Reamed intramedullary nailing of diaphyseal multifragmentary femur fractures (AO/OTA 32-C) without fluoroscopy guidance: prospective analysis of methods and short-term outcomes in a low-resource setting.

PURPOSE: To describe the methods and outcomes of reamed intramedullary nailing (IMN) of diaphyseal multifragmentary femur (AO/OTA C2 and C3) fractures (DMFFs) in a low-resource setting without fluoroscopy and fracture table. METHODS: The prospective study involved 35 DMFFs among 318 femur fractures treated ≤ 3 weeks post-injury with SIGN nails. The fractures were fixed without fluoroscopy, fracture table and power reaming. Closed, mini-open or open reduction was done. Anatomical length and alignment were ensured using a surgical support triangle during retrograde nailing, and by an assistant during antegrade nailing. Follow-ups were done at 6 weeks, 12 weeks and 6 months. RESULTS: DMFFs constituted 11.0% of the 318 fractures. Twenty-four (68.6%) were males. The mean age was 39.0 years (range 17-75 years). About 94.3% were injured in road traffic accidents. Fracture reduction was closed in 18, mini-open in 8 and full-open in 9. The operative times were significantly shorter for closed than open reduction (p = 0.001). Five fractures received a supplemental fixation with plate or lag screws. By the 12th post-operative week, 97.1% demonstrated continuing radiographic healing, 94.1% tolerated painless weight-bearing and 91.2% could squat & smile. There was no infection or noticeable rotational malunion. Five fractures healed with a limb-length discrepancy of < 2 cm. CONCLUSION: The study demonstrates the feasibility of reamed IMN of DMFFs without fluoroscopy. The outcomes were satisfactory. Although the small sample size and short follow-up period are limitations, the study could serve as a basis for future larger studies in low-resource settings.

Retrograde intramedullary nailing with supplemental plate and lag screws allows early weight bearing following distal end-segment femur fractures (AO/OTA 33) in a low-resource setting.

PURPOSE: To underline the feasibility of achieving early weight bearing in patients with distal end-segment femur fractures (AO/OTA 33) treated with retrograde intramedullary nailing and supplemental plate or lag screws in the absence of C-arm. METHODS: 41 distal end-segment femur fractures (DFFs) included in the study were treated with SIGN nails with or without a side plate in a center that lacked intraoperative fluoroscopy and fracture table. A medial or lateral para-patellar incision was used for fracture reduction, nail insertion and side plate placement. Follow-ups were done at six weeks, 12 weeks, and six months post-operatively. RESULTS: Distal end-segment fractures constituted 13.2% of all femur fractures treated. The patients' mean age and range were 49.6 and 23-83 years respectively. They were mostly injured in road traffic accidents. 27 were daily-income earners. By the 12th week post-operatively, 82.1% of them could flex their knee beyond 90°, all of them could bear weight fully, and 71.8% could squat & smile. CONCLUSION: The study highlighted the procedure for retrograde nailing of DFFs in a setting without the requisite facilities for minimally-invasive surgeries. The findings demonstrated the feasibility of achieving an expedited weight bearing for the predominantly daily-income-earning victims to ensure early return to work and poverty reduction. While the small sample size is a limitation, the study does provide information that could serve as a basis for future randomized controlled trials in low-resource settings.

Follow-up non-attendance after long-bone fractures in a low-resource setting: a prospective study of predictors and interventions to increase attendance rates.

BACKGROUND: While the majority of traumatic injuries occur in low- and middle-income countries, the published literature comes chiefly from high-income countries due to poor follow-up. Clinical and radiographic post-surgical trauma follow-up is essential to high-quality research and objective monitoring for healing and/or complications. This study aimed to identify the predictors of follow-up non-attendance in a low-resource setting and investigate the extent to which interventional efforts based on mobile phone technology (MPT) and home visits improved the follow-up rates for fractures treated with SIGN nails. METHODS: This was a prospective study of 594 patients with long-bone fractures. Socio-demographic (e.g. age, gender, marital status, education level, etc.) and clinical (e.g. fracture type, concomitant injuries, comorbidity, etc.) data were collected on each patient. Before discharge, the importance of follow-up was explained to patients and their relations. They were encouraged to attend even if they felt well. Their residential addresses and telephone numbers were validated and securely stored. Patients who missed their appointments were contacted by phone. Those who failed to honour 2 or 3 rescheduled appointments were visited in their home. The patients were divided into those who returned for the primarily scheduled follow-up without prompting (volition group) and those who did not come (non-attenders). Univariate analyses and binary logistic regression were conducted to determine the significant predictors of non-attendance. RESULTS: The proportion of patients in the volition group reduced from 96.1% at 6 weeks to 53.0% at 12 weeks and 39.2% at 6 months. However, interventional efforts increased these values to 98.5%, 92.5%, and 72.4% respectively. Walking unaided before the primarily scheduled 12-week appointment was the major reason for not attending the follow-up. Education, occupation, post-operative length of hospital stay (PLOS) and infection were significantly associated with non-attendance but younger age, long distances from the hospital, being separated or divorced, difficulty paying the in-patient care bill, closed fracture, having no (or a non-limb) concomitant injury, achieving painless weight bearing ≤ 6 weeks post-operatively and needing no additional surgery were independent predictors of non-attendance. CONCLUSIONS: Our study sheds light on the predictors of follow-up non-attendance and demonstrates how interventional efforts improved attendance rates in a low-resource setting. In addition, efforts that better the socio-economic status of people such as more-encompassing health insurance coverage and greater work flexibility can improve the follow-up attendance rates.

Locked intramedullary nailing of diaphyseal femur fractures without intraoperative fluoroscopy, fracture table and power reaming: retrograde affords greater procedural efficiency than antegrade approach.

PURPOSE: To compare the intraoperative procedural efficiency of antegrade and retrograde locked intramedullary nailing of diaphyseal femur fractures without intraoperative fluoroscopy, power reaming devices and fracture tables. METHODS: A secondary analysis of prospectively collected data was conducted on 238 isolated diaphyseal femur fractures fixed with SIGN Standard and Fin nails within three weeks of injury. The data included baseline patient and fracture characteristics, nail type and diameter, fracture reduction methods, operative times and outcome measures. RESULTS: There were 84 and 154 fractures in the antegrade and retrograde groups respectively. Both groups were similar vis-a-vis baseline patient and fracture characteristics. Closed reduction of the fractures was significantly easier for retrograde than an antegrade approach. The retrograde approach more readily permitted the use of Fin nails. The mean nail diameter used for retrograde was significantly larger than that for antegrade. The time taken to achieve retrograde nailing was significantly lesser than that of antegrade. There was no statistically significant difference between the outcomes of the two groups. CONCLUSION: In the absence of expensive fracture-surgery gadgets, retrograde nailing offers many procedural advantages over antegrade, such as easier closed reduction and canal reaming, the greater possibility of using the Fin nail with fewer interlocking screws and shorter operative times. However, we acknowledge the lack of randomisation and the presence of an unequal number of fractures in the two groups as limitations of this study.

Histoplasma duboisii of the femoral bone.

Histoplasmosis due to Histoplasma duboisii is an emerging AIDS-defining opportunistic infection in HIV positive seen predominantly on the African continent between the Tropics of Cancer and Capricorn. Histoplasma duboisii is an invasive fungal organism with tropism for lymph nodes, skin and bones. The infection occurs more in patients with a CD4 count <50/mm3 and is usually dissemnnated Histoplasmosis due to Histoplasma duboisii is an emerging AIDS-defining opportunistic infection in HIV positive seen predominantly on the African continent between the Tropics of Cancer and Capricorn. Histoplasma duboisii is an invasive fungal organism with tropism for lymph nodes, skin and bones. The infection occurs more in patients with a CD4 count <50/mm3 and is usually disseminated. Literature reports of its occurrence in HIV negative patients are scanty. We report a case of histoplasma dubiosii infection of the left femur in a 9 year old HIV negative Nigerian with swelling in the left thigh of 5 months duration. Oral antibiotics and analgesics were prescribed for the patient with satisfactory clinical outcome. To our knowledge, this is the first reported case in an immunocompetent child in Nigeria. Literature reports of its occurrence in HIV negative patients are scanty. We report a case of histoplasma dubiosii infection of the left femur in a 9 year old HIV negative Nigerian with swelling in the left thigh of 5 months duration. Oral antibiotics and analgesics were prescribed for the patient with satisfactory clinical outcome. To our knowledge, this is the first reported case in an immunocompetent child in Nigeria.

Non-ossifying fibroma of the right clavicle.

Non-ossifying fibromas (NOFs) or fibroxanthomas are benign intracortical, multilocular and well-circumscribed lesions, which most commonly affect children and adolescents with an estimated prevalence of 30%-40% of all normal children. They are most commonly located in the distal femoral and distal tibial metaphysis although they can also be found in the fibula and upper extremity. Clinically, NOFs are asymptomatic and are detected only incidentally on radiographs where they appear as solitary, eccentric and lytic lesion in the metaphysis of a long bone and often polycyclic in shape. In most cases, no treatment is needed for an NOF other than simple observation due to a high rate of spontaneous regression at skeletal maturity. However, surgical treatment is considered in certain cases when the NOF is large or symptoms are present. We present an unusual case of a large NOF in the right clavicle of a 27-year-old woman who came to us with a 3-year history of a painless swelling on the right side of her upper chest. Radiographic evaluation of her tumour revealed a Ritschl Stage C lesion which was subsequently treated successfully by a near-total cleidectomy without recurrence over a 4-year of the follow-up period. We concluded that open-mindedness remains an important attribute a doctor must possess in order not to miss some rather unlikely diagnosis.

Intramuscular lipomas posing diagnostic and pre-operative counselling challenges in a low-resource setting: A case series.

INTRODUCTION: Intramuscular lipomas (IMLs) are uncommon primary adipose tissue tumours deep within the muscle. A high likelihood of misdiagnosing them as other benign and malignant masses necessitates imaging studies to confirm the diagnosis and plan treatment. Ultrasonography is useful but CT and MRI provide a more accurate diagnosis. While diagnostic tests are suitable, they may not always be accessible or affordable in low-resource settings. We present three cases of IMLs that emphasise the difficulties posed by limited resources and the significance of a comprehensive medical history and physical examination in low-resource settings. PRESENTATION OF CASES: The patients included a 57-year-old male with a distal right thigh mass, a 65-year-old female with a proximal right thigh mass, and a 60-year-old female with a mass at the left scapular area. The three patients underwent surgical excision and had an uneventful postoperative course, with no reported recurrence during their ongoing follow-up. DISCUSSION: The management of IMLs is not complicated if the requisite resources are available. Conversely, in low-resource settings with limited diagnostic facilities and human expertise, management may take a challenging path. Patient 1, despite undergoing diagnostic tests confirming IML, initially declined treatment due to challenges with pre-operative counselling. Patients 2 and 3 lacked health insurance and could not afford diagnostic imaging tests. CONCLUSION: Healthcare professionals in low-resource settings should familiarise themselves with the clinical characteristics and pathology of IMLs to minimise misdiagnosis and ensure appropriate counselling is provided to patients. IMLs are slow-growing mostly asymptomatic benign swelling. On physical examination, they are usually non-tender, soft, masses, not fixed to the bed or overlying tissue. The overlying skin is normal and lymphadenopathy is absent.

Epidemiology of geriatric orthopaedic injuries in a tertiary hospital in southwestern Nigeria.

Life expectancy in sub-Saharan Africa (SSA) has increased owing to economic growth and improvements in medical care. An increased representation of older people among orthopaedic trauma victims is a significant consequence of population ageing, as shown in previous studies, including few in SSA. This retrospective review in Nigeria aims to corroborate previous studies and highlight the emergence of geriatric orthopaedic trauma (GOT) as a public health concern in SSA. Among 241 orthopaedic trauma in-patients aged ≥ 60, the mortality rate was 3.7%. They made up 21.2% of adult orthopaedic trauma admissions. The incidence of GOT increased steadily over the five-year study period with a spike during COVID-19 lockdown. Males constituted 51%. Mean age was 72.5 years (range, 60-105 years). Mean distance to the hospital was 35.8 km and 50.6% lived farther than 10 km. The main causes of injury were falls (50.6%) and traffic crashes (48.1%). Fractures were the predominant (91.7%) injuries. Univariate analyses revealed significant differences along age and gender stratifications. Longer distance to the hospital significantly delayed presentation. The study supports previous studies and shows that GOT is evolving as a public health concern in SSA. The 2030 Sustainable Development agenda is apt to stem the trend.

Solid locked intramedullary nailing for expeditious return of bone-setting-induced abnormal fracture union victims to work in South-western Nigeria.

Wage earning in low- and middle-income countries (LMICs) is predominantly through physical labour. Consequently, limb-related disabilities caused by abnormal fracture unions (AFUs) preclude gainful employment and perpetuate the cycle of poverty. Many AFUs result from traditional bone-setting (TBS), a pervasive treatment for long bone fractures in LMICs. The objective of this study was to accentuate the expediency of solid locked intramedullary nail in the early restoration of victims of TBS-induced abnormal fracture unions (AFUs) to their pre-injury functioning, including work. One hundred AFUs in 98 patients treated with a solid locked intramedullary nail in our center over a period of 7 years were prospectively studied. We found the mean age to be 47.97 years. Males constituted 63.9% of the patients' population. Atrophic non-union accounted for 54.1% of the AFUs. The mean fracture-surgery interval was 21.30 months. By the 12th post-operative week, more than 75% of the fractures had achieved knee flexion/shoulder abduction beyond 90°, were able to squat and smile (or do shoulder abduction-external rotation), and were able to bear weight fully. The study demonstrated the expediency of solid locked nail in salvaging TBS-induced abnormal fracture unions in a way that permitted early return to pre-injury daily activities and work, thereby reducing fracture-associated poverty.

Radiation-free interlocking intramedullary nailing of three-hundred and seventy long bone fractures in Ogbomoso, Nigeria.

Long bone fracture care in developing countries remains largely different from that of the developed world where closed reduction and internal fixation with locked intramedullary nail is the standard treatment. This study in a developing country presents the pattern and outcome of treatment of 370 long bone fractures using the SIGN nail over a five-year period in order to underline the wide array of patients and fractures treatable with the nail. Using a prospective descriptive approach, all the 342 patients with 370 fractures of the humerus, femur and tibia treated from July 2014 to June 2019 were studied. The fractures were reduced without image intensifier or fracture table and fixed with the SIGN nail. Post-discharge, the patients were followed up at the out-patient clinic. The mean age of the patients was 43.45 years with a range of 10-99 years. Sixty-six percent were males who were mostly injured in motorcycle accidents. Femur, tibia and humerus fractures accounted for 59.7%, 28.4% and 11.9% respectively. Eighty-six percent were diaphyseal fractures, 73% were fresh and the main previous treatment was traditional bone setting. Deep infection occurred in 4.9%, 66.0% achieved knee flexion > 90° by sixth week, the majority achieved full weight bearing and could squat and smile by 12th week. The SIGN nail is versatile, useful for treating a wide range of fractures in most age groups particularly in developing countries where orthopaedic fractures are prevalent but the more sophisticated facilities are lacking or poorly maintained.

Benign fibrous histiocytoma of a metacarpal bone.

Benign fibrous histiocytoma (BFH) is a rare skeletal tumour. Its occurrence in the metacarpal bones is even rarer. The management in this location can be challenging, involving tumour resection and metacarpal reconstruction. The authors present a case of BFH involving the second metacarpal bone.