Does the Proximal Femur Geometry Predict Early Functional Outcome after Plate Fixation of Geriatric Pertrochanteric Fractures?

BACKGROUND: The proximal femur geometry determines the hip force distribution. The femoral neck axis length (FNAL), the hip axis length (HAL), the femoral head diameter, and the femoral neck-shaft angle (FNSA) could influence the risk and outcome of pertrochanteric fractures. Restoring these parameters to their prefracture values could predict early hip function. AIM: To determine if the postoperative proximal femur geometry of geriatric patients with plating for pertrochanteric fractures predicts the early functional outcome. MATERIALS AND METHODS: The study was a prospective study carried out at the National Orthopaedic Hospital Enugu for 18 months. Geriatric patients who had Proximal Femoral Locking fixation for pertrochanteric fractures were recruited. Radiological parameters of the proximal femur in the unaffected and fixed hips were measured and compared. The functional outcomes of the patients were measured at 3 months postoperative period using the Harris hip score (HHS). Multiple linear regression was conducted on the parameters to determine the HHS. RESULTS: Thirty patients participated in the study, with a significant difference (P < 0.001) in the mean FNSA between unaffected (M = 128.69, standard deviation (SD) =2.93) and operated hips (M = 121.81, SD = 8.86). The FNSA was the only significant predictor of hip function, with a 1-degree increase improving the HHS by 1.30. CONCLUSION: There is a significant difference in the FNSA between the unaffected and the operated hips. The FNSA significantly predicts the early hip function and should be reconstructed to within normal range during surgery.

Clinical measurement of angular profile of the knee and correlation with intermalleolar distance in children in Enugu metropolis.

BACKGROUND: Angular deformities of the lower limbs are commonly encountered deformities in pediatric orthopedic clinics. The values of the tibiofemoral angle undergoes changes as the child grows and these changes are self-limiting. The aim of the study is to establish the normal variation of knee angles of children between 2 and 12 years of age in Enugu metropolis and to establish any correlation between the knee angles and the intermalleolar distances (IMDs). SUBJECTS AND METHODS: This study was done on 630 school children in Enugu metropolis between the age groups of 2 and 12 years. Multistage sampling was used in the study. The tibiofemoral angles and intermalleolar/intercondylar distances were measured. RESULTS: The maximum tibiofemoral angle from this study was 7.6° ± 2.4° and the age corresponding to this value was 4 years. Only 23 subjects (3.5%) had varus knee angle. The values of the mean tibiofemoral angle and IMDs plateaued from 8 to 12 years. There was a significant positive correlation between average knee angle and IMD (r = 0.785, P < 0.001). CONCLUSION: The physiological changes in the knee angle (tibiofemoral) follow a similar pattern as established in the literature and there was positive correlation between IMD and the tibiofemoral angle.

Ponseti clubfoot management method: Initial experience with 273 clubfeet treated in a clubfoot clinic of a Nigerian regional orthopedic hospital.

OBJECTIVE: The aim of this study was to evaluate the initial experience and outcome of clubfoot treated using the Ponseti technique in a regional orthopedic hospital setting of a developing country. METHODS: This was a retrospective review of all the clubfoot patients who were treated at the clubfoot clinic of National Orthopaedic Hospital Enugu from 1st of August 2013 to 31st January 2015. RESULT: There were 175 patients with 273 clubfeet. The male to female ratio was 1.2:1, and the age range was 1 week to 27 years with a median age of 11 months. One hundred and fifty-one patients (86.5%) had congenital clubfoot, whereas 24 (13.5%) had acquired clubfoot. The mean Pirani score of the patients at presentation was 4. The mean number of cast sessions needed for correction was 6.3. The majority of the feet (96.6%) were treated and correction achieved with Ponseti method alone, whereas 3.4% had other additional surgical procedures. Seventy-two (41.1%) patients afforded and used foot abduction brace as prescribed. Plaster sores in 12.5% of patients were the most common complication. At a mean follow-up period of 6 months, a relapse rate of 3.4% was observed. CONCLUSION: Ponseti clubfoot management technique alone is very effective in most cases of clubfoot in our setting. Late presentation of patients and foot abduction brace related challenges observed call for a policy response aimed at educating the public on the importance of early presentation and improving the use of foot abduction brace.

Total hip replacement in sickle cell disorder: A preliminary report of challenges and early outcome of 21 consecutive patients.

OBJECTIVE: The aim of this study is to describe the pattern of presentation osteoarthritic patients with sickle cell disorder (SCD) in our environment, determine the implant sizes taking the peculiar nature of the pathology and our operating environment into consideration, highlight the challenges and technical difficulties encountered during the procedure, measure the functional outcome and observe complications of treatment, recommend ways of improving outcome. PATIENTS AND METHODS: Between November 2008 and November 2012, 29 consecutive primary total hip replacements (THRs) were performed on 21 patients with avascular necrosis of the head of femur secondary to SCD. Patients' evaluation was performed at two different times of follow-up (1 and 5 years, respectively). RESULTS: Twenty-one patients were available at 1 year as well as 5-year follow-up. The mean preoperative Harris Hip Score was 20.17 ± 11. The mean postoperative Harris Hip Score was 92.25 ± 13 (P < 0.001) at 1 year and 88.75 ± 10 (P < 0.001) at 5 years. Eighteen patients had regional anesthesia while three had general anesthesia. The average cup size used was 49.43 with a range of 46-54. The average liner size was 49.43 with a range of 46-54. The head size used in all patients was 28. The average stem size was 6.57 with a range of 6-8. The offset used in all the patients was standard All the patients had 1-2 screw fixation of the acetabular shell. Four patients had complications as follows: periprosthetic fracture 1, superficial wound infection 1, pulmonary complication 1, and abdominal crisis 1. CONCLUSION:: THR is a veritable means of treatment of patients with avascular necrosis of the femoral head arising from SCDs. The challenges encountered during the surgery are related to the quality of bone of the affected patient. Arthroplasty Surgeons in our environment must be fully prepared for the challenges by ensuring a preoperative plan that will take care of the technical problems such as recreating femoral canals, wiring of intraoperative fractures as well as treatment of acetabular defects. A detailed planned total hip arthroplasty can be performed in patients with SCD in younger patients with good clinical benefits.

Total knee replacement in a resource constrained environment: A preliminary report.

INTRODUCTION: Total knee replacement surgery is relatively new in Nigeria and available in few centres only. It has been evolving at a slow pace because of the lack of facilities, structures and adequate surgical expertise alongside patient ignorance and poverty. OBJECTIVE: The aim of this article is to review the cases done in a resource constrained institution in Nigeria and report the short term outcomes. METHODOLOGY: All the patients that were booked for Total knee replacement, using same prosthesis over a 40 month period, were recruited into the study. Using a prepared data tool, information on personal biological information, clinical presentation, peri-operative management, and outcome of management were obtained after an informed verbal consent. All the patients were further followed up for at least one year. RESULTS: 45 knees were replaced in 38 patients. The age range of the patients was 41-85 years with a mean age of 62.6. The male to female ratio was 1: 4.4. The indications for surgery were a combination of pain and deformity. All the patients came with varying forms and degrees of angular deformities. Eight knees had bone defects that required bone grafting while 5 knees had tibia extension rods. The commonest complication, which was recorded, was drop foot (8.9%). Knee society pain scores in the patients improved from the average of 21.35 to 83. CONCLUSION: Despite the challenges inherent in health care in developing countries, with proper institutional planning and team work, the short term outcome of arthroplasty in our resource constrained environment is good.

Pattern of femoral fractures and associated injuries in a Nigerian tertiary trauma centre.

BACKGROUND: The femur is the strongest and largest bone in the human body. It therefore requires high-energy trauma for it to fracture unless there is an ongoing pathology that weakens the bone. Femoral fractures are thus associated with significant pain, deformities, bleeding and varying degrees of injuries. The aim of this study is to determine the pattern of femoral fractures and the associated injuries in our region while recommending possible means of averting these injuries. MATERIALS AND METHODS: A 10-year retrospective study was done in National Orthopedic Hospital Enugu from 1994 to 2003. The demographic data, etiology, the part of femur affected and associated injuries were collated from the hospital records/folders. The analysis was performed using descriptive statistics in Microsoft Excel 2007. RESULTS: A total of 562 cases were reviewed, 63.7% of all the patients were males and the most common etiological factor was road traffic accidents. The site of fracture varied with age and etiology with 26.5% occurring at the mid-shaft with an average age of 27.2 years and 16% occurring at the neck of femur, more in the elderly, with 55.6% following minor falls and trips. The most common associated injury was soft tissue injuries requiring secondary wound closure. CONCLUSION: Femoral fractures are common and the pattern varies with age and the mechanism of injury. They are associated with other injuries that may be life-threatening.

Sideswipes injuries of upper limbs: a case series report and review of literature.

BACKGROUND: Sideswipe injuries are consequent to object striking an elbow on the window edge of a moving vehicle. It often results in severe soft tissue and bony injuries or partial amputation of the upper limb. Functional outcome in most patients is poor. The aim is to highlight the occurrence and functional outcome of these injuries. METHOD: In our series we report three cases which presented to us in succession within four weeks. RESULTS: Two of the patients were passengers of commercial buses while one patient is the driver of a private car. Two were males. All were protruding their arm from the open vehicle window at the time of impact. All presented within five hours of injury. All sustained open fracture-dislocations. All were managed with external fixation and soft tissue cover. They all had poor outcome as evidenced by joint stiffness. CONCLUSION: The functional outcome of such injuries is usually poor especially if the dominant limb is involved. Therefore the need for prevention cannot be overemphasized. Simple measures like ensuring that no part of the limb is Sticking outside a moving vehicle, winding up glass up to mid window level etc will greatly reduce the occurrence of these injuries.

The impact of water mattresses on incidence of PUs in patients with spinal cord injuries in Nigeria.

OBJECTIVE: To evaluate the impact of water mattresses on the incidence of pressure ulcers and length of hospitalisation in patients with spinal cord injuries in Nigeria. METHOD: A retrospective review was conducted of all patients who presented and were managed for complete traumatic spinal cord injury between January 2005 and December 2008. This period included 2 years prior to, and 2 years following, the introduction of water mattresses to the ward; patients from these periods were grouped as A and B, respectively. Information collated from the medical records included demographic data, wound aetiology, time to presentation, level of injury, complications, treatment, and duration of hospitalisation and follow-up. Outcome measures were presence or absence of pressure ulcers and length of hospital stay. RESULTS: In total, 201 patients were treated within the study period. Of these, 99 patients met the inclusion criteria; 35 patients (19 paraplegics and 16 tetraplegics) were managed between 2005 and 2006 (group A), while 64 patients (28 paraplegics and 36 tetraplegics) were managed in 2007 and 2008 (group B). The age range of the included patients was 9-76 years (39.0 ± 4.6 years and 41.5 ± 3.2 years for groups A and B, respectively) and all were male. Patient characteristics were similar for the two groups; however, there was a significant difference between the two groups in terms of presence of pressure ulcers, deteriorating of existing ulcers and condition of the patient on discharge (p < 0.05). CONCLUSION: The majority of pressure ulcers are preventable and a simple support surface, such as water mattresses, can reduce the incidence and magnitude of pressure ulceration, thus reducing hospital stay. DECLARATION OF INTEREST: The authors do not have any financial relationship with any organisation that manufactures water mattresses, either locally or overseas. There were no external sources of funding for this study.

Above-elbow amputation and death following human bite mismanaged by quacks: a case report and review of literature.

BACKGROUND: Human bite is a common injury sustained during a fight, love passion, self mutilation, cannibalism or vampirism. Although widely reported as being more dangerous than animal bites, such complications as limb amputation from gangrene and eventually death is either uncommon or scarcely reported in our environment. OBJECTIVE: To highlight the dangers of human bite as a potential cause of severe morbidity and mortality especially when poorly managed. METHODOLOGY: A 30 year old Fulani herdsman with gangrene of the right hand, and distal forearm presenting in coma 10 days after sustaining human bite is presented and relevant related literature reviewed. CASE REPORT: M.U. is a 30 year old Fulani herdsman who presented to us at the accident and emergency unit with 10 days history of human bite to the first web space of the right hand, 5 days history of gangrenous hand and distal foreman, and 2 days history of loss of consciousness. The injury was inflicted by a fellow herdsman during a fight. He then commenced treatment with a patent medicine dealer. A few days later the hand became swollen with associated severe pains, serous discharge and subsequent darkish discoloration, frank pus exudates and loss of hand function. Two days prior to presentation, he lapsed into unconsciousness after complaining of severe weakness and fever. Following his presentation, clinical examination and investigation, he was offered a below elbow guillotine amputation. However by the next day, he deteriorated with GCS of 5/15 and subsequently died after 24 hours of presentation. CONCLUSION: Human bite can be a cause of severe morbidity and mortality. Treatment by quacks should be discouraged while early presentation, surgical debridement and delayed wound closure should be emphasized along with other surgical principles.

Anaesthetic requirement in spinal cord injured patients undergoing operation below the level of cord injury.

BACKGROUND: Anaesthesia in spinal cord injured (SCI) can be hazardous. In complete injuries above T6, the abnormal state of the respiratory and the cardiovascular systems pose special problems. The objective of this study therefore was to evaluate the anaesthetic requirements in patients with complete SCI undergoing operation below the level of the cord lesion. PATIENTS AND METHOD: The medical records and the operation notes of all patients with complete SCI who underwent surgical operations between January 2001 and December 2005 were reviewed. Information about their demographics, level of injury, indications for operation, type of operation done and the type anaesthesia used were collated. The choice anaesthesia was guarded by the proximity of operation site to the level of cord transaction and by patient's preference. The pre-operative and intra-operative blood pressure, pulse rate and respiratory rate were used to monitor cardiovascular and respiratory responses. RESULTS: They were twenty-eight, all male except one. The age range was 13-67 years with an average of32 years. The level of cord lesion varied. The thoracic spine was most involved followed by the cervical spine. The most common indication for operation was pressure sore. The anesthetic requirement varied, and ranged from general anesthesia (GA) to no anaesthesia at all. Three broad groups were observed: no anaesthesia; sedation with diazepam; and general anaesthesia. There was no remarkable change in the blood pressure readings in the three groups. However, three patients who had GA and whose operation sites were in the twilight zone had remarkable changes in the pulse and respiratory rates. CONCLUSION: Even though spinal patients are insensate below the level of their injury, significant proportions that need operation below the level of cord lesion require anaesthesia.

Iatrogenic pyogenic spondylodiscitis: a case report and a review of literature.

BACKGROUND: Iatrogenic Pyogenic Spondylodicitis is a disease not commonly reported probably because of the way it is acquired, from the health practitioner. METHOD: The case of a 62 year old man that presented in our outpatient department with features of spondylodiscitis after several attempts at spinal anaesthesia at a rural hospital was reported and the literature reviewed. RESULT: The patient showed remarkable improvement few days with parenteral antibiotics and made complete recovery subsequently. CONCLUSIONS: Adequate asepsis is required for spinal anaesthesia and parenteral antibiotics given presumptively following numerous attempts at spinals.

Management of penetrating spinal cord injuries in a non spinal centre: experience at Enugu, Nigeria.

BACKGROUND: Penetrating injuries of the spinal cord are among the most dangerous of injuries. They are often associated with injuries to other vital organs of the body, which may demand priority attention. The objectives of this study were to determine the pattern of the penetrating spinal cord injuries and to evaluate outcome of treatment in our setting. METHODS: This is a retrospective study of all penetrating spinal cord injuries seen at the National Orthopaedic Hospital, Enugu over a fifteen-year period (April 1990 March 2005). Information about the demographics aetiology, level of injury, associated injuries, time of presentation, duration of hospitalization and outcome of treatment were retrieved from patients case notes. Data were analyzed using SPSS for windows version 11. RESULT: There were 22 patients, 13 males and 9 females, giving a M:F ratio of 1.7:1. Gunshot injury was the most common aetiological factor. The thoracic spine {9 (41%)} was most often involved. Chest and abdominal injuries were common associated injuries in 5 cases. The circumstances of the injury were mostly armed robbery attack {13 (59%)}. On admission the neurological status was Frankel grade A in 20(91%) cases. Period of hospitalization ranged from 1 week to 36 weeks with a mean of 11 weeks. Pressure sore was the most common complication that delayed rehabilitation. Five (23%) patients with injury at cervical level died from respiratory failure. CONCLUSION: Penetrating spinal cord injuries are relatively rare and demand extra care. Early recognition of associated injuries, minimal wound excision and antibiotic therapy give good result.

Effects of cyclooxygenase inhibitors on bone and cartilage metabolism--a review.

BACKGROUND: In this era of increeasing use of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) for treatment of painful/inflammatory disorders, it is necessary to review the effect of these drugs on bone and cartilage metabolism. Inflammation is an essential component of the healing process in bone, and cyclooxygenase (cox-1 and cox-2) enzymes play important roles in fracture repair. Therefore, there is concern that NSAIDs, which have anti-inflammatory and analgesic properties that are mediated by inhibition of cox-1 and cox-2 may delay the healing of bone injuries. Also as newer drugs, selective cox-2 inhibitors are being developed to avert the gastrointestinal symptoms of the non-specific NSAIDs, it is imperative that these substances are studied for any deleterious effect on bone and cartilage metabolism. METHODS: Literature on the subject was reviewed using manual library search, articles in journals and internet search. The search words were: NSAIDs and bone metabolism, cyclooxygenase inhibitors and bone metabolism. The search was done using medscape, ortolink and pubmed search engines. The search covered a period of 35 years (1970-2005). RESULTS: NSAIDs can either reversibly or irreversibly block the cyclooxygenase pathway thereby inhibiting prostaglandin synthesis. These cox inhibitors especially the cox-2 have been found to inhibit the production of prostaglandins which are necessary in bone healing. Prostaglandins play a role in both osteoblastogenesis and bone resorption, and so, cox inhibitors suppress these functions. CONCLUSION: NSAIDs especially the cox-2 inhibitors should be avoided following fractures or implant surgery. They should be reserved for other painful inflammatory disorders in which bone resorption and formation mediated by prostaglandins are not required.

Fractures in children.

BACKGROUND: The burden of diseases in children in our environment is dominated by infections and malnutrition; paediatric trauma has low advocacy and as such is given scant attention. The aim of this study is to review and describe the pattern of paediatric fractures in our local setting. METHOD: A retrospective review of all the medical records of children below the age of fourteen years who were admitted to our center on account of major trauma between January 1999 and December 2003 was done. Those with incomplete records were excluded. RESULTS: The patients ranged in age from 1 +/-13 years with mean of 6.7 +/- 2.9 years. They were mostly males 60 (61.2%) and females 38 (38.8%). The causes of the accidents were diverse. Road traffic accidents were most common 47(51%). A great number of these resulted from unguarded children hit by motor vehicles while crossing the road 33 (36.7%). Forty-one (41.8%) patients fell from various heights. Of these number thirty (30.6%) fell while playing. Most fractures were close 70 (71.4%) while 25 (25.5%) were open fractures and 3 (3.1%) pathological fractures. The most common site of injury was the femoral shaft 33.7%; this was followed by fractures of the supracondylar region of the humerus 17.3%, distal radius 15.3% and tibialfibula 15.3%. More than half of the patients 58 (59.2%) presented fresh to our hospital, while 27 (27.6%) presented initially to traditional bonesetter (TBS) and 13 (13.3%) were referred from private practitioners. Of those twenty-seven patients from the TBS, seven came with compartment syndrome and three had frank gangrene. Most of the patients were managed conservatively. Preliminary traction followed by plaster of Paris (POP) application in 36 (36.7%), and manipulation under anaesthesia (M.U.A) and POP (30.6%), were common definitive treatments given. Sixteen patients (16.3%) had open reduction and internal fixation. Acute compartment syndrome 7 (7.1%) and frank gangrene 3 (3.1%) were the commonest complications and were due to late referral by traditional bonesetters. CONCLUSION: In our environment, fractures in children are common and are frequently associated with morbidities due to interference by traditional bonesetters. These injuries are highly preventable and paediatric trauma prevention strategies directed at parents, children as well as other road users would help to reduce the burden of such fractures especially in the developing countries where the burden of other childhood diseases obscures trauma care.

Pattern of severe electrical injuries in a Nigerian regional burn centre.

BACKGROUND: Electrical injuries, though uncommon usually have devastating consequences. They are largely preventable. The objectives of the study were to highlight the pattern of severe electrical injuries seen in our environment, the management problems faced here compared with other studies and proffer suggestions for improvement and prevention. METHODS: A 10-year retrospective study of case files of patients seen with electrical injuries in our centre was carried out from January 1995 to December 2004. Case notes were retrieved and data collated from them were analysed by descriptive statistics. RESULTS: Twenty four (24) case files met the inclusion criteria and were analysed. Electrical burns constituted 2.8% of total burn admissions. Patients' ages ranged from 15 months to 42 years. Male: Female ratio was 4.8:1. Seven (29%) had high voltage injuries, mostly work-related. Sixteen (67%) had low voltage injuries while one (4%) had a lightening injury. Fourteen (58%) presented or were referred more than 24 hours post injury. Fifteen (63%) had a form of surgical treatment with wound debridement (33%) skin grafting (38%) and amputations (29%) being the commonest ones. The mortality was 12.5% with septicaemia as the leading cause of death. CONCLUSION: Late presentation of patients to specialised centres, inadequate management at the primary centres of treatment, poverty and inadequate facilities even at the specialised centres were the main problems encountered. We recommend re-education of the populace including medical practitioners, enforcement of safety rules in the home and workplaces and upgrading of our health facilities to decrease the menace of severe electrical injuries.

Unwholesome trauma care: a cautionary note.

BACKGROUND: Trauma care requires proper training on how to diagnose life and limb threatening conditions. The aim of this paper is to report an extreme case of unwholesome practice that drained the patient physically, emotionally and financially. METHODS: The medical record of the patient and relevant literature were reviewed. RESULT: A 25-year-old commercial motorcyclist (okada) presented with a huge discharging leg ulcer with exposed plate and necrotic distal half of the right tibia on the account of uninformed treatment he received from his primary physician and a traditional bonesetter spanning a period of five months. The foot was found to be grossly deformed and insensate. Below knee amputation was done as salvage. CONCLUSION: Our undergraduate curriculum should change to expose medical students more to basic trauma care. A designated body should regulate activities of traditional bonesetters. The practitioners should be made to undergo some form of training to recognize high-risk trauma patients and the need for early referral.

Traumatic spinal cord injuries (SCI): a study of 104 cases.

BACKGROUND: Management of spinal cord injured patients is an integral part of trauma care. There is need to congregate these patients in spinal units where dedicated experts and facilities exist for better outcome of treatment and rehabilitation. The objective of this study therefore, is to promote improved quality of care in the group of patients by highlighting the deficiencies in our setting. METHODS: This is a retrospective study of all traumatic spinal cord injured (SCI) seen at the National Orthopaedic Hospital, Enugu over a six-year period. Information about the demographics, aetiology, level of injury, associated injuries, time of presentation, referral hospital, state of injury, duration of hospitalization, outcome of treatment were obtained from patients' records. Data were analyzed using commercially available SPSS for windows 9. Descriptive statistics are given. RESULTS: There were 104 patients, 88 males and 16 females, giving a ratio of 5.5:1. Road traffic accident, 60 (57.7%), was the commonest aetiological factor and the cervical spine, 70 (67.3%), was most often involved. Head and neck injuries were common associated injuries, 19 (18.3%) in patients with cervical spine injury. Six (5.8%) of our patients were obtunded. Most patients, 69 (66.4%), were received from private hospitals after a mean duration of 7 days. Hospitalization ranged from 1 week-120 weeks with a mean of 11 weeks. Pressure sore was the commonest complication, 30 (28.8%). Thirty six (34.4%) of patients died mainly from respiratory failure. Most of the discharged wheel bound patients (97%) were lost to follow up. CONCLUSION: For better outcome we re-emphasize the need to establish and congregate these patients into regional spinal units. We also suggest a social legislation, which will be fundamental to social re-integration of these SCI and other severely disabled patients.