Outcome analysis of surgical treatment of Blount disease in Nigeria.

OBJECTIVE: The objective was to evaluate the results of surgery of Blount diseases using the postoperative metaphyseal-diaphyseal angle (MDA) at 2-year follow-up. BACKGROUND: The goal of surgery in Blount disease is to restore the normal configuration of the articular surface of the proximal end of the tibia in proper relationship to the mechanical axis of the limb. Our hypothesis is that patients will demonstrate significant clinical improvements following surgery and predictive models can be developed. MATERIALS AND METHODS: All patients who had surgery for Blount disease from January 2002 till December 2007 at the National Orthopaedic Hospital Lagos Nigeria and follow-up for 2 years were included. Data extracted were gender, affected limb, Blount's type, age when deformity was noted, and age at presentation, preoperative femoral tibial angle (TFA), Langenskiold score, preoperative MDA, and postoperative MDA. Linear regression was used to assess the predictive effect of selected clinical and radiographic measures on post-MDA. The model was adjusted for confounders: age deformity noted, age at presentation, affected limb, Blount's type, and gender. Variables in the adjusted model achieving significance at P < 0.05 were included in a multiple regression analysis. RESULTS: Eighty-six knees in 57 patients were included. The mean preoperative and postoperative MDA at 2 years was 34.6° ± 8.9° and 10.6° ± 4.3°, respectively. Seventy-three knees (84.9%) have correction of ≤10° with recurrence in 13 (15.1%) knees at 2 years (P < 0.001). The postoperative MDA was graded into good outcome if ≤10°. There was a significant improvement between preoperative MDA and postoperative MDA (P < 0.001). The multilinear analysis demonstrated that the preoperative MDA was a significant predictor of the postoperative MDA. The postoperative MDA was predicted with a standard error of 0.92 with the following formula: post-MDA = 1.027 + 0.404 pre-MDA. CONCLUSION: The mean postoperative MDA of 84.9% of the knees operated at 2 years was 9.4° ± 3.1° with recurrence rate of 15.1%. Postoperative MDA is a good outcome measure for surgical treatment of Blount disease and surgical correction should aim at producing post MDA ≤10°.

Review of the practice of traditional bone setting in Nigeria.

BACKGROUND: The practice of traditional bone setting (TBS) is extensive in Nigeria and it enjoys enormous patronage by the populace. However, the outcome of the intervention of TBS treatment is usually poor with profound effects on the patient. There are many publications highlighting different aspects of this subject but none has summarized the entire practice and problems as a single publication. OBJECTIVE: This work aims at reviewing the entire subject of traditional bone setting in Nigeria in a single article to enable easy understanding and appreciation of the practice and problems of traditional bone setting by orthodox practitioners. METHOD: A total of thirty-one relevant published original scientific research papers involving all aspects of the subject were reviewed and the practices and problems were documented. RESULTS: The results showed that the origin of the practice is shrouded in mystery but passed on by practitioners from one generation to another. There is no formal training of bonesetters. Though the methods of treatment vary, the problems caused by them are usually similar with extremity gangrene being the worst. When attempts have been made to train the bone setters, improvement have been noted in their performance. CONCLUSION: In other to prevent some of the most debilitating outcomes like amputation, it is suggested that the TBS practitioners undergo some training from orthopaedic practitioners.

Risk factors for pressure ulceration in a resource constrained spinal injury service.

STUDY DESIGN: Pressure ulceration and other complications constitute an encumbrance in the management of spinal cord injury in many services with limited resources in developing countries. These services undertake patients' care without adequate prehospital care, limited modern infrastructure and limited number of trained staff. OBJECTIVES: To evaluate the associated risk factors for pressure ulceration in traumatic spinal cord injured managed in a resource constrained spinal injury unit in Lagos, Nigeria. A regional acute trauma and rehabilitation centre serving a population of >20 million. METHODS: This is a prospective study in patients presenting with traumatic spinal cord injury between 1 October 2004 and 30 November 2006. The data collected include demographic characteristics, interval before admission in the unit, type of spinal cord injury and serum albumin. The incidence of pressure ulcers and the isolated organisms was recorded for patients who developed pressure ulcers on admission and during the period of stay in the unit. The length of hospital stay was also recorded for all the patients. RESULTS: The overall incidence of pressure ulceration on admission was 57.1%. There was an average lengthening of hospital stay of 33.1 days in the group of patients with pressure ulceration compared to patients without pressure ulcers. The nutritional status on admission, interval before admission and the type of neurological injury were significant factors for the incidence of pressure ulcers. CONCLUSION: The incidence of pressure ulceration was high, delay in admission and poor nutritional status may be significant factors in the incidence of pressure ulceration in spinal cord injury.

Review of the Practice of Traditional Bone Setting in Nigeria

Background: The practice of traditional bone setting (TBS) is extensive in Nigeria and it enjoys enormous patronage by the populace. However; the outcome of the intervention of TBS treatment is usually poor with profound effects on the patient. There are many publications highlighting different aspects of this subject but none has summarized the entire practice and problems as a single publication. Objective: This work aims at reviewing the entire subject of traditional bone setting in Nigeria in a single article to enable easy understanding and appreciation of the practice and problems of traditional bone setting by orthodox practitioners. Method: A total of thirty-one relevant published original scientific research papers involving all aspects of the subject were reviewed and the practices and problems were documented. Results: The results showed that the origin of the practice is shrouded in mystery but passed on by practitioners from one generation to another. There is no formal training of bonesetters. Though the methods of treatment vary; the problems caused by them are usually similar with extremity gangrene being the worst. When attempts have been made to train the bone setters; improvement have been noted in their performance. Conclusion: In other to prevent some of the most debilitating outcomes like amputation; it is suggested that the TBS practitioners undergo some training from orthopaedic practitioners

In-situ pinning for Slipped Capital Femoral Epiphysis in blacks: experience in a regional orthopaedic centre.

BACKGROUND: Slipped Capital Femoral Epiphysis (SCFE) is the commonest pathology affecting the adolescent hip with an incidence of approximately 2 per 100,000 population. Blacks are more commonly affected than Caucasians. Of many treatment options available, in-situ-pinning appears to be the most widely employed. AIMS AND OBJECTIVES: To determine the epidemiological pattern and the outcome of in-situ pinning for slipped capital femoral epiphysis in Nigerian adolescents. PATIENTS AND METHODS: This is a six-year retrospective review of all the cases of slipped capital femoral epiphysis treated by in-situ pinning between 1st January 1998 and 31st December 2003 at the National Orthopaedic Hospital, Igbobi, Lagos, Nigeria. RESULTS: Thirty-one patients with 35 affected hips were managed with in-situ pinning during the period of review. Twenty-one females (67.7%) and 10 males (32.3%) with a F:M ratio of 2.1:1 were affected. The mean age for all the patients was 12.45 years (range 6 - 16; SD ± 1.79). The most common presenting complaint was hip pain seen in 48.4% of cases. Satisfactory results were obtained in 13 hips (37%) while the results in the remaining 22 hips were unsatisfactory. The most common complication was limb length discrepancy. CONCLUSION: This study shows that SCFE is not an uncommon condition in orthopaedic practice in Nigeria. The high rate of unsatisfactory results is associated with the severity of the slips and the unavailability of image intensifier at the time of surgery.

Hereditary multiple exostoses: case report.

OBJECTIVE: Hereditary Multiple Exostoses (HME) is a genetically transmitted bone dysplasia that is inherited in an autosomal dominant manner. It usually presents after the age of two years as multiple bony growths on the appendicular skeleton. As a rare condition (incidence of 0.9-2/100,000), it is not commonly seen in our environment. This paper presents the clinical and radiological features of two patients seen in our hospital within a period of six months. METHOD: The case records of two patients with hereditary multiple exostoses are presented to highlight the clinical presentation and management options of the condition. RESULTS: A boy and a girl who respectively manifested the features of hereditary multiple exostoses at the age of two and six years are presented. The main presenting features were painless progressively increasing bony swellings in both upper and lower limbs, with forearm deformity and ulnar deviation of the wrist. One of them had pressure symptoms which necessitated surgical excision of the symptomatic exostosis. Fine needle aspiration cytology confirmed the diagnosis ofosteochondroma. CONCLUSION: Hereditary multiple exostoses though rare, do occur in our environment and the management is essentially by masterly inactivity except when the bony swellings exhibit any complications or there is concomitant deformity.

Lower limb injuries arising from motorcycle crashes.

BACKGROUND: Motorcycle accidents are the second most common cause of road traffic accidents in both developing and developed countries. In this study we aim to look at the pattern and characteristics of lower limb injuries arising from motorcycle accidents and evaluate early outcome of treatment. METHODS: All the patients with lower limb injuries arising from motorcycle accidents who presented in our hospital between 1st October 2006 and 30th September 2007 were reviewed. History was obtained and detailed examination was done after resuscitation to determine the site, nature and the characteristics of injuries. Definitive treatment (conservative or operative) given was based on the pattern and type of injuries. Patients were followed up in the clinic for both clinical and radiological review. Functional outcome assessment was commenced after the onset of weight bearing. The data were recorded on a designated proforma and analyzed using a statistical programme. RESULTS: A total of 429 motorcycle accident victims were seen during this period and lower limb injuries represented the commonest type of injury (238, 55.5%). Male:female ratio was 2.2:1 with a mean age of 43.1years. Fractures were the commonest lower limb injuries (73.4%) and closed fractures were commoner than the open fractures. The commonest anatomical location of fractures in lower limbs was tibial shaft. Joint stiffness was found to be the commonest post treatment complication. CONCLUSION: Lower limb injuries represent the commonest form of injuries among the motorcycle accident victims. Fractures were the commonest type of injury seen and the most common location was shaft of tibia.

Bilateral simultaneous fracture of the carpal scaphoid successfully treated with conservative cast immobilisation: a case report.

BACKGROUND: The scaphoid is the most prominent of the carpal bones in the first row and the most frequently fractured of all the carpal bones. Bilateral simultaneous scaphoid fractures are uncommon. OBJECTIVE: To report bilateral simultaneous fractures of the carpal scaphoid bones and their successful treatment with bilateral thumb spica casts METHODS: A 28-year-old medical practitioner presented with a day history of painful swollen wrists following a fall on both outstretched hands. He was fully examined and had both wrists X-rayed. He was subsequently treated with bilateral below elbow thumb spica POP cast. RESULTS: He had previously been healthy until this fall. Physical examination showed a healthy looking young man in pain. There were swelling and tenderness over both anatomical snuff boxes with associated limitation of movements at the wrists. X-rays revealed an undisplaced scaphoid wrist fracture and proximal pole fracture on the right and left respectively. He was successfully treated with bilateral below elbow thumb spica POP cast applied over a period of eight weeks. CONCLUSION: Although recent opinions tend to favour internal fixation for bilateral simultaneous fractures of the scaphoid bones to avoid prolonged cast immobilization and loss of man hours at work, they can be successfully treated with conservative cast immobilisation with comparatively early return to full activity.

Lower Limb Injuries Arising From Motorcycle Crashes

Background: Motorcycle accidents are the second most common cause of road traffic accidents in both developing and developed countries. In this study we aim to look at the pattern and characteristics of lower limb injuries arising from motorcycle accidents and evaluate early outcome of treatment. Methods: All the patients with lower limb injuries arising from motorcycle accidents who presented in our hospital between 1st October 2006 and 30th September 2007 were reviewed. History was obtained and detailed examination was done after resuscitation to determine the site; nature and the characteristics of injuries. Definitive treatment (conservative or operative) given was based on the pattern and type of injuries. Patients were followed up in the clinic for both clinical and radiological review. Functional outcome assessment was commenced after the onset of weight bearing. The data were recorded on a designated proforma and analyzed using a statistical programme. Results: A total of 429 motorcycle accident victims were seen during this period and lower limb injuries represented the commonest type of injury(238; 55.5). Male: female ratio was 2.2:1 with a mean age of 43.1years. Fractures were the commonest lower limb injuries(73.4) and closed fractures were commoner than the open fractures. The commonest anatomical location of fractures in lower limbs was tibial shaft. Joint stiffness was found to be the commonest post treatment complication. Conclusion: Lower limb injuries represent the commonest form of injuries among the motorcycle accident victims. Fractures were the commonest type of injury seen and the most common location was shaft of tibia

Complications of treatment of musculoskeletal injuries by bone setters.

BACKGROUND: Traditional bone setters (TBS) have existed for decades in Nigeria and other countries. Their treatment methods often lead to several complications, the most dangerous being extremity gangrene which usually leads to proximal amputation. OBJECTIVE: To apprise the Orthodox Practitioners of complications of musculoskeletal injuries treated by the bone setters, the factors that encourage patronage of TBS services and the outcome of the treatment of these complications by the orthodox practitioners. METHODS: This was a one-year prospective study involving one hundred and twenty-one consecutive patients presenting with complications related to treatment of their musculoskeletal injuries by bone setters. The following data were obtained using observer-administered questionnaires viz; demography, details of initial injury, reasons for patronage of TBS, nature of treatment, estimated cost of treatment and disability of patients at presentation. The outcome of orthodox treatment of these complications was assessed at six months using the following parameters --wound healing, bone union and use of prosthesis by the patients. RESULTS: One hundred and twenty-one patients with 155 musculoskeletal injuries and 168 complications of treatment by the TBS were seen 75 (57%) were male and 52 (43%) were female. The ages of the patients ranged from 6 weeks--72 years (mean 29.49 years). The common complications of TBS treatment were malunion and non-union which each accounted for 27 (16.1%) cases. The major reasons for TBS patronage was the perceived low cost of treatment in 47 (27.9%) and pressure from family and friends in 36 (25%) patients. The cost of treatment of the TBS ranged from USD 18-380, whereas, at the Orthopaedic Hospital, it ranged from USD 34-98. At six months after orthodox surgery, 10 (91%) of the patients who had amputation were yet to start using prosthesis, 3 (23%) who had internal fixation failed to unite. CONCLUSION: The commonest reason for patronage was the believed cheapness of the TBS services. However, this study showed that orthodox treatment is actually cheaper in most cases. Despite all the complications associated with their treatment, majority of the people still have a strong belief in their capability. A suggested solution will be the incorporation of the TBS into the healthcare system so that they could be better trained and controlled.

Ankle arthrodesis- a 5 year review.

BACKGROUND: Painful arthrosis is the commonest indication for ankle arthrodesis. This procedure is infrequently undertaken in our centre - National Orthopaedic Hospital, Igbobi, Lagos (NOHIL), which is the biggest orthopaedic hospital in Nigeria. In order to determine its relevance to orthopaedic practice in Nigeria, we carried out a retrospective study on the indications, complications and functional outcome of ankle arthrodesis at the NOHIL, Nigeria. METHOD: The study was a 15-year retrospective analysis of all cases of ankle arthrodesis undertaken at NOHIL. There were 58 patients that underwent ankle arthrodesis during the period 1989 to 2003. Thirty five of these with complete records and radiographic films were included in the study. Demographic data, indications, surgical techniques, complications and outcome of treatment were analysed using SPSS version 11. RESULTS: There were 37 arthrodeses, involving 18 male and 17 female patients. The mean age was 41.4years with a mean follow-up period of 17months. The main indication for arthrodesis was posttraumatic arthrosis followed by severe acute ankle injuries. AO and Charnley compression techniques were the commonest surgical procedures employed. Eighteen (48.6%) patients had a good outcome, 10 (27.0%) patients had a fair outcome and 5 (13.5%) had a poor outcome. The outcome of the remaining 4 cases could not be ascertained as they were lost to follow up at an average of 4.6 months post surgery. CONCLUSION: The commonest indication for ankle arthrodesis was post-traumatic ankle arthrosis in this study. The use of external fixation technique was the most prevalent method of achieving arthrodesis with a fusion rate of 85%. Post surgical infection was however high but a good outcome was achieved in majority of cases.

Management of Civilian Gunshot Injuries to the Extremities in Nigeria-an Overview

There is an increasing incidence of missile injury attributable to improved technology; and increased crime and conflict rates in both developing and developed nations of the world. We undertook a review of civilian gunshot injuries to the extremities in Nigeria. The pathology of these injuries as well as their implications for management are presented. The peculiar challenges they present to the orthopaedic surgeons in the management of gunshot injuries in a resource depleted country are highlighted. Community based socially and culturally acceptable conflict resolution mechanisms; control of fire arms and revision of the treatment guidelines are recommended as preventive and management strategies of gunshot injuries in Nigeria

Locked intramedullary nailing for the treatment of femoral shaft fractures: experience and result in 19 cases.

BACKGROUND: Fractures in the proximal or distal third of the femoral shaft or those with severe comminution are known to be less suitable for intramedullary nailing with Kuntscher nail. With the introduction of interlocking intramedullary nailing the problems of rotational malalignment and shortening that accompany such fractures are now less common. At the National Orthopaedic Hospital Igbobi, Interlocking Intramedullary Nailing was introduced as a form of surgical treatment for fractures of the femur, our initial experience in this type of intramedullary nailing form the basis of this report. METHOD: This is a retrospective study of all cases of fractured femur that were treated with locked intramedullary nailing between March 2002 and September 2003. RESULTS: During a 19-month period, 19 patients with 19 fractures were treated for fracture of the femoral shaft with locked intramedullary nailing using the Russell-Taylor (18 fractures) and Grosse-Kempf (1 fracture) nails. Thirteen fractures (68.5%) had comminution of the Winquist-Hansen type III and IV 12 of which were statically locked. There were three intra-operative technical problems including the case of a subtrochanteric fracture, where the nail missed the medullary canal of the proximal segment. There were 2 cases of superficial wound infection, which responded to local wound care and antibiotics. Although limb length discrepancy and rotational mal-alignment were not assessed routinely during the follow-up of patients, no symptomatic malrotation was recorded. Sixteen out of the 19 patients were available for follow-up for an average period of 11 months. All these cases progressed to union, without the need for dynamization in statically locked fixations. CONCLUSION: In spite of the initial problems encountered with this relatively new procedure in our centre, we were able to achieve a reasonably good result in addition to supporting the notion that dynamization of a statically locked nail is not always necessary for healing of fractures.

Short-term antibiotic prophylaxis in implant surgery: a comparison of three antibiotics.

OBJECTIVE: To investigate the efficacy, tolerability and cost effectiveness of three antibiotics in a short-term antibiotic regimen in patients undergoing elective implant surgery. PATIENTS AND METHODS: 89 patients who underwent 101 implantation procedures were enrolled during a period of five years and randomly divided into three groups to receive: (a) Rocephin (Ceftriaxone) 1g intravenously at induction and 1g 12 hours later (Group 1). (b) Zinacef (Cefuroxime) 1.5 g intravenously at induction and 750 mg six hourly for 12 hours (Group 2). Ciprotab (ciprofloxacine) 400mg intravenously at induction and 200mg six hourly for 12 hours (group 3). RESULTS: The patients in the three groups were comparable regarding age, gender, pre-operative length of hospitalization and duration of surgery. The overall surgical site infection rate was 6.9% (7/101) with gram-negative organisms being the most common causative organisms (71.4%). The infection rates of 6.3% in group 1,7.3% in group 2 and 7.1% in group 3 show no statistical significance (P>0.05). The cost benefit ratio for the three drugs showed that treatment with Ciprotab was cheaper than that with Rocephin or Zinacef. Severe complications warranting discontinuation of therapy did not occur in any of the three groups of patients. CONCLUSION: While we can safely conclude that all the drugs have similar efficacy and safely in preventing post-operative wound complications, it appears that Ciprotab is most cost-effective. We recommend that a larger study be undertaken to confirm the predominance of gram-negative organisms in implant surgery.

Prescription error in an orthopaedic practice.

A retrospective review of 17,833 prescription items was undertaken at the National Orthopaedic Hospital, Lagos, Nigeria with the aim of determining the prevalence and types of prescription error. The percentage prescription error was 4.5 with type C (minor nuisance) being the most common prescription error. Incomplete prescription was the reason for these errors in 71% of cases. Our results revealed that the higher the professional status of the prescriber, the lower the prescription error. Even though the errors were recognised and corrected at the dispensing point, there was no indication that the prescriber was informed of his mistakes. We suggest, amongst others, regular clinical meeting of Doctors and Pharmacists where various aspects of rational drug could be discussed.

Glove punctures in orthopaedic surgery.

From February 2001 to May 2001, 792 latex gloves used in 100 operations from three orthopaedic sub-specialties (paediatrics, hand and spine) were tested for puncture by a water infusion test. Sixty-nine gloves from 45 operations were punctured, giving an overall glove perforation rate of 8.7% (69/792) and an operative perforation rate of 45% (45/100). The hand operations had the lowest operative perforation rate (19.4%) while the spine operations had the highest (63.6%). The glove perforation rate increased in bony procedures (60% versus 22.5%), in procedures with major instrumentation (66% versus 18%) and in more lengthy procedures. The thumbs and the left index finger had more punctures than other parts. In addition, the glove perforation rate for single gloving was 9.6% (53/552) while that for the inner glove of double gloving was 0.8% (1/120). Based on these findings, we would like to recommend double gloving and regular glove changing in these high-risk surgeries.

Problems of amputation surgery in a developing country.

We studied prospectively 87 patients who underwent extremity amputation in the National Orthopaedic Hospital in Lagos in 1995-1996. Trauma from road traffic accident was the most common indication (34/87) with peripheral vascular disease being the least encountered (2/87). Traditional bonesetters' gangrene accounted for 9/87 cases in circumstances that were largely avoidable. Our study revealed that amputation is still being performed as a life-saving procedure, as 44/87 patients presented with gangrene of a limb. The nonavailability of special investigations such as Doppler ultrasound, arteriography, and CT scan was responsible for a delay in definitive treatment in 28 cases. Poor prosthetic services and the absence of a well-coordinated amputee clinic were responsible for some of the unsatisfactory results. We believe that the availability of specialized diagnostic tools and facilities for microvascular surgery, together with a multidisciplinary approach to the management of the amputee, would considerably change the current gloomy picture of amputation in developing countries such as Nigeria.

Incidence of glove failure during orthopedic operations and the protective effect of double gloves.

OBJECTIVE: To determine the usefulness of double gloves in protecting against the exposure of surgical team members' hands to blood. METHODOLOGY: Five-hundred-ninety-six gloves were studied during 71 orthopedic operations using the water-loading test (filling a glove with water and occluding its cuff tightly to identify leaking points). RESULTS: In all, 73 glove perforations occurred, but only nine resulted in exposure to blood (blood touching the skin). The incidence of glove perforation was 12% (73/596), and overall exposure (blood touching the skin) per operation was 13% (9/71). The latter would have been 87% (62/71) but for the use of double gloves. Sixteen percent of the perforations in double gloves were in the inner gloves, while 84% were in the outer gloves. Exposure of surgeons was reduced from 54% to 10%, first assistants from 27% to 3%, and second assistants from 7% to 0 (p < 0.02, df = 2) by double-gloving. Significantly more perforations occurred during operations on bone, compared with soft tissue operations, p < 0.0001, RR = 4 (95% CL 1.87-8.55). The most common sites of glove perforation were the index finger (47%), thumb, and the palm region: 14% each. More glove perforations occurred in nondominant hands. CONCLUSION: Double-gloving offers additional protection to surgeons and assistants by preventing hand exposure to blood intraoperatively.