Outcomes of closed interlocking intramedullary nailing of the tibia without fluoroscopy in resource-limited settings: experience from two hospitals in Cameroon.

INTRODUCTION: closed static interlocking nailing with c-arm guidance is the standard procedure for the treatment of closed diaphyseal leg fractures. It is still very difficult to carry out such procedures in a low-income setting because of few or absent image intensifiers (c-arm) despite the necessity. The aim of this study was to describe the outcomes of patients with tibial fractures treated with closed interlocking intramedullary nails without c-arm guidance in a Cameroonian population. METHODS: this was a prospective study including adult patients treated for tibial fractures without a c-arm in two regional hospitals. RESULTS: finally, 22 patients were included. The mean age was 34 ± 12.6 years with a male predominance (16 males and 6 females). Ninety percent of the fracture lines were simple or with a wedge fragment grade 42A or 42B respectively according to the AO classification. The mean surgery time was 1 hour 26 ± 34 minutes. The various aspects evaluated were the nail entry point which was good in 19 (86.4%) cases; proper nail driving which was considered good in 15 (68%) cases; the distal locking which was missed in 6 (27.3%) cases. Bone consolidation was obtained in an average of 4 ± 1.2 months in all 22 cases. CONCLUSION: in resource constraints settings where c-arm are not always available, closed interlocked nail of tibia without c-arm guidance still gives overall good results. Nevertheless, there is a need to improve equipment in sub-Saharan African hospitals to make trauma surgery with c-arm a gold standard as currently recommended.

Global incidence of surgical site infection after appendectomy: a systematic review and meta-analysis.

BACKGROUND: Although surgical site infection (SSI) is one of the most studied healthcare-associated infections, the global burden of SSI after appendectomy remains unknown. OBJECTIVE: We estimated the incidence of SSI after appendectomy at global and regional levels. DESIGN: Systematic review and meta-analysis. PARTICIPANTS: Appendectomy patients. DATA SOURCES: EMBASE, PubMed and Web of Science were searched, with no language restrictions, to identify observational studies and clinical trials published between 1 January 2000 and 30 December 2018 and reporting on the incidence of SSI after appendectomy. A random-effect model meta-analysis served to obtain the pooled incidence of SSI after appendectomy. RESULTS: In total, 226 studies (729 434 participants from 49 countries) were included in the meta-analysis. With regard to methodological quality, 59 (26.1%) studies had low risk of bias, 147 (65.0%) had moderate risk of bias and 20 (8.8%) had high risk of bias. We found an overall incidence of SSI of 7.0 per 100 appendectomies (95% prediction interval: 1.0-17.6), varying from 0 to 37.4 per 100 appendectomies. A subgroup analysis to identify sources of heterogeneity showed that the incidence varied from 5.8 in Europe to 12.6 per 100 appendectomies in Africa (p<0.0001). The incidence of SSI after appendectomy increased when the level of income decreased, from 6.2 in high-income countries to 11.1 per 100 appendectomies in low-income countries (p=0.015). Open appendectomy (11.0 per 100 surgical procedures) was found to have a higher incidence of SSI compared with laparoscopy (4.6 per 100 appendectomies) (p=0.0002). CONCLUSION: This study suggests a high burden of SSI after appendectomy in some regions (especially Africa) and in low-income countries. Strategies are needed to implement and disseminate the WHO guidelines to decrease the burden of SSI after appendectomy in these regions. PROSPERO REGISTRATION NUMBER: CRD42017075257.

Ainhum, a rare mutilating dermatological disease in a female Cameroonian: a case report.

BACKGROUND: Ainhum is an idiopathic dermatological disease characterized by a progressive constricting ring usually on the fifth toe, which may lead to spontaneous auto-amputation of the affected toe. Timely diagnosis and treatment are the key elements to avert amputations with resultant mutilating deformities, permanent handicaps and psychological sequelae. Though common in African descents, this pathology has not been described in the Cameroonian literature. Herein, we report the case of an adult Cameroonian woman presenting with ainhum. CASE PRESENTATION: A 54-year old Cameroonian was admitted to our primary healthcare centre with a 6-month history of a painful constriction band developing at the base of her right fifth toe. Her past history was uneventful. Based on the absence of trauma and spontaneous onset of the condition, the diagnosis of ainhum was most suggestive. She was managed surgically by excision of the band, disarticulated at right fifth metatarsophalangeal joint and skin closure. Her post-operative course after 1 year was uneventful. CONCLUSION: Here we presented a case of ainhum, a rare dermatological disease with few reports. In view of the serious complications of ainhum such as mutilating deformities with permanent physical disabilities and psychological trauma, we draw clinicians' attention, especially wound care specialists to this rare but potentially handicapping disease, for timely diagnosis and management.

Giant sixteen kilogram lymphangioma mesenteric cyst: An unusual presentation of a rare benign tumour.

BACKGROUND: Mesenteric cysts are rare abdominal benign tumours with an incidence of 1:100.000-250.000 surgical admissions located in the mesentery. Theirs presentations may range from incidental asymptomatic discovery during imaging to non-specific abdominal symptoms. CASE PRESENTATION: We present the case of a 46 year old female who presented with 9 months history of progressive abdominal distension. CT scan showed a giant abdominal mass. After the necessary preoperative work up, a midline incision laparotomy was performed. Intraoperative findings were a mesenteric cyst originates from the transverse mesocolon. The cyst weighed 16 kg and histopathology analyses confirmed a lymphangioma mesenteric cyst. DISCUSSION: In low incomes countries like our own, the interval between the onset of symptoms and consultation is often significant, leading to unusual and sometimes spectacular presentations at the time of diagnosis. To our knowledge, it is the heaviest mesenteric cyst reported in the literature to date. CONCLUSION: Mesenteric cysts may present as giant abdominal masses. The publication of this atypical case is a plea for us for the establishment of universal health coverage in our country in particular and in Africa in general.

Brachiocephalic A-V fistula through the median cubital vein; A reliable option to failure of forearm fistulas. A case report from CHU Yaoundé.

INTRODUCTION: Renal replacement therapy in end-stage kidney disease relies on dialysis in low-income countries. This maintenance treatment needs a reliable vascular access and is done through central venous catheter or creation of A-V fistulas. Several types of A-V fistulas can be done but due to some individual conditions, those possibilities may be exhausted rapidly. CASE PRESENTATION: A 31 year old female was diagnosed with an end stage renal disease for which she was prescribed maintenance dialysis. She first denied her condition and went to traditional healer. After some months her clinical state worsened and she was dialyse with catheter and refer to us for A-V fistula construction. The first two attempts on the forearm failed and we found small radial artery both proximally and distally on the left forearm. We finally did a left brachiocephalic fistula with initial retrograde flow on the median cubital vein. DISCUSSION: Despite arm base fistula may be theoretically easy to build because of bigger size vessels, brachiobasilic fistula may be less effective due to difficult venipuncture. Brachiocephalic fistula through median cubital vein may be more effective option with no further procedure needed. CONCLUSION: Brachiocephalic fistula should be considered as option in vascular access especially when a reliable option is needed after previous attempt failure.

Paediatric fractures in a sub-saharan tertiary care center: a cohort analysis of demographic characteristics, clinical presentation, therapeutic patterns and outcomes.

INTRODUCTION: Paediatric fractures are often of good prognosis due to auto-correction of insufficient fracture reduction by bone remodeling. In sub-Saharan Africa, traditional healers are renowned for managing fractures and there is a neglect for specialized pediatric fracture care. We aimed to determine the demographic characteristics, clinical presentation, treatment patterns and outcomes of paediatric fractures in a tertiary health care centre in Yaoundé. METHODS: We conducted a prospective cohort study of all consenting consecutive cases of fractures in patients younger than 16 years managed between January 2011 and June 2015 at the University Teaching Hospital, Cameroon. We analysed demographic data, injury characteristics, fracture patterns, treatment details, therapeutic challenges and outcome of treatment at 12 months of follow-up. RESULTS: We enrolled 147 fractures from 145 children with a mean age of 7 years and male-to-female sex ratio of 2.5:1. The main mechanisms of injury were games (53%) and accidental falls (20.7%). Forearm fractures were the most common fractures (38%). The mainstay of management was non-operative in 130 (88.5%) fractures, with 29.3% manipulations under anesthesia and 17 (11.5%) open reductions with internal fixation. The most surgically reduced fractures were supracondylar humeral fractures. Major difficulties were long therapeutic delay, lack of diligent anaesthesia and the lack of fluoroscopy. The outcome of treatment was favorable in 146 (99.3%) paediatric fractures. CONCLUSION: With the growing population of sub-Saharan Africa and the objective of becoming an emergent region, public policies should match the technical realities.

Spontaneous cecal perforation in a 40-year-old pregnant woman treated by primary repair and omental patch: a case report.

BACKGROUND: Spontaneous colonic perforations are scarce, and cecal perforations even more so. Preoperative diagnosis of the latter in a pregnant woman is particularly difficult because of physiologic changes and restrictions on some diagnostic imaging techniques, such as X-rays. Furthermore, management of these patients is a big challenge. CASE PRESENTATION: We present a case of a spontaneous cecal perforation in a 40-year-old pregnant black woman in the Regional Hospital of Bafoussam in Cameroon. The results of clinical examination and ultrasonography on admission were in line with acute generalized peritonitis in a woman at 20 weeks of a viable pregnancy, indicating an urgent laparotomy. Operative findings were a 1 × 1-cm perforation on a distended cecum with minimal fecal contamination. The treatment consisted of excision of the edges, primary suture of the perforation, and omentoplasty. The recovery of the patient was uneventful. CONCLUSIONS: The management of spontaneous cecal perforation in a pregnant woman was a big challenge. The perforation was repaired by primary suture and omentoplasty. Further studies comparing this approach with right hemicolectomy are recommended.

A Prospective Cohort Study of the Therapeutic Patterns, Challenges and Outcomes of Paediatric Femoral Fractures in a Cameroonian Tertiary Center.

BACKGROUND: Knowledge of the therapeutic patterns, challenges and outcomes of treatment of paediatric femoral fractures (PFF) helps to better choose the ideal therapeutic modality which is still controversial. However, this data is scarce in the sub-Saharan African literature. OBJECTIVE: To determine the therapeutic patterns, treatment challenges and outcomes of treatment of PFF in a tertiary care centre in Cameroon. METHOD: We conducted a prospective cohort study of all consenting consecutive cases of femoral fractures in patients younger than 16 years managed between 2011 and 2015 at the surgical unit of Yaoundé University Teaching Hospital, Cameroon. We analysed demographic data, injury characteristics, fracture patterns, treatment details, therapeutic challenges and outcomes of treatment at 12 months using Flynn's criteria. RESULTS: We enrolled 30 femoral fractures from 29 children with mean age was 4.2 ± 3.3 years. The male gender, diaphyseal locations and spiral fracture lines were predominant. Main mechanisms of injury were accidental falls, road traffic accidents and game injuries. Fracture management entailed 12 tractions followed by casting, 10 casting alone, four closed reductions followed by casting, two cannulated screw fixations, one pin fixation and one external fixation. The mean duration of consolidation was 10.3 ± 3.9 weeks. The outcome was rated excellent in 28 cases. Limited resources precluded fluoroscopy use, proper anaesthetic management, early rehabilitation and patient-parent satisfaction. CONCLUSION: Conservative management of PFF yields a good outcome in our setting. However, an improvement in surgical, radiology and anaesthetic infrastructure is needed for optimal PFF care.

Surgical Management of Chronic Wounds in a Buruli Ulcer Endemic Area in Central Africa.

BACKGROUND: Chronic wounds, especially Buruli ulcers (BU) are emerging public health threat in West and Central Africa. Akonolinga in Cameroon is one of the four health districts affected by BU. Since 2002, Médécins Sans Frontières has established a specialized wound carecenter to actively diagnose and provide treatment of chronic wounds that is accessible and affordable for all patients. Our objectives were to report the surgical activities in Akonolinga, to provide description of the types of chronic wounds and elements of anticipation of treatment needs in a public health perspective. METHOD: We carried out a retrospective cohort and descriptive study from January 2012 to June 2014 (30 months) on a series of consecutive patients with chronic wounds, managed surgically in Akonolinga, Centre Region, Cameroon. Among BU patients only those with necessity of surgery were included and the others followed only their 8 weeks medical treatment with antibiotics. RESULTS: A total of 148 patients were recorded. 101 cases of BU and related disability and 47 cases of non-Buruli chronic wounds. Patients had a mean age of 34 years. Most of the procedures used were debridement 40 %, skin graft 29 %, stripping 5 %, plastic procedures 7 %, and amputation 4 %. The mean number of procedures was 2 for each patient in this series. CONCLUSION: Chronic wounds occur worldwide and may be caused by specific health conditions. Medical and paramedical education should provide both the theoretical knowledge and practical skills to help health care personnel to face this problem in their communities.

Don't be scared: insert a mesh!

Mesh repair is now the gold standard technique of repair on incisional hernias. Infection of the mesh is a challenging complication of this type of repair. The risk of mesh infection has been shown to be greater in case of complicated hernia. We present the case of a 64 years old female who presented with an incarcerated incisional hernia with bowel infarction. Treated with a non absorbable mesh repair, she developed mesh infection. The infection was successively treated with simple drainage. This case and review of relevant literature seem to be an indication that mesh repair could still be considered in cases of complicated hernia. Simple drainage usually helps manage the cases of mesh infection.

Analysis of epidemiology, lesions, treatment and outcome of 354 consecutive cases of blunt and penetrating trauma to the chest in an African setting.

BACKGROUND: The proportion of death and disability related to trauma is increasing in Third-World countries. Thoracic trauma is significantly involved, but few data are available on this issue in African countries with specific local conditions. METHODS: The aim of the study is to analyse the diagnosis and management procedures in thoracic trauma in a typical African country. The records of 354 patients admitted to an emergency unit for chest trauma over a 13-year period were retrospectively analysed. RESULTS: The sample included patients with 231 cases of blunt and 123 of penetrating trauma to the chest; their mean age was 41.86 years, and the male:female ratio was 4.2:1. The majority (N=226) of the injuries were sustained in road traffic accidents, and the most common lesions were rib fractures (50.3%) and haemothorax (38.7%). The diagnosis was based on physical examination and standard chest radiographs in most cases. At least one associated lesion was found in 260 (73.45%) patients. The mean injury severity score (ISS) for our patients was 16.39. Most patients were managed conservatively (N=303); thoracotomy was performed mostly on penetrating trauma patients. Morbidity occurred in 49 patients, mainly affecting those treated with thoracic drainage, and 27 patients (7.6%) died. Factors related to mortality were ISS score and association with neurotrauma. CONCLUSIONS: Chest trauma can be managed in our Cameroonian environment, with morbidity and mortality comparable with that of Western countries. Diagnosis must still rely on physical examination, chest radiographs and thoracic echography, which are affordable tools.

Meckel's diverticulum: a case report from the University Hospital Center Yaoundé, Cameroon.

To the best of our knowledge there is no reported case of Meckel's diverticulum (MD) in Cameroon. The prevalence of MD in the general population is 2-3 %. The aim of this paper is to recapitulate the role of this pathology in acute abdomens and abdominal pain of uncertain aetiology in young patients and to review the medical literature.

Retained sponge after abdominal surgery: experience from a third world country.

BACKGROUND: Retained abdominal sponge after surgery is a quite rare condition which can have heavy medico-legal consequences; its frequency is generally underestimated. Few reports of these conditions are available in African environment with specific technical and medico-legal background. We present our local experience of retained sponges after abdominal surgery and review current literature. METHOD: A retrospective analysis of the medical files of 14 consecutive patients with a retained surgical sponge after abdominal and urological surgery. RESULTS: The incidence was 1every 677 abdominal operations; no metallic foreign body described, only sponges; the female sex predominated with 10/14 patients. 85.71% of retained sponge occurred after an emergency procedure and 64.28% were gynecological or obstetrical procedures. Most cases presented as intestinal obstruction, localized persistent pain or abdominal mass and pre-operative diagnosis could be done only in 28.57% of cases. A falsely correct sponge count was reported in 71.42% of cases 92.85% of patients were re-operated and the morbidity was low; no death was reported. None of our cases ended in a medico-legal claim despite proper counseling. CONCLUSION: The incidence of retained sponge might be significantly higher in an environment with reduced medico-legal threat; most cases of retained sponges are still related to human errors; the incidence will probably be reduced by a greater awareness about the condition.