Preliminary outcome of use of parenterally administered tranexamic acid during primary total knee replacement.

Background: Perioperative blood loss and the need for blood transfusion following total knee arthroplasty (TKA) has been a source of concern for many arthroplasty surgeons and patients over the years. Tranexamic acid (TXA) is increasingly being used by surgeons in limiting perioperative blood loss and the subsequent need for transfusion during TKA. Aim: This study aims to determine the efficacy of TXA in preventing perioperative blood loss, transfusion needs of patients that underwent TKA, complications, and its financial implications of its use in our institution. Patients and Methods: The study was a clinical comparative audit of perioperative blood loss and transfusion needs in primary TKA patients. The study population was divided into two groups of equal numbers (n = 40). Group A, who did not receive perioperative TXA, had TKA prior to the adoption of TXA in our institution, whereas group B, who received TXA, had TKA after TXA was adopted. Results: The mean postoperative hemoglobin was 9.49 g/dl for group A and 10.15 g/dl for group B (P = 0.021). The mean postoperative blood drainage was 888.25 ml for group A and 821.67 ml for group B (P = 0.397). The number of patients transfused in group A was 17 (42.5%) against 7 (17.5%) in group B. The mean postoperative transfusion volume was 270 ml and 101.25 ml for group A and B, respectively (P = 0.014). The mean total transfusion volume was 450 ml and 277 ml in group A and B, respectively (P = 0.063). Conclusions: The use of TXA in TKA was shown to be beneficial in our study as it resulted in a statistically significant reduction in the postoperative transfusion volumes and higher postoperative hemoglobin levels.

The Efficacy of Local Infiltration Analgesia in the Control of Post-Operative Pain after Total Joint Replacement Surgeries.

BACKGROUND: Total joint replacement surgeries can produce severe pain in the post-operative period that can prolong the duration of hospital stay. The aim of the study, was to determine the efficacy of Local Infiltration Analgesia in the management of post-operative pain after total joint replacement. METHOD: This was a prospective study with patients recruited for the study divided into group A and B. Group A received intra-operative analgesic cocktail while those in group B (control group) received an equal volume of normal saline. Both groups received the same post-operative pain management protocol. Pain assessment in the post-operative period was done using the visual analogue scale, at 4 hours, 8 hours, 24 hours and 48 hours post surgery. Time to achieving assisted ambulation, occurrence of adverse events, and the number of times analgesic was administered for breakthrough pain were assessed. RESULTS: A total number of 50 patients who had either total joint arthroplasty (25 in each group) were recruited for the study. The Normal saline group had significantly higher VAS scores in the first 8 hours after surgery (p values 0.016 at 4 hours and 0.037 at 8 hours post-operation) while both groups had similar pain scores thereafter. Mobilization times were not significantly different between both groups and adverse events occurred with almost equal frequency in both groups. CONCLUSION: Periarticular local infiltration analgesia as part of multimodal pain control protocol is effective in the control of early post-operative pain after total joint replacement.

CONTEXTE: Les chirurgies de remplacement total de l'articulation peuvent produire une douleur intense pendant la période postopératoire qui peut prolonger la durée du séjour à l'hôpital. Le but de l'étude était de déterminer l'efficacité de l'analgésie locale par infiltration dans la gestion de la douleur postopératoire après une arthroplastie totale. MÉTHODES: Il s'agissait d'une étude prospective avec des patients recrutés pour l'étude ont été divisés en groupes A et B. Le groupe A a reçu un cocktail analgésique intra-op¼ratoire. tandis que les patients du groupe B (groupe témoin ont reçu un volume égal de solution saline normale. Les deux groupes ont reçu le même protocole de gestion de la douleur post-opératoire. L'évaluation de la douleur dans la période postopératoire a été réalisée à l'aide de l'échelle visuelle analogique, à 4 heures, 8 heures, 24 heures et 48 heures après l'opération après l'opération. Le temps nécessaire à l'obtention d'une l'ambulance assistée, la survenue d'événements indésirables et le nombre de fois où un analgésique a été administré en cas de percée de la évalués. RÉSULTATS: 50 patients ayant subi une arthroplastie totale (25 dans chaque groupe) ont été recrutés pour l'étude. Le groupe recevant du sérum physiologique présentait des scores VAS significativement plus élevés dans les 8 heures après l'opération (valeurs p de 0,016 à 4 heures et 0,037 à 8 heures après l'opération), alors que les deux groupes avaient des scores de douleur similaires par la suite. Les temps de mobilisation n'étaient pas significativement différents entre les deux groupes et les événements indésirables sont survenus à une fréquence presque égale dans les deux groupes. CONCLUSION: L'analgésie périarticulaire par infiltration locale dansle cadre d'un d'un protocole multimodal de contrôle de la douleur est efficace dans le contrôle de la douleur postopératoire précoce après une arthroplastie totale. Mots clés: Analgésie par infiltration locale; arthroplastie totale; arthroplastie; douleur postopératoire.

Predictors of early elbow function following paediatric humeral supracondylar fractures: A retrospective analysis.

BACKGROUND: Supracondylar fracture usually occurs as a result of fall on an outstretched hand. Prompt management is essential to prevent complications. Functional outcome after management of this fracture may be predicted by some factors. AIMS: The study aimed to review the management of supracondylar fractures and determine what factors have an impact on the functional outcome of the elbow using MEPS score in the early post-operative period. PATIENTS AND METHODS: This study was a retrospective study of all patients with supracondylar fractures that presented at the accident and emergency department of a tertiary institution over a 2-year period. Their relevant data were retrieved from their folders and analysis done using SPSS 20. The MEPS score at 6 months was calculated. Multiple linear regressions were used to determine factors that can predict early elbow function using the MEPS score at 6 months. RESULTS: In the study, 61.4% (35) patients were males and 38.6% (22) females. The commonest mechanism of injury was fall on the outstretched hand (FOOSH), 70.2%. The mean duration of presentation to the hospital was 38 h (SD = 56.9). Among treatment offered to the patients, a higher number had open reduction with pinning. The mean postoperative Mayo elbow score was 87.6. Age of patients, Gartland type and the duration of cast immobilization were significant predictors of the MEPS at 6 months after treatment. CONCLUSION: The Gartland type and duration of cast immobilization are the most important predictors of the MEPS score at 6 months in this study.

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.

Traumatic hip dislocation at a regional trauma centre in Nigeria.

BACKGROUND: Traumatic dislocation or fracture-dislocation of the hip is an orthopaedic emergency that is steadily increasing in incidence due to high-speed motor vehicular accidents. These injuries need to be recognized early and promptly treated to prevent morbidity and long-term complications. Some of the fundamental issues in the management of traumatic dislocations of the hip are the critical interval between injury and reduction, the type of reduction most suitable for various types of injury and the duration of immobilization that give the best results. This study was carried out at the National Orthopaedic Hospital Enugu, a regional trauma and orthopaedic centre in South-East Nigeria. The purpose of the study is to describe the pattern of presentation and to identify the factors that determine the long-term outcome in the treatment of traumatic dislocations and fracture-dislocations of the hip at Enugu, Nigeria. METHODS: The case notes of all the patients that presented with traumatic dislocations and fracture-dislocations of the hip between January 2003 and December 2007 were reviewed. The information extracted and analyzed included the patients' demographics, etiology of injury, time interval before reduction, associated injuries, treatment offered, complications and follow-up. Thompson-Epstein classification was used to grade the posterior hip dislocations. The outcome of treatment was evaluated using the clinical and radiological criteria proposed by Epstein (1974). Three patients with incomplete data and two patients with central fracture dislocation were excluded from this study. RESULTS: Forty-eight patients with 50 hip dislocations were analyzed. The age range was 12 years to 67 years with a mean age of 34.8 years. Thirty-nine patients (81.3%) were males and 9 (18.7%) were females. Road-traffic accident was the leading cause of traumatic hip dislocation in this series, 44 cases (91.6%). Posterior dislocation occurred in 48 hips (96%) while anterior dislocation occurred in 2 hips (4%). Forty-seven hips (94%) were treated by primary closed reduction, two hips (4%) were treated with open reduction and one patient (2%) had Girdlestone excision arthroplasty. Thirty-six hips (73.5%) were reduced with 12 hours of the injury. Concomitant injuries were found in 37 patients (77%). The follow up period ranged from 10 months to 36 months with a mean follow up period of 15 months. Post-traumatic osteoarthritis occurred in 2 hips (4%) avascular necrosis of the femoral head was seen in 2 hips (4%). Five patients had sciatic nerve paresis while there was recurrence in one hip. No mortality was recorded. CONCLUSION: Traumatic dislocations and fracture-dislocations of the hip are severe injuries caused mostly by high-speed motor-vehicular accidents. Young adult males are most commonly affected, and there is a high rate of concomitant injuries. Excellent results can be achieved by early and stable closed reduction of these injuries with immobilization of the affected hips.

Oucome of management of non-gonococcal septic arethritis at National Orthopaedic Hospital, Enugu, Nigeria.

BACKGROUND: Septic arthritis is an accute bacterial infection of a synovial joint. It is an orthopaedic emergency that can lead to morbidity or mortality if not properly treated. the fundamental issues in the management of septic arthritis include the duration of antibiotic therapy, the mode of joint drainage and the role of physiotherapy. There is a paucity of local data on septic arthritis in Nigeria. The study wa carried out at the National Orthopoedic Hospital, Enugu; a regional trauma and orthopaedic center with wide catchments area covering at least three geopolitical zones of Nigeria. The objective of the study is to describe the pattern and distribution of non-gonococcal septic arthritis, the causative organisms, and the outcome of management of this condition at Enugu, Nigeria and make recommendations on the antibiotic therapy. METHOD: A retrospective study of all the patients that presented at the National Orthopaedic Hospital Enugu with Non-gonococcal septic arthritis between January 1997 and December, 2006 was done. The patient's case notes were retrieved from the Medical Record Department. Information extracted and analyzed included demographic data, joints affected, cultured organisms, antibiotic sensitivity pattern, duration of parenteral and oral antibiotics therapy, complications and follow-up period. Patients with incomplete records, immune-compromised patients and those with subjacent osteomyelitis were excluded from the study. RESULT: Forty-three patients were seen within the period and 40 had analyzable data. The age range was 1 month to 39 years, with a mean age of 10.2 years. Twenty-one patients (52.5%) were males and 19 (47.5%) were females. The hip joint was the most commonly affected (47.5%). Staphylococcus aureus was the most common organism (50%), followed by Coliformn (42.5%). Most patients (75%) had parenteral antibiotics for 3-5 days, while 77.5% of patients received oral antibiotics for 2-4 weeks. All the patients had arthrotomy and joint irrigation within 48 hours of admission. Complicatins were recorded in 11 patients (27.5%). Fixed flexion deformity was the commonest complication (17.5%). No mortality was recorded. CONCLUSION: Septic arthritis is an orthopaedic emergency. Early diagnosis and prompt treatment with appropriate ontibiiotics and surgical drainage are the keys to a successful outcome. In our environment (Enugu), the coliforms ore competing favourably with stophylococcus oaureus as causative agents of septic arthritis. Short term parenteral antibiotics of 3-5 days seems to be as effective as the 1-2 weeks therapy in the non-immune compromised patients and in cases not complicated by juxtarticular osteomyehlitis or presence of prosthetic implants.

Non-Steroidal anti inflammatory drugs usage in orthopaedics and trauma practice. A guide and review.

BACKGROUND: Non steroidal anti-inflammatory drugs (NSAIDs) are a group of heterogeneous compounds with anti inflammatory, analgesic and often times anti pyretic properties. They are weak organic acids and are the most commonly used drugs in Orthopaedic/Trauma practice. They provide mild to moderate pain relief. NSAID share common therapeutic and side effects irrespective of the class or group to which an individual drug may belong. These side effects are many and varied and constitute a major concern in their usage since most of them are life threatening. The NSAIDs are also one of the most commonly abused drugs. The abuses stem mostly from poor prescription habit by the health professionals. The poor prescription habit by the professionals and laissez-a-faire attitude to NSAID Usage informed the need for this review which addresses the issues, controversies and preventive strategies to reduce the complications in Orthopedics/Trauma practice. METHODS: Literature on the subject was reviewed extensively using manual library internet search. Publications from local and international Journals spanning a period of over thirty years were reviewed. The internet search was done using pubmed and ortholink search engines. RESULTS: NSAIDs act locally at the site of origin of pain by inhibiting the cyclooxygenase enzymes and induce no change in mood and dependency The inhibition of the Cox enzymes can be reversible or irreversible and leads to inhibition of prostaglandin synthesis. All the therapeutic and most of the side effects of NSAIDs result from the inhibition of the cyclooxygenase pathway. Thus the Cox-2 selective inhibitors have lesser side effects than the non selective Cox inhibitors; though there is recent evidence linking them with adverse cardiovascular events. There is paucity of information in literature on the guidelines of the prescription/usage of NSAIDs, and the preventive strategies in orthopedics and traumatology. CONCLUSION: NSAIDs are the most commonly prescribed group of drugs in orthopedics and trauma practice. They constitute a great asset to any Doctor who deals with pains associated with inflammation which they relief quite effectively. NSAID Usage is froth with significant life threatening complications. A high index of suspicion of the possibility of occurrence of these complications, adherence to proper prescription guidelines and preventive strategies, change of the laissez-a-faire attitude of the professionals to NSAID prescription and appropriate monitoring of the patients on the drugs are paramount in improving their safety profiles. Orthopedic and Trauma surgeons need to be aware of the serious side effects and the role of preventive strategies in the use of NSAIDs.

Outcome of management of chronic osteomyelitis at National Orthopaedic Hospital, Enugu.

INTRODUCTION: Chronic osteomyelitis remains challenging to treat despite advances in antibiotics and new operative techniques. The associated morbidity and difficulty in eradicating the infection has posed a problem for the surgeon. The objective of the study is to evaluate the management of chronic osteomyelitis using the National Orthopaedic Hospital Enugu experience and recommend some modification of the treatment protocol in antibiotic usage. METHOD: A retrospective study was carried out. Records of fifty patients presenting with chronic osteomyelitis over a ten year period from 1997 to 2006 were analyzed. Patients with incomplete records were excluded. RESULTS: The young active age group was more involved. Majority of the patients presented quite late, more than 6 months from onset of symptoms. Saucerization, curettage and sequestrectomy were the commonest surgical intervention done; as types III and IV [Cierny Mader] chronic osteomyelitis prevailed over the others. The duration of parenteral (intravenous) antibiotics usage was within 72 hours in most of the patients; with oral antibiotic continued for about 48 weeks in most of the patients. Most of the patients had stopped discharging at 12 weeks of follow-up and showed clinical evidence of arrest of the infection. CONCLUSION: Following adequate surgical debridement in chronic osteomyelitis, short term sensitivity based intravenous antibiotics for 48-72 hours and subsequent oral antibiotics for a variable period of 48 weeks is adequate treatment for chronic osteomyelitis in a non-immuno compromised patient.

Osteoclastoma in an infant.

BACKGROUND: Conventionally, osteoclastoma is a benign but locally aggressive bone tumour with a tendency for local recurrence and rarely distant metastasis, diagnosed mainly in young adults, 15-40 years of age. Diagnosis before skeletal maturity is circumspect. We report a case of giant cell tumour of the clavicle (uncommon site) in a 2% year old girl that was first noticed at 6 months of age. METHOD: The case files of the patient as well as relevant literature were reviewed. RESULTS: A 2%-year-old girl presented with a 2-year history of right clavicularswelling first noticed at 6 months of age. The mass was initially painless and very slow growing involving the medial third of the clavicle. It rapidly increased in size to involve the entire clavicle with associated pain following manipulation by a traditional bone setter about 6 months after onset. She had incisional biopsy; the histological report of which was osteoclastoma. She then had excision of the mass with the involved clavicle uneventfully. She is being followed up for recurrence. CONCLUSION: Osteoclastoma can develop in early childhood far before skeletal maturity, may be congenital in manifestation and can affect anybone in the body.

Austin-moore hemiarthroplasty; the Enugu experience.

BACKGROUND: Femoral neck fracture is the commonest fracture among the elderly who frequently have co-morbid medical conditions. It commonly follows trivial falls at home. Prosthetic replacement with Austin Moore prothesis is one of the treatment options open to Orthopaedic Surgeons in this age group who need to be mobilised as early as possible to prevent the complications of prolonged immobilization. This study shows our experience with Austin Moore hemiarthroplasty [AMH] as a treatment option for femoral neck fractures over a 10 year period. METHOD: Hospital records of 46 out of 59 patients who had AMH in NOHE between 1995-2004 (10 year period) were reviewed retrospectively. The 13 patients who had incomplete records were excluded. RESULTS: The age range of the patients was 26-99 yrs with 67:2 yrs as the mean. There was a slight female to male preponderance [F:M = 1.1:1]. Most of the patients clustered between 61 and 80yrs. Majority presented late [76%], with only 2 patients presenting within 24hrs of injury. Fracture neck of femur was the commonest indication for AMH [89.1%] with domestic falls and RTA having 54.3% & 32% respectively as aetiological factors. Hypertension was the most prevalent co morbid medical condition [76%]. Majority of the patients had preoperative traction, 58% (skin: 32.6%, skeletal 26.1%) while general anaethesia was used in 63% of patients. Blood transfusion was common; 87.1. 58.7% of patients were mobilized within 2-3 wks of operation while 26.9% were delayed for more than 3 wks. 2 patients [4.3%] died while on admission. 76.1% were mobilized initially on Zimmer frames, 13.0% on crutches, 6.5% on wheel chair. 80% were able to walk with walking stick[cane] in 6 weeks while 87% achieved this in 12 weeks. Follow up time of patients was poor as patients default frequently after few visits. Wound infection was the commonest complication 26.1%, mostly treated by dressing and antibiotics. 13.0% were hospitalized for 2-3 weeks, 36%-4-6 wks while 50% stayed beyond 6 wks. Mortality rate was 4.3% [2].