Discharge against Medical Advice in Eight Tertiary Hospitals in Nigeria: A Prospective Study.

BACKGROUND: Discharge against medical advice (DAMA) is when a patient decides to leave the hospital without the consent of the treating physician. It poses serious clinical, ethical, and legal challenges to the individual physician as well as the hospital. AIM: To determine the prevalence and reasons for DAMA in orthopedic departments of eight tertiary hospitals in Nigeria. MATERIALS AND METHODS: This was a prospective multi-center descriptive study undertaken in eight tertiary Nigerian hospitals. Consecutive patients who requested for DAMA within 1 year of the study and who consented to participate in the study had face-to-face interviews. Data obtained were documented in a questionnaire and analyzed with SPSS version 20. RESULTS: The total number of patients studied was 373 with a mean age 34.7 ± 17.5 years. About a quarter of them (25.5%) were between 31 and 40 years. A prevalence rate of 1.9% was found with financial constraint being the predominant reason for DAMA (40.8%). Other reasons include family preference for unorthodox treatment (18.8%) and treatment dissatisfaction (7.0%) among others. CONCLUSION: The study findings indicate a low DAMA rate when compared to previous studies in this region. It also indicates that financial constraints, family preference for unorthodox care, and low educational status are major drivers of DAMA. Deepened health insurance and other measures that can reduce the prevalence of DAMA should be prioritized to improve treatment outcomes.

Antegrade Versus Retrograde Approach to Interlocking Nail Fixation of Femoral Diaphyseal Fractures: Is there Difference in Time to Union?

BACKGROUND: Antegrade reamed interlocked intramedullary nailing is the treatment of choice forfemoral diaphyseal fractures. More recently, retrograde intramedullary nailing of the femur has been seen as a viable alternative to the antegrade nail. METHODS: This was a prospective comparative study. Consecutive patients were placed alternately into a study group (retrograde nailing) and a control group (antegrade nailing) in a ratio of 2:1 i.e two retrograde nailing for every antegrade nailing. Forty one fractures had interlocking intramedullary fixation via the retrograde approach (study group), while the control group consisted of twenty fractures that had fixation via the antegrade approach. All were followed up for a minimum period of nine months (range of nine to twenty-four months). RESULTS: The mean duration of surgery in the retrograde group was 157.07minutes and 137.40 minutes in the antegrade group (p=0.093). The mean duration to fracture union was 16.98±4.71 weeks in the retrograde group and 15.80±5.43 weeks in the antegrade group (p = 0.388). There was no incidence of non-union in the two groups. CONCLUSION: Retrograde approach compares favourably with antegrade approach for intramedullary interlocking nail fixation of diaphyseal femoral fracture in adults with respect to time of fracture healing.

Comparison of effect of retrograde and antegrade approaches to interlocking nail fixation of femoral diaphyseal fractures on ipsilateral hip and knee joint motion.

PURPOSE: The objective of this study was to evaluate the early impact of antegrade and retrograde interlocking nail fixation of femoral diaphyseal fractures on the ipsilateral hip and knee joint range of motion. METHODS: A prospective evaluation was performed of 62 consecutive limbs with femoral diaphyseal fractures that had interlocking nail fixation through the antegrade or retrograde approaches. All participants had post-operative physiotherapy. Follow-up was for 9 months. RESULTS: The mean maximum hip flexion angle at 9 months was 137.50 in the antegrade group and 133.80 in the retrograde group (p = 0.150). Trendelenburg test was negative in both groups and there was no knee extension lag at 9 months. While the mean maximum knee flexion angle at 9 months was 119.90 in the retrograde group and 134.50 in the antegrade group (p = 0.023). All patients had achieved radiologic and clinical fracture union by twenty four weeks post-operatively. CONCLUSION: There was no significant effect of antegrade or retrograde approach on the range of motion of the hip joint. However, knee motion improved more quickly in the group that had antegrade nailing.