Ic Ikem

An assessment of peripheral vascular disease in patients with diabetic foot ulcer

BACKGROUND Peripheral vascular disease (PVD) is a chronic limb ischaemia caused by atherosclerosis of the peripheral arteries. Diabetes mellitus is a risk factor for this disease. The most common symptom of PVD is muscle pain in the lower limbs on exercise. In diabetes, pain perception may be blunted by the presence of peripheral neuropathy. Therefore, a patient with diabetes and PVD is more likely to present with an ischaemic ulcer or gangrene than a patient without diabetes. The use of ankle-brachial-pressure index (ABI) in the clinic and bedside provide a measure of blood flow to the ankle. This could help early detection, initiate early therapy and may thus reduce the risk of critical limb ischaemia and limb loss. OBJECTIVE The purpose of this study is to evaluate the occurrence of peripheral vascular disease using ankle-brachial index in diabetic patients with and without foot ulcers and the risk factors associated with diabetic foot ulcer (DFU). METHOD This prospective study involved all type 2 DM patients with foot ulcer (DFU population) and those without foot ulcers (non-DFU population) seen in our hospital. Their demographic, clinical and laboratory parameters were noted and documented. Measurement of ABI was done using a portable hand held Doppler and ankle pressures<0.9 is suggestive of PVD. RESULTS A total of 74 patients were recruited. Males were 42 (56.8%) and females were 32 (43.2%). The mean age of the patients was 62.89±10.66 years and the duration of diabetes was 7.61±7.57 years. Forty-six (62.2%) presented with foot ulcer while 28 (37.8%) were without foot ulcer. Patients with PVD represented by ABI<0.9 was DFU 31(76.4%) while in non-DFU it was 10 (13.4%). Multivariant analysis of variables associated with DFU in those with ABI<0.9 showed correlation with tobacco use r=.235, p=0.044; duration of diabetes r=-.427; p=0.001; and systolic blood pressure r=-.301; p=0.009. DISCUSSION The occurrence of PVD determined by the absence of >2 pulses by palpation alone and using ABI was 25.7% and 55.4% respectively. This suggests that assessment by palpation is subjective while the use of Doppler is quantitative and more reliable. DFU patients with PVD showed a significant correlation with tobacco use, duration of diabetes and systolic blood pressure but not with dyslipidaemia. CONCLUSION This study shows that these patients had risk factors for PVD. The use of hand held Doppler will aid early diagnosis of critical limb at risk of loss and help to prevent and reduce the high rate of limb loss in our patients.

Reconstruction of mandibular defects using nonvascularized autogenous bone graft in Nigerians

Objectives: The aim of this study is to evaluate the success rate and complications of mandibular reconstruction with nonvascularized bone graft in Ile-Ife, Nigeria. Patients and Methods: A total of 25 patients who underwent reconstruction of mandibular discontinuity defects between January 2003 and February 2012, at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife constituted the study sample. Relevant information was retrieved from the patients′ records. This information include patients′ demographics (age and sex) as well as the type of mandibular defect, cause of the defect, type of mandibular resection done, source of the bone graft used, and the method of graft immobilization. Morbidity associated with the graft procedures were assessed by retrieving information on graft failures, length of hospital stay following surgery, rehabilitation device used and associated graft donor and recipient site complications. Result: There were 12 males and 13 females with a male:female ratio was 1:1.1. The age of the patients ranged from 13 to 73 years with a mean age for males 32.7 ± standard deviation (SD) 12.9 and for females 35.0 ± SD 17.1. Jaw defect was caused by resection for tumours and other jaw pathologies in 92% of cases. Complete symphyseal involvement defect was the most common defect recorded 11 (44%). Reconstruction with nonvascularized rib graft accounted for 68% of cases while iliac crest graft was used in 32% of the patients. Successful take of the grafts was recorded in 22 patients while three cases failed. Wound dehiscence (two patients) and postoperative wound infection (eight patients) were the most common complications recorded. Conclusion: The use of nonvascularized graft is still relevant in the reconstruction of large mandibular defects caused by surgical ablation of benign conditions in Nigerians. Precise surgical planning and execution, extended antibiotic therapy, and meticulous postoperative care contributed to the good outcome.

Comparison of serum and urinary calcium profile of immobilized and ambulant trauma patients

BACKGROUND Hypercalcemia occurs more frequently than is recognized in patients who are immobilized, but most of these patients are asymptomatic. This study is to determine serum and urinary calcium levels, incidence of hypercalcemia and hypercalciuria in immobilized and ambulant trauma patients. METHODS A prospective comparative study was carried out over a period of seven months. Total serum calcium level and 24-hour urinary calcium output were measured weekly over 4weeks in 55 immobilized trauma patients as study group and 51 ambulant trauma patients as control group. RESULTS Mean total serum calcium of immobilized patients increased progressively (on admission: 2.315±0.056mmol/l and week 4: 2.552±0.231mmol/l, p<.001) while that of ambulant patients did not change significantly (on admission: 2.306±0.041mmol/l, and week 4: 2.300±0.028mmol/l, p=.348). There is a significant difference in overall mean total serum calcium between immobilized and ambulant patients (p<.001). In immobilized and ambulant patients, mean 24-hour urinary calcium increased progressively from baseline (3.044±0.480mmol/day and 3.056±0.540mmol/day respectively), till the end of the study (8.543±2.142mmol/day and 6.783±1.372mmol/day respectively). Overall mean 24-hour urinary calcium is significantly different between immobilized and ambulant patients {multivariate Pillai F (5,100)=883.124, p<.001}. Incidence of hypercalcemia increased progressively in immobilized patients (end of week 1=7.27% and end of week 4=29.09%) while none of the ambulant patients had hypercalcemia. Incidence of hypercalciuria also increased progressively in immobilized patients (end of week 1=7.27% and end of week 4=63.64%) while ambulant patients only had hypercalciuria at the end of week 3 (9.8%) and week 4 (21.57%). CONCLUSION Mean total serum calcium increased with increased duration of immobilization in trauma patients. Both immobilized and ambulant trauma patients developed hypercalciuria but it is worse and earlier in the immobilized trauma patients.

Bellini duct carcinoma of the kidney masquerading as an iliac bone tumour in an adult Nigerian

Bellini Duct Carcinoma (BDC) of the Kidney is a rare type of Renal Cell Carcinoma. It usually presents with features of local advancement or metastasis and rarely diagnosed incidentally. We present a case report of a young man who was found to have BDC of the Right Kidney following presentation with an iliac bone tumour. A 40 year old man presented to the Orthopaedic outpatient clinic on account of right sided pelvic pain and limping following a trivial fall at home. There was no antecedent history of loin pain, loin mass or haematuria. On evaluation, he was found to have a huge right iliac bone tumour invading the contiguous muscles. An incidental hypodense central ipsilateral renal mass with enlarged peri-hilar lymph nodes were found. He subsequently had right radical nephrectomy via a right sub-coastal approach and wide local excision of the Iliac bone tumour in two separate procedures. The resection margins were negative for tumour cells. Histology of the resected specimens were consistent with a metastatic right BDC of the kidney. He had a smooth post-operative recovery. One third of BDC of the kidney presents with metastasis. A high index of suspicion is required in order to diagnose BDC following such unusual presentations.

Femoral bifurcation with ipsilateral tibia hemimelia: Early outcome of ablation and prosthetic fitting

Femoral bifurcation and tibia hemimelia are rare anomalies. Hereby, we present a case report of a 2-year-old boy who first presented in our orthopedic clinic as a 12-day-old neonate, with a grossly deformed right lower limb from a combination of complete tibia hemimelia and ipsilateral femoral bifurcation. Excision of femoral exostosis, knee disarticulation and prosthetic fitting gives satisfactory early outcome.

Quadriceps strength and anterior knee pain following tibia intramedullary nailing: Any clinical relationship?

Introduction: Anterior knee pain can be chronic sequelae of intramedullary nailing of the tibia. Several causes have been identified; no single reason can fully explain the occurrence. We, therefore, set out to find the rate of anterior knee pain in our practice and if any relationship exists between the anterior knee pain and extensor muscle strength. Methodology: A total of 72 knees in 36 patients with no prior history of knee pain, but had unilateral tibiofibular fracture, who had internal fixation with interlocking intramedullary nailing done and were followed up for at least 1 year were recruited into the study. The tension generated on extension of the knee against a resistance using tensiometer was measured in Newton. The ranges of motion of the knees were documented, as well as Lysholm score which measures activities and document the presence and limitation caused by anterior knee pain. Results: A total of 36 patients with 72 knees were studied. Anterior knee pain occurred in 7 (19.4%) patients in this study. There was no statistically significant relationship between the force of tension (N) generated in the extensor in patients with anterior knee pain compared with those without knee pain (158.43 ± 49.35, 189.54 ± 74.63, P = 0.304). There was, however, a significant statistical relationship between the mean Lysholm score of the operated and unoperated knee (P = 0.042). Conclusion: Anterior knee pain rate was 19.4% in our series and no statistical association exists between the extensor strength and occurrence of anterior knee pain.

Sonographic assessment of the shoulders in asymptomatic elderly diabetics in a Nigerian population

Dysplasia epiphysealis hemimelica (DEH) is a rare osteochondromatous condition arising unilaterally from an epiphysis in the developing skeleton. Unhindered, this osseocartilaginous lesion continues to grow until skeletal maturity. Characteristic radiographic features are usually sufficient to make the diagnosis. One common site of occurrence is the talus, which has the potential to cause pain, joint deformity or limit range of motion. We report a case of DEH of the talus causing fixed hindfoot valgus deformity, successfully treated with surgery, and review the literature on DEH and its current treatment strategies.Spondylolysis is a defect of the pars interarticularis of the vertebral arch. Its cause is often multifactorial but mostly thought to be as a result of a stress fracture. Most fractures occur at L5 (71%-95%) and L4 (5%-23%).1CITATION: Venter, R. G., Solomon, C. & Baartman, M. 2015. Mycobacterium fortuitum as infectious agent in a septic total knee replacement : case study and literature review. South African Orthopaedic Journal, 14(2):52-56, doi:10.17159/2309-8309.We present a rare case of subpubic cartilaginous cyst in a multiparous female patient as a cause of a pelvic soft tissue (vulvar) mass. We discuss the relevant imaging and differential diagnosis as well as specific considerations in making the diagnosis of a subpubic cartilaginous cyst.

External jig in the placement of distal interlocking screws

Background: Placement of distal locking screws is a challenge to many surgeons involved in interlocking nails. Objectives: The aim of this study is to evaluate the accuracy of external jig as a target arm for distal locking screw insertion. Methods: 85 consecutive patients with 90 fractures treated with SIGN interlocking nails were prospectively studied. We report the assessment of the accuracy of insertion of distal locking screws with the use of SIGN external jigs. The patients demographic data and fracture characteristics were documented. Two distal screws are usually inserted. However, in very difficult cases, one distal screw may be inserted. In all cases there was no access to intra operative radiograph. Results: There were 85 patients and 90 fractures. There were 57 males and 28 females giving a ratio of M:F 2:1. The mean±SD age of the patients was 41.19±16.28 years and the range was 18-85 years. The two bones studied were femur 62.3% and tibia 37.8%. Retrograde (52.2%) was the commonest surgical approach used for femur. The main indication for SIGN interlocking surgery was recent fracture 77.8%. Open reduction 97.8% was the commonest method of reduction used. The mean±SD bone union time was 3.58±0.56 months and range 3-5 months. Distal screw insertion was successful (2 screws) in 93.3% and partial success (1 screw) in 6.7%. At first attempt 96.7% of distal screws were inserted while 3.3% distal screws were inserted at 2nd attempt (2nd visit to theatre). The main complication was screw loosing seen in 3.3%. Conclusion: External jig as a target arm is effective for the placement of distal locking screw. Keywords: External jig; Target arm; Distal screws; Interlocking nails.