauma is now the undisputed leading cause of USD in our environment. The incidence of post catheterisation strictures has also risen rapidly. Increased safety on our roads, improvement in medical education and quality of urethral catheters are suggested by this study in order to reduce the incidence of USD.

Penile fasciocutaneous flap urethroplasty: recent experience and challenges in a sub-Saharan African teaching hospital.

OBJECTIVE: To evaluate penile fasciocutaneous flap urethroplasty for complex anterior urethral strictures in circumcised West African men. METHODS: Between January 2002 and December 2006, 26 patients with anterior urethral strictures underwent penile fasciocutaneous flap urethroplasty (PFU), using a modification of the technique described by Quartey (Quartey JKM. J Urol. 1985;134:474-475). Of these patients, 21 had dorsal onlay patches and 5 had tubularize patches. Average follow-up was 19 months. RESULTS: There was a 100% immediate success rate with the dorsal onlay group. No recurrence was seen in all patients available for follow-up at 30 months. The tubularized flap had an immediate success of 80% but at 30 months it was only 40%. Troublesome postvoid dribbling was completely eliminated and complications were minor and few, which included 1 case of distal superficial dorsal penile skin loss, 1 case of urethrocutaneous fistula, and 2 cases of postvoid dribbling all of which were managed conservatively. CONCLUSIONS: PFU when used as a dorsal onlay gives excellent results at least in the immediate and intermediate periods in black West African population. A multiracial study to compare the effect of skin color on the short- and long-term outcome of PFU is also suggested.

Management of long bone fractures and associated injuries from gunshots at a nigerian tertiary hospital.

BACKGROUND: Globally, management of gunshot injuries (GSI) encompasses resuscitation, evaluation and treatment. Wound debridement is mandatory, while definitive treatment of any associated fracture varies from one part of the world to another. In developed countries aggressive modalities of early operative fixation of such fractures have produced good results. In the Nigerian environment, the approach to such fractures is controversial and cautious, with secondary operative and even non-operative methods still being predominant. OBJECTIVE: To compare operative versus non-operative methods of treatment of long bone fractures and associated injuries from gunshots in our centre. METHODS: This is a prospective study of long bone fractures and associated injuries from civilian gunshots presenting at Lagos University Teaching Hospital (LUTH), Lagos, Nigeria between 1st January 2000 and 31st December 2003. LUTH, one of the tertiary hospitals in Nigeria receives most of the multi-system trauma referrals in Lagos State, Nigeria. RESULTS: Three hundred and sixty patients with GSI were studied, 322 (89.4%) were males while 38 (10.6%) were females, giving a male: female ratio of 8.5:1. One hundred and thirty-six patients (37.8%) had long bone fractures, 94 (69.1%) on the lower limbs. All wounds were debrided and 198 (55.0%) had serial debridement. Eighty-two (60.3%) of 136 patients with fractures from G.S.I had operative treatment done secondarily and 87.5% of them achieved union. Also 42 (77.8%) of 54 patients treated non-operatively achieved union. Two hundred and thirty-four (65.0%) of the gunshot wounds healed by secondary intention, 81 (22.5%) had split thickness skin grafting and 18 (5.0%) had flap cover. CONCLUSION: This study showed that secondary operative treatment of long bone fractures in GSI produces good outcome.

Concerns, attitudes, and practices of orthopaedic surgeons towards management of patients with HIV/AIDS in Nigeria.

The increasing number of people living with HIV/AIDS is causing concern among surgeons over risk of occupationally acquired HIV infection. This may influence their attitude to such patients. The purpose of this study was to develop a cross-sectional survey of orthopaedic surgeons to assess their concerns, attitudes, and practices towards management of HIV-positive patients in Nigeria. All respondents were males, 55 (73.3%) of them indicated concern over the risk of occupational acquisition of HIV infection and 37 (49.3%) had examined or operated on at least one HIV/AIDS patient. Sixty (79.9%) were willing to be tested for HIV and 51 (67.9%) were previously tested. Fifty-seven (75.9%) would order preoperative HIV screening of high risk patients, and 67 (89.3%) would operate on HIV-positive patients. Most orthopaedic surgeons in Nigeria would operate on HIV-positive patients.

Day-case surgery for inguinal hernia: a multi-specialist private hospital experience in Nigeria.

BACKGROUND: The growing popularity of day-case surgery derives mainly from its twin benefits of convenience and cost-effectiveness. It is particularly useful in treating inguinal hernia which remains one of the most common presenting surgical problems. OBJECTIVE: To evaluate the results of inguinal herniotomy or herniorrhaphy done as a day-case. METHODS: A cross-sectional study of 72 cases of inguinal hernia treated by day-case herniotomy or herniorrhaphy at Havana Specialist Hospital, Lagos, Nigeria between July 2002 and June 2004. Post-operative follow up ranged from 2 to 4 years. Patients with concurrent systemic illness that needed admission as well as those who preferred admission were excluded. Data including age, gender, hernia characteristics, type of anaesthesia, complications and outcomes were collected and analysed. RESULTS: A total of 72 cases were studied. Only 4 were females, the remaining 68 were males. Ages 6 months to 60 years were affected with a mean age of 26.7 years and a peak incidence in the 21-30 years age group. The commonest complication was pain felt post-operatively by 62.5% of the study population. However, wound infection (seen in 11.2%) was the most significant complication. Other complications were wound and scrotal haematoma (8.3%), hemia recurrence (1.4%) and hypertrophic scar (1.4%). No mortality was recorded. CONCLUSION: The study showed that post-operative pain is the commonest complication of day-case inguinal hemiotomy and herniorrhaphy. Wound infection was however the most common significant complication. The overall outcome was good.

Pattern of extremity gunshot injuries seen in Lagos University Teaching Hospital, Lagos, Nigeria.

BACKGROUND: The rising incidence of gunshot injuries (GSI) remains one of the leading causes of death, long hospitalization and economic losses worldwide. This study was undertaken due to rising incidence of civilian GSI in Lagos, Nigeria. OBJECTIVE: To determine the epidemiological characteristics of extremity gunshot injuries in Lagos, Nigeria. METHODS: This three year crossectional study of extremity gunshot injuries was conducted at the Lagos University Teaching Hospital (LUTH), Lagos, Nigeria between 1st January 2000 and 31st December 2002. RESULTS: Two hundred and fifty four patients with extremity gunshot injuries presented with 240 analyzed. Those brought in dead (BID) were excluded from the study. Ninety-five percent of the patients were males. One hundred and twenty six patients (52.5%) were in the 21-40 years age group. The patients were shot mainly (75%) at night and mostly (80%) by armed robbers. Shot guns were used in shooting 47.5% of patients. CONCLUSION: The study showed that young adult males were more affected by GSI. Most of the shootings occurred at night by armed robbers.