Il Dahiru

Use of non-vascularized autologous fibula strut graft in the treatment of segmental bone loss

BACKGROUND Fractures resulting in segmental bone loss challenge the orthopedic surgeon. Orthopedic surgeons in developed countries have the option of choosing vascularized bone transfers, bone transport, allogenic bone grafts, bone graft substitutes and several other means to treat such conditions. In developing countries where such facilities or expertise may not be readily available, the surgeon has to rely on other techniques of treatment. Non-vascularized fibula strut graft and cancellous bone grafting provides a reliable means of treating such conditions in developing countries. MATERIALS AND METHODS Over a period of six years all patients with segmental bone loss either from trauma or oncologic resection were included in the study. Data concerning the type of wound, size of gap and skin loss at tumor or fracture were obtained from clinical examination and radiographs. RESULT Ten patients satisfied the inclusion criteria for the study. The average length of the fibula strut is 7 cm, the longest being 15 cm and the shortest 3 cm long. The average defect length was 6.5 cm. Five patients had Gustillo III B open tibial fractures. One patient had recurrent giant cell tumor of the distal radius and another had a polyostotic bone cyst of the femur, which was later confirmed to be osteosarcoma. Another had non-union of distal tibial fracture with shortening. One other patient had gunshot injury to the femur and was initially managed by skeletal traction. The tenth patient had a comminuted femoral fracture. All trauma patients had measurement of missing segment, tissue envelope assessment, neurological examination, and debridement under general anesthesia with fracture stabilization with external fixators or casts. Graft incorporation was 80% in all treated patients. CONCLUSION Autologous free, non-vascularized fibula and cancellous graft is a useful addition to the armamentarium of orthopedic surgeon in developing countries attempting to manage segmental bone loss, whether created by trauma or excision of tumors.

On the use of drains in orthopedic and trauma

INTRODUCTION The use of drains in trauma and Orthopaedic practice has been affected by the concept of evidence based medicine that has become accepted as standard of care for all surgical or medical practice, which questions all care processes that cannot be backed by evidence to be beneficial to the patient. There have been a large number of multi centre meta-analytical studies that found drains to be of little or no benefit in trauma and Orthopaedic operations. Because of these studies, there are few situations where drains are routinely used e.g. Calcaneal fractures in developed countries. Even major procedures like total knee and arthroplasties are being performed without drains. We set to find out whether such evidence can be found in our practice. MATERIALS AND METHODS Between 2004 and 2012, eighty six patients matched for sex and type of injury and operative procedures to be done were prospectively selected and assigned to use or no use of drains in their operations. Complications like haematoma, drain migration, infection, inadvertent drain stitching were observed in the two groups. RESULTS Eighty six major orthopaedic operations were studied. There was no evidence of occurrence of complication arising from non use of drains in the undrained group. Those patients whose wounds were drained had no need for drain change thus making the wound care less eventful CONCLUSION Postoperative wound drains make for neat postoperative period with less tissue swelling. There was no statistically significant differences between the drained and undrained wounds in terms of infection rates, haematoma or seroma formation.

Tropical diabetic hand syndrome among diabetic patients attending endocrine clinic of Ahmadu Bello University Teaching Hospital, Shika Zaria, North Central Nigeria

Background: Tropical diabetic hand syndrome (TDHS) is a known complication affecting patients with diabetes mellitus in the tropics. However, there has been no previous report on the condition from the Northern Nigeria. This study assessed the prevalence of the syndrome among diabetic patients attending the endocrine clinic of Ahmadu Bello University Teaching Hospital (ABUTH), North Central Nigeria. Materials and Methods: A retrospective cohort study was employed for the study from January 2010 to May 2013. All patients with incomplete treatment records were excluded from the study. Data analysis was done with Statistical Packages for Social Sciences (SPSS) version 20.0 and presented as tables and charts. Results: Of the total 894 cases reviewed, the prevalence of diseases condition was 12 (1.3%), with female to male ratio of 2:1. Majority (75.0%) of the initiating events were minor trauma, followed by spontaneous blisters and subsequent rupture (16.7%) and the least (8.3%) was burns. The mean interval between onset of disease and presentation in the hospital was 22.9 days. Staphylococcus aureus was the main microbial isolates (75.0%) and majority (88.9%) were sensitive to ciprofloxacin. Mortality rate among the patients was 25.0% while amputation and healing with fixed flexion deformity of digits accounted for 33.3% and 58.3%, respectively. Conclusion: TDHS is a significant complication among diabetic patients in ABUTH, and the most common initiating risk factor was minor trauma. Mortality rate among the patients was also high. Hence, there is a need for intensive education of diabetic patients on the benefits of early diagnosis and treatment and avoidance of trauma.

An overview of diabetic foot disease

The incidence of diabetes globally is reaching an epidemic proportion and with it carries the risk of complications and diabetic foot disease inclusive. The pathophysiology of diabetic foot disease is multifactorial and includes neuropathy, infection, ischaemia and abnormal foot structure and biomechanics. Early recognition of the aetiology of these lesions is important for good functional outcome. Managing the diabetic foot is a complex clinical problem requiring a multidisciplinary collaboration of health care workers to achieve limb salvage. Adequate off-loading, frequent debridement, moist wound care, treatment of infection and revascularisation of ischaemic limbs are the mainstays of treatment. Even with proper management, some of the foot ulcers do not heal and are arrested in a state of chronic inflammation. These wounds can frequently benefit from various adjuvants, such as aggressive debridement, growth factors, bioactive skin equivalents and negative pressure wound therapy. We reviewed current literature including original and review articles obtained through a search of PubMed database, Medline, Google scholar and hand searching of bibliographies of published articles using the keywords: Diabetes, diabetic foot, neuropathy, peripheral arterial disease and ulceration. The enormity of the challenges associated with the management of this important complication of diabetes, coupled with the various progresses being made in this area, and the need to streamline the principles of management, especially in our environment prompted us to review this subject matter.

Tropical diabetic hand syndrome: Surgical management and proposed classification

Introduction: Hand complications of diabetes mellitus are rare compared to those in the foot. They occur in the ratio of 1:20 in our observations. We managed 36 patients with tropical diabetic hand syndrome and propose a classification for the disease that will allow communication between physicians and prognostication. Materials and Methods: Patients with hand infections and background diabetes mellitus were admitted. Their age, sex and occupations were noted. A clinical diagnosis was made and drained. Wound swab for culture was taken. Wounds were generally serially debrided at bed side with wound being allowed to granulate over time to be subsequently closed by split thickness skin graft. Results: Thirty six patients were studied. Based on their clinical diagnosis, they were classified into three (I,II,III) groups in increasing order of severity. The classification correlated with the type and severity of the disease. It also guided the choice of appropriate treatment. Conclusion: Based on our findings, tropical diabetic hand syndrome was classified and prognosticated based on the degree of soft tissue and bone involvement. The classification allows for communication with other physicians.

Reducing diabetes-related major limb amputations: A plea for a multidisciplinary team approach

Background: Diabetic foot is a challenging complication of diabetes mellitus, affecting a significant number of diabetic patients and often resulting in amputations especially in resource-poor nations. Patients and Methods: A 4-year retrospective review of clinical records of patients with diabetic foot lesions (DFLs) treated at Ahmadu Bello University Teaching Hospital, Zaria. Results: One hundred and thirty-eight patients were admitted with DFLs, but only 109 patients had complete medical records available for review. Nine patients had bilateral lesions at presentation. Seventy-three (61.9%) were male and 45 (38.1%) were female. Three (2.6%) were young adults (<40 years) while 89 (75.4%) were middle age (40-65 years) and 26 (22.0%) were elderly (>65 years). Fifty-two (44.0%) of the lesions were admitted through the diabetic clinic while 66 (56.0%) presented to the emergency room. Wagner Grade IV and V lesions constitute the majority (68.7%). The mean duration of the lesions at presentation was 6 weeks while the mean interval between first review by an endocrinologist and first surgical review was 17 days for those admitted through the diabetic clinic. Seventy-seven had surgical interventions, 30 of which were major amputations. The mortality rate was 14.6%. Conclusion: Diabetes-related foot lesions pose a great challenge in developing countries, with a significant number of the patients undergoing major amputation, an incapacitating outcome largely contributed to by late presentation and poor quality of diabetic foot care. With the impact being made by public health enlightenment programs on diabetes complications, a multidisciplinary team care approach from the outset goes a long way in reducing major amputations in these patients.

Simultaneous bilateral femoral neck fractures following electroconvulsive therapy

Fracture neck of femur occurs commonly among elderly people with osteoporosis being the risk factor favoring its occurrence. Its occurrence among young adults, though uncommon, follows high-energy trauma with multisystem affectation. Fracture neck of femur poses a management challenge to the surgeon in deciding on the best option of treatment, in achieving accurate reduction and fixation, and in dealing with complications which may be inevitable. Fracture neck of femur following electroconvulsive therapy is rare. Simultaneous bilateral femoral neck fractures following electroconvulsive therapy are even rarer. Simultaneous bilateral femoral neck fractures management is technically demanding, requiring considerable experience, appropriate instrumentation, and equipment. It is also associated with high morbidity which includes nonunion and avascular necrosis. These fractures can be prevented by the use of modified electroconvulsive therapy. This case seeks to reemphasize the rarity of simultaneous bilateral femoral neck fractures following electroconvulsive therapy, highlight the challenges of managing this condition and proffer ways of avoiding its occurrence.

Locked intramedullary nailing for tibial and femoral shaft fractures: Challenges and prospects in a Tertiary Health Care Facility in a resource constraint setting

Background: Locked intramedullary nailing for operative fixation of tibial and femoral shaft fractures has become the gold standard in the operative stabilization of these fractures. The results of these procedures from various centers have been quiet impressive and compares to that reported globally. The sustenance of these important procedures are however not without challenges, which is the main reason for reporting the experience from our institution. Patients and Methods: This is a prospective study involving 163 consecutive patients with closed tibial and femoral shaft fractures over a period of two years (June 2011 to May 2013). Parameters such as blood loss, postoperative wound infection, length of hospital stay, and fracture union were followed up. Results: One hundred and fifteen (70.6%) of the patients were males while 48 (29.4%) were females. Of the 176 operations, 136 (77.3%) were carried out for femoral shaft fractures whereas 40 (22.7%) were carried out for tibial shaft fractures. Thirty eight (21.6%) femurs and 14 (7.9%) tibiae had locked intramedullary nailing. Intraoperative blood loss was less than 250 ml in patients who had locked intramedullary nailing, and the average length of hospital stay was 10 and 16 days for those that had locked intramedullary nailing and plating, respectively. Forty-four (84.2%) fractures stabilized with locked intramedullary nail showing solid union at 16 weeks whereas only 32 (70%) and 55 (70%) of the fractures stabilized with Kuntscher nail and plate, respectively, showing solid union at 16 weeks. Conclusion: Our study suggests satisfactory outcome with locked intramedullary nailing for the operative fixation of tibial and femoral shaft fractures. The choice of implant to be used depends significantly on affordability by patients and to a lesser extent on surgeons preference.

Teaching the Surgical Craft: Surgery Residents Perception of the Operating Theater Educational Environment in a Tertiary Institution in Nigeria

Background: The transformation of a surgical trainee into a surgeon is strongly influenced by the quality of teaching in the operating theater. This study investigates the perceptions of residents about the educational environment of the operating theater and identifies variables that may improve the operating theater education of our trainees. Materials and Methods: Residents in the department of surgery anonymously evaluated teaching in the operating room using the operating theater education environment measure. The residents evaluated 33 variables that might have an impact on their surgical skills within the operating theater. The variables were grouped into four subscales; teaching and training, learning opportunities, operating theater atmosphere and workload/supervision/support. Differences between male and female residents and junior and senior registrars were assessed using Mann-Whitney test. Statistical analysis was completed with the statistics package for the social sciences version 17. Results: A total of 33 residents were participated in this study. Twenty nine (88%) males and 4 (12%) females. 30 (90%) were junior registrars. The mean total score was 67.5%. Operating theater atmosphere subscale had the highest score of 79.2% while workload/supervision/support subscale had the least score of 48.3%. There were significant differences between male and female resident′s perception of workload/supervision/support P < 0.05; however, there was no significant differences in junior registrar versus senior registrar′s perception of the education environment in all the subscales P > 0.05. Conclusion: This study has shown a satisfactory teaching environment based on the existing local realities of means, resources and tools and highlighted the need for improvement in workload/supervision/support in our institution. An acceptable learning environment in the operating theatre will produce surgeons that are technically competent to bridge the gap in the enormous unmet need for surgical care in Nigeria.

Rational antimicrobial prophylaxis in orthopedics and trauma surgical practice

Background : Antimicrobial prophylaxis in surgical practice is a concept that has been in practice for over 3 decades. The aim is to prevent surgical site infection (SSI), a menace acknowledged as the most common nosocomial infection in surgical patients. Over the years, several international guidelines have been published in the literature to guide the practice. Yet some surgeons still practice outside these guidelines especially in orthopedics and trauma surgical practice. This has led to emergence of resistant strains of bacteria and increased cost of healthcare. The only option left to check this problem therefore lies in the proper use of available antibiotics. The objective of this study was to review the current literature on the guidelines and practice of antibiotic prophylaxis in orthopedics and trauma surgery. Materials and Methods : A review of the literature on this subject was done on Medline, EBSCOhost database, and recent articles from relevant journals and texts. The database was searched using the keywords; antibiotic prophylaxis; orthopedic and trauma surgery. Results: There are several guidelines and protocols that were established from evidence based information. However, compliance to these guidelines amongst surgeons and health institutions is suboptimal for various reasons. This is associated with increased morbidity and cost of treatment. Conclusion : There is a need to be guided by evidence based guidelines in our antimicrobial prophylaxis practice; as surgery is both a science and an art.