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.

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.

Soft tissue sarcomas in the Niger Delta Region of Nigeria (a referral hospital's study).

BACKGROUND: Soft tissue sarcomas are rare tumours in this environment. Recently, an upsurge in frequency was noticed that called for attention. The aim of this study is to study soft tissue sarcomas based on age, sex of patients, tumour sites and histologic types. METHODOLOGY: A 14 year retrospective study in University of Port Harcourt Teaching Hospital (UPTH) Port Harcourt. Histological slides previously processed and stained with hematoxylin and eosin stains (H & E) were reviewed and re-evaluated. Special stains were also used for proper diagnosis of some tumours. The tumours were classified based on World Health Organization (WHO) classification of soft tissue tumours. RESULTS: Only 66 soft tissue sarcomas were used for this study which accounted for 2.8% of the total malignancies diagnosed during the period under review. The youngest was a 3 year old girl while the eldest was a 76 year old female. A total of 38 and 28 tumours were diagnosed in males and females respectively, giving a sex ratio of 1.4:1. Rhabdomyosarcoma was most frequent (39.4%) while the least was leiomyosarcoma (1.5%). These tumours are more frequent in the under 20 years (22.7%) and least in 70 years and above (7.6%). The lower limb was most affected (36.4%) while the least was the retroperitoneum (6.1%). The commonest predilection sites vary with different classes of these group malignancies. CONCLUSION: Soft tissue malignancies are globally uncommon but they constituted an integral part of malignant tumours causing serious morbidity and mortality in this environment. The recent upsurge noticed necessitated the need for regional studies in Nigeria in order to come up with a national epidemiologic data of these malignancies.

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.