The Pedicled Anterolateral Thigh Flap as a Versatile Option for Resurfacing Extensive Lower Trunk Defects.

BACKGROUND: The resurfacing of large abdominal and perineal defects is a major concern, and it poses a great challenge to the reconstructive surgeon. The main target in the reconstruction of the abdomen is to ensure a stable soft-tissue cover, and a strong and reliable fascia to prevent hernia recurrence and fecal contamination. The pedicled anterolateral thigh flap (ALT) either in the myocutaneous or fasciocutaneous form is a work-horse for the closure of abdominal and perineal defects. AIM: There is a paucity of studies on the use of the anterolateral thigh flap among black Africans especially in Nigeria; hence, we present our experience with the use of this flap for extensive abdominal and perineal defects. PATIENTS AND METHODS: The folders of all patients who had pedicled anterolateral thigh flap between January 2019 and July 2022 in our institution were reviewed. The patients' demographic data and the available details about the flap reconstruction were extracted from the folders. RESULTS: There were three males and two females, and the age range was between 22 and 48 years. Four cases resulted from tumor extirpation, while one was following extensive necrotizing fasciitis of the lower anterior abdominal wall. No gross anatomical variations were encountered intraoperatively. Four flaps had full survival, while one had marginal flap tip loss. CONCLUSION: The pedicled anterolateral thigh flap is an excellent reconstructive tool for the coverage of extensive abdominal and perineal defects.

Building a responsive healthcare system - A Nigerian experience.

Background: A healthcare system must be responsive to the needs of its clients, and this entails elements such as dignity, confidentiality, autonomy, prompt attention, social support, basic amenities, and choice of provider. This is targeted toward improvement and maintenance of the quality of healthcare with consequent improvement in patient outcomes at a reduced cost. Aim: The aim of this study is to articulate the approach that was adopted by the Federal Medical Centre, Ebute-Metta, Lagos, Nigeria, to confront some of the challenges faced by the health sector in Nigeria and make recommendations for the future. Materials and Methods: To identify and solve the problems mitigating quality service delivery in the hospital over an initial 18-month period, the management deployed the following tools: (i) mystery shopping; (ii) patient experience survey; and (iii) quality improvement using the SafeCare methodology. Results: The diagnosis identified the following problems: (i) service failure; (ii) financial and material leakages; (iii) challenges of human resources - poor attitude, indiscipline, inadequacy, and poor understanding of roles; (iv) infrastructural deficit and dilapidation; and (v) absence of technological support. The baseline quality assessment conducted with the SafeCare Standards gave a score of 45%, while performance at the follow-up quality assessment was 69%. Conclusion: As a direct result of the findings, the hospital designed an 18-month renewable strategic plan premised on five pillars: (i) human resources development; (ii) improvement of quality of service; (iii) expansion of services and infrastructure renewals; (iv) financial re-engineering and partnership; and (v) appropriate utilization of technology. Through this policy redirection and constant re-evaluation, our quality improvement journey continues to yield desired positive health system outcomes. We recommend collaborative quality improvement initiatives with strong internal political will that can harness both the institution's resources and independent experts on health system development.

Risk factors for surgical site infections following clean orthopaedic operations.

BACKGROUND: Surgical site infections can follow clean orthopaedic operations and can cause serious morbidity, mortality and increased resource utilization. Despite this, there are few studies on risk factors for surgical site infections in the Nigerian orthopaedic literature. We conducted a prospective study to determine the host and environmental risk factors for surgical site infections following clean orthopaedic operations. MATERIALS AND METHODS: Consecutive patients who satisfied the inclusion criteria and were to undergo clean orthopaedic operations performed at the National Orthopaedic Hospital, Igbobi, Lagos from January 2007 to July 2008 were included. Patient's biodata, duration of preoperative hospitalization and other risk factors were analyzed. The risk factors for surgical site infection were determined with Chi square test. RESULTS: The overall rate of surgical site infection during the 18 months of the study was 9.9% (12 of 121). Independent risk factors for this were: Prolonged duration of preoperative hospital stay greater than 13 days (21% infection rate), increasing age greater than 60 years (31% infection rate), and use of implants and drains (only one un-drained wound was infected). CONCLUSION AND RECOMMENDATIONS: Patient's age, duration of preoperative hospitalization, type of surgery (implant or non-implant), and use of drains were the most significant risk factors affecting surgical site infection. It is recommended that preoperative hospital stay should be as short as possible and extra care/precautions taken when working on the elderly, using implants or requiring drainage.

Neoadjuvant chemotherapy for locally advanced premenopausal breast cancer in Nigerian women: early experience.

BACKGROUND: Breast cancer, the commonest female malignancy in Nigeria presents late, with bulky locoregional masses and predominantly in a pre and peri-menopausal setting. Treatment when feasible has been with mutilative surgery with a poor patient acceptance rate. Chemotherapy which is widely used in adjuvant and metastatic settings has recently been indicated in the neo-adjuvant setting. METHODS: Locally-advanced female breast cancer patients [AJCC Stages IIIA, IIIB, IIIC], seen in the breast clinic from July, 2006 to March 2007 were recruited into the study after informed consent. Patients received doxorubicin, 5-fluoro-uracil and cyclophsphamide by intravenous bolus or infusional injection on a three weekly regimen as day cases. The dominant lesion was assessed by calipers at each visit. Therapeutic clinical responses were assessed as none; partial, complete. RESULTS: During the period 32 women (33 breast cancers) were seen and recruited. The numbers steadily declined over time and only 28 completed the treatment modality. Mean pre-chemotherapy tumour size was 13.5cm which declined to 7 cm at the 5th. One patient (3.6%) exhibited complete clinical response, 25 (89%), partial response and 2 had no response. No serious toxicities were noted. CONCLUSION: Neo-adjuvant chemotherapy using anthracycline based regimens is efficacious and safe in reducing tumour bulk in locally advanced breast cancers. The use should be encouraged to make bulky tumours operable.

Giant fibrosarcoma prostuberans of abodominal wall: management problems in resources-constrained country.

BACKGROUND: Abdominal wall sarcomas represent less than 1% of adult malignancies. Dermatofibrosarcoma protuberans can grow to very large sizes and the recommended resection 2-3 cm from the macroscopic tumour margin can produce very large full thickness defects of the abdominal wall. Reconstruction of such defects can be quite challenging in resource constrained areas where patients present late with giant lesions. OBJECTIVE: To highlight the presentation and management challenges faced by the surgical oncologist and reconstructive surgeon in a resource constrained country when faced with giant Dermatofibrosarcoma protuberans of the abdominal wall. METHODS: Prospective study of patients with abdominal wall soft tissue sarcoma presenting to the authors. Cases of giant dermatofibrosarcoma protuberns who underwent surgery were analysed. RESULTS: Seven cases managed over an eight year period (January 2000 to December 2007). Age ranged from 27-70 yrs with slight female preponderance 1.5:1 F:M. Three presented with recurrent fungating masses. Only one could be reconstructed with prolene mesh. One recurrence was noted during the period under study. CONCLUSION: Poverty, ignorance and lack of necessary working tools are major challenges faced by the surgical oncologist and reconstructive surgeon in resource constrained areas and pose a major obstacle to the control of cancer in these areas.

Groin flap for coverage of upper extremity defects in Enugu, Nigeria.

BACKGROUND: Extensive tissue loss of the hand has remained a big challenge to the Plastic and Reconstructive Surgeon. The objective of this study is to review the use of pedicle groin flap for coverage of distal forearm and hand defects in our centre, and to find out problems of using the flap and make suggestions for improvement. METHOD: This is a retrospective study done using case records of patients treated with pedicle groin flaps for upper extremity defects at the National Orthopaedic Hospital Enugu from January 1999 to December 2004 (six year period). Information on biodata, clinical presentation, treatment, complications and outcome was extracted and analyzed using descriptive statistics. RESULTS: Thirteen (13) patient's case files met the inclusion criteria and were analyzed. There were seven (7) males and six (6) females with mean age ranges between 9 years and 42 years. Four (4) had distal forearm and nine (9) hand wound coverage's. Flap survival was very good to excellent in all cases and the outcome quite satisfactory. CONCLUSION: Use of pedicle groin flap for coverage of defects of the hand and distal forearm remains a very valuable treatment option in our environment.

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.

An accessory flexor of the fifth toe.

The presence of accessory muscles and other organs on the lower limbs of some individuals have variously been reported in the literature. We report an unusual muscle located on the plantar surface of the left foot of a cadaver, which had not been previously described. This muscle originated from the tendon of tibialis posterior and inserted into the middle phalanx of the fifth toe. It differed from the 'expansions' of the tibialis posterior tendon, which usually pass from its insertion on the navicular bone to other tarsal bones and are ligamentous in nature. The muscle produced flexion of the fifth toe and is innervated by the medial plantar nerve. Awareness of this is important to Anatomists and surgeons, especially those working on the foot.