Mortality Trends among Older Patients Admitted to the Geriatric Centre, University College Hospital, Ibadan, Nigeria, 2013-2017

BACKGROUND

Attaining successful clinical outcomes in the management of hospitalised older patients in the overburdened healthcare services in Nigeria constitutes a major challenge against the backdrop of dearth of data on the predictors of mortality among them.

OBJECTIVES

To describe the mortality trends and associated factors among older patients (>60 years) at the Geriatric Centre, University College Hospital, Ibadan between January 2013 and December 2017.

METHODS

Hospital records of older patients admitted were analysed. Data extracted included socio-demographic, diagnoses, length of stay from date of admission to discharge or death. Results of vital signs, anthropometric measurements and laboratory tests carried out at admission were also obtained.

RESULTS

The mean age of the 1,091 older patients admitted was 73.6±8.6 years. The overall crude proportion of in-hospital deaths was 9.0% (males=11.3% > females=7.2%, p=0.024) and it increased from 4.1% in 2013 to 12.1% in 2017. The overall unadjusted 30-day mortality rate per 1000 patient-days was 28.9 deaths (95% CI 23.5-35.3). The predictors of mortality were increased length of stay on admission OR=1.061 (95% CI 1.005-1.119), being retired OR=1.672 (95% CI 1.011-2.778), stroke OR=4.019 (95% CI 2.258- 7.138), heart failure OR=3.435 (95% CI 1.455-8.100), Sepsis OR=2.176 (95% CI 1.294-3.654), Anaemia OR=2.820 (95% CI 1.320-6.017), Dementia OR=3.701 (95% CI 1.433-9.549) and malignancies OR=2.658 (95% CI 1.181-5.979).

CONCLUSION

There was a temporal increase in mortality among older patients. Similarly, staying longer on admission and chronic medical conditions with their complications were the most significant contributors to mortality.

A descriptive study of the morbidity pattern of older persons presenting at a Geriatric Centre in Southwestern Nigeria

CONTEXT

Rapid population ageing is a demographic reality in most countries of the world. Old age is associated with changes which may culminate in health problems, necessitating provision of appropriate preventive, curative, and rehabilitative services. However, reports from many low- and middle-income countries have shown lack of preparedness to cater for the healthcare needs of older persons.

AIM

This study described the morbidity profile and its determinants among persons aged 60 years and above who presented at an established geriatric centre in southwestern Nigeria.

MATERIALS AND METHODS

Data were obtained from electronic health records of 4886 patients aged ≥60 years who visited the facility between 1st January 2013 and 31st December 2014. Data were analyzed using Stata version 13 (Texas, USA). Frequency distributions were used for descriptive analysis, and chi-square test was used to test associations.

RESULTS

More than a half, 2919 (59.7%), of the respondents were females and almost three quarters 3501 (71.7%) were aged between 60 and 74 years. Mean number of morbidities was 1.81 ± 0.9, and less than half, 1097 (42.0%), presented with only one morbidity, most commonly, hypertension. There were significant age-related differences for musculoskeletal (P = 0.001), endocrine (P = 0.01), and psychological problems (P = 0.01). In addition, gender differences were observed as a significantly higher proportion of females presented with general symptoms (P = 0.02) and musculoskeletal problems (P = 0.0001) than men.

CONCLUSION

The most common presenting morbidities at this geriatric health centre were mostly noncommunicable diseases. Information obtained will be useful in the design of similar facilities in other parts of the country and region at large.

Physical functionality and self-rated health status of adult patients with knee osteoarthritis presenting in a primary care clinic

BACKGROUND

Knee osteoarthritis is a chronic medical condition of public health importance in Nigeria which causes disability and impacts daily activities in the sufferers. This study aimed to describe the physical functionality and self-rated health status of adult patients with clinical knee osteoarthritis presenting at the Family Medicine Department, University College Hospital, Ibadan, Nigeria.

METHODS

This was a cross-sectional study of 400 respondents. Knee osteoarthritis was diagnosed clinically using the criteria of the American College of Rheumatology. Morbidities, self-rated health status and physical functionality of the respondents were also assessed.

RESULTS

Knee osteoarthritis was diagnosed in 46(11.5%) respondents. Respondents with knee osteoarthritis significantly rated their health worse than those without knee osteoarthritis (p <0.0001). Experience of pain, stiffness and performance of daily activities were significantly worse among respondents with knee osteoarthritis. Those who had knee osteoarthritis had significantly higher waist (p <0.0001), hip (p <0.0001) and knee circumferences (p <0.0001) respectively. Logistic regression analysis showed increasing age (OR=1.103; 95% CI=1.022 - 1.191), self-rated health worse than six months ago (OR=12.562; 95% CI=1.178-125.243), experience of stiffness after waking up in the morning (OR=12.758; 95% CI=3.572-45.569), stiffness after sitting/lying down/resting (OR=21.517; 95% CI=2.213-209.220) and waist circumference (OR=1.225;95% CI=1.017-1.477) to be the most significantly associated with knee osteoarthritis.

CONCLUSION

Knee osteoarthritis significantly impairs the health and daily activities of adult patients in Ibadan, Nigeria. Healthcare workers need to screen adult patients routinely at first-contact to detect knee osteoarthritis clinically early and manage appropriately.

Orthopaedic anaesthesia for upper extremity procedures in a Nigerian hospital

BACKGROUND

General anaesthesia and regional anaesthesia have been used successfully for upper extremity orthopaedic procedures. Despite the advantages of regional anaesthesia, there is low utilisation in Nigeria. In this study, we assessed the types of anaesthesia employed for upper extremity surgeries in our centre.

METHODS

After obtaining approval from the institutional ethics committee, all the patients who had upper extremity surgeries from 1 January 2011 to 31 December 2012 were included in this review. Both prospective and retrospective data were gathered. The choice of anaesthesia was at the discretion of the attending anaesthetist.

RESULTS

A total of 226 patients with a male-to-female ratio of 1.6:1 and median age of 35.0 (range 2 - 89) years, had orthopaedic upper extremity procedures during the study period. Sixty-three cases (27.9%) had general anaesthesia, 5 (2.2%) combined regional and general anaesthesia while 158 (69.9%) had regional blocks. The regional blocks comprised 145 (89%) different approaches to the brachial plexus and 18 (11%) local anaesthetic infiltrations. The arm was the site mostly operated upon; while supraclavicular and axillary brachial plexus blocks were performed in equal amounts. In 14 (6.2%) patients, brachial plexus blocks were performed with spinal anaesthesia because of concomitant iliac crest bone grafts. While the duration of surgery did not differ significantly, regional anaesthesia provided a significantly longer duration of anaesthesia than general anaesthesia (251 ± 70.8 min versus 141.3 ± 65.5 min; p = 0.0000001).

CONCLUSION

There is a high use of regional anaesthesia for upper extremity orthopaedic surgeries in our centre, which is a positive development in a resource limited setting.

GEOGRAPIC INFORMATION SYSTEMS IN DETERMINING ROAD TRAFFIC CRASH ANALYSIS IN IBADAN, NIGERIA

BACKGROUND

Road traffic accidents are frequent in this environment, hence the need to determine the place of geographic information systems in the documentation of road traffic accidents.

AIM & OBJECTIVES

To investigate and document the variations in crash frequencies by types and across different road types in Ibadan, Nigeria.

MATERIALS & METHODS

Road traffic accident data between January and June 2011 were obtained from the University College Hospital Emergency Department's trauma registry. All the traffic accidents were categorized into motor vehicular, motorbike and pedestrian crashes. Georeferencing of accident locations mentioned by patients was done using a combination of Google Earth and ArcGIS software. Nearest neighbor statistic, Moran's-I, Getis-Ord statistics, Student T-test, and ANOVA were used in investigating the spatial dynamics in crashes.

RESULTS

Out of 600 locations recorded, 492 (82.0%) locations were correctly georeferenced. Crashes were clustered in space with motorbike crashes showing greatest clustering. There was significant difference in crashes between dual and non-dual carriage roads (P = 0.0001), but none between the inner city and the periphery (p = 0.115). However, significant variations also exist among the three categories analyzed (p = 0.004) and across the eleven Local Government Areas (P = 0.017).

CONCLUSION

This study showed that the use of Geographic Information System can help in understanding variations in road traffic accident occurrence, while at the same time identifying locations and neighborhoods with unusually higher accidents frequency.

Bone Scintigraphy in Breast Cancer Patients in Ibadan, Nigeria

BACKGROUND

The bone is the commonest site of metastases from breast carcinoma. Radionuclide isotope scanning is a sensitive scanning procedure for the demonstration of bone pathology. In May 2006, a gamma camera was introduced into clinical use for skeletal scintigraphy at the University College Hospital, Ibadan, Nigeria.

OBJECTIVE

To review the first five years findings of skeletal scintigraphy in our breast cancer patients.

METHODS

We retrospectively reviewed the clinical data and scintigraphic bone studies of patients with histology proven breast carcinoma managed in the Surgical Oncology Division, University College Hospital, Ibadan, Nigeria between May 2006 and April 2011.

RESULTS

Within the period, a total of 597 breast cancer patients had skeletal scintigraphy (SS). Of the 594 (99.5%) SS reports available for review, scintigraphic evidence of bone metastases was found in 232 (39.1%) patients. Correlation of bone involvement and clinical stage showed that a large majority of the patients had stage IV (83.3%) and III (15.7%) disease. Most patients (71.6%) had multiple bone lesions. The bone lesions were osteoblastic in 88.9% of the patients; only 1.8% had purely osteolytic lesions with the remainder being a mix of both.

CONCLUSION

There was scintigraphic evidence of bone metastasis in most of our patients with stage four breast cancer and in some with locally advanced disease. Multiple bone lesions were found in many of them and almost all the lesions were osteoblastic. Moreover, both the truncal and axial skeletal bones were involved in similar proportions.

Plasma homocysteine, B vitamins and bone mineral density in osteoporosis: a possible risk for bone fracture

BACKGROUND

Changes in plasma total homocysteine (tHcy) folic acid, vitamins B12 and B6 in individuals with osteoporosis are reported to impair collagen cross-linking and contribute to low bone mineral density (BMD). There is paucity of information on these associations in osteoporotic patients at risk of bone fractures in Nigeria. The study evaluated plasma tHcy, folic acid, vitamins B12 and B6, in relation to BMD in individuals with osteoporosis.

METHODS

Fifty osteoporotic patients age 57.05 +/- 1.9 years were selected and fifty non osteoporotic volunteer's age 54.8 +/- 0.9 years were included as controls. The osteoporotic group consisted of 11 males and 39 females (1:3.5) while the controls consisted of 13 males and 37 females (1:2.8) respectively. Bone mineral density, anthropometric indices plasma tHcy, folic acid, vitamins B12 and B6, were determined using standard procedures.

RESULTS

The results showed remarkably significant increase in plasma tHcy (p < 0.001) (180%) compared with the control value. Striking significant decreases were observed in folic acid (62%), vitamins B12 (42%), B6 (59%) and BMI p < 0.001) compared with control values. Positive correlation was obtained between vitamin B12 and BMD (r = 0.311, p < 0.05).

CONCLUSION

Significant increase in tHcy with corresponding decreases in folic acid, vitamins B12 and B6 are related to decrease in BMD in osteoporotic patients. These changes could be important risk factors for bone fracture in osteoporotic Nigerians. Supplementation with the B vitamins may be beneficial to the patients.

Prevalence of abnormal bone mineral density in hiv-positive patients in ibadan, Nigeria

BACKGROUND

There have been reports of high rate of abnormal bone mineral densities (BMD) among people living with HIV. Following the introduction of combination antiretroviral therapy (CART) into Nigeria, the country is now home to increasing population of HIV positive patients. There is paucity of data about osteoporosis/osteopaenia and bone mineral density in this population.

AIM AND OBJECTIVES

The aim of the study was to determine the prevalence and determinants of osteopaenia/osteoporosis in a cohort of HIV-positive patients in Nigeria.

PATIENTS AND METHODS

The BMD of a group of patients attending the outpatient clinic of the University of Ibadan, Nigeria was assessed using a DXA machine. The relationship of bone mineral density to body weight, CART status, protease inhibitor use, and gender was investigated. Their CD4 counts and viral load were also estimated.

RESULTS

A total of 1005 patients participated with a mean age of 41.3 ± 10 years. There were 724 females (72.0%) and 29.7% were single. The median length of diagnosis was 2 years (Range 1-18 years). The Median CD4 count was 371cells/ml and Median viral load was 200 copies/ml. Of this sample, 785 (78.1%) were on CART with 99 (12.6%) on protease inhibitor. The mean body mass index (BMI) was 23.7±4.7 with 9.2% underweight and 10% obese. The prevalence of osteopaenia and osteoporosis were 46.6% and 31.9% respectively, while 19.6% had normal bone mineral density (BMD). Osteoporosis was significantly higher in those aged above 40 years (p= 0.00001), the females (p= 0.022), the single (p=0.028) and the underweight (p=0.0001). There was no significant difference in BMD of those with or without protease inhibitor containing medications as well as treatment naïve patients.

CONCLUSION

A high prevalence of abnormal bone mineral density was found in HIV positive patients in Nigeria. Patient age above 40 years and a body mass index class of underweight were significant associated factors. Routine bone mineral density assessment is recommended as an adjunct in the evaluation of HIV positive patients in Nigeria.

Removal of orthopaedic implants from patients at the University College Hospital, Ibadan

BACKGROUND

Removal of orthopaedic implants is often done after complete healing of fractures. Orthopaedic implants are removed for a variety of reasons such as patients' request after fracture union, implant failure and other complications arising from the use of implants.

AIMS AND OBJECTIVES

To determine the indications and complications of removal of orthopaedic implants in our hospital.

METHODS

A retrospective study of medical records of all patients who underwent removal of orthopaedic implants used for fracture fixation at a Nigeria teaching hospital during the five year period between 2007 and 2011. Information about age, sex, indications for fracture fixation, indications for removal of implant, types of implants removed, complications of implant removal and its treatment were studied.

RESULTS

Thirty patients whose orthopaedic implants had been in place for a mean duration of 12 months before removal were included in the study. 80% of the implants were removed from the femur. Implant failure is the commonest indication for implant removal accounting for 60% of cases.

CONCLUSION

Healed fractures and implant failure are the commonest indications for removal of orthopaedic implants in our centre. Implant removal should be advocated when they have failed or become symptomatic. However, appropriate patient selection and adequate surgical technique should be employed to achieve satisfactory outcome.

Socio demographic and clinical correlates of knee pain in adult women attending a primary care clinic

AIMS AND OBJECTIVES

The objectives of the study were to determine the socio demographic and clinical correlates of knee pain in women in a primary care clinic.

PATIENTS AND METHODS

The study was a cross-sectional survey of 400 women attending the General Outpatients' clinic of the University College Hospital (U.C.H.), Ibadan, Nigeria using the systematic random sampling technique.

RESULTS

The prevalence of knee pain was 42.0% (95% CI 40.0- 41.0). The radiographic findings in the knees showed mostly osteophytes in 24 out of the 28(85.7%) respondents who had radiographs done. The highest prevalence of knee pain was found in caterers and traders, 62.5% and 51.6%, respectively (p= 0.001). Multivariate analysis done using logistic regression with a backward selection showed that the odds of developing knee pain increases with age (Odds Ratio=1.585, 95% CI 1.321-1.903, p=0.000), and body mass index (Odds Ratio 1.587, 95% CI 1.295-1.946, p=0.000).

CONCLUSION

The prevalence of knee pain in women seen at the primary care clinic is high. Preventive measures for knee pain need to be instituted.

Effects of honey, glutamine and their combination on canine small bowel epithelial cell proliferation following massive resection

The effects of honey, glutamine and honey/glutamine combination on the healing and adaptive process of the bowel following massive small bowel resection were studied in some Nigerian nondescript breeds of dogs. 24 dogs (3-4 months old) of mixed sexes with mean body weight of 4.42±0.70 kg were studied. They were randomized into four treatment groups following 70% small bowel resection. Group A dogs were placed on glutamine treatment, Group B on oral glutamine/honey and group C on honey and group D normal saline (control). Their body weights were evaluated for 15 days and the pre- and post-treatment gut biopsy samples were obtained and processed for morphometric evaluation. All groups exhibited signs of small bowel adaptation (Glutamine/honey>glutamine > honey > control) at the end of the experiment (4 weeks). Glutamine/honey combination, glutamine and honey had gradual increase in body weight from days 3-15 of weight evaluation. The control group, however, had a remarkable drop in body weight compared with other groups. Oral glutamine/honey combination showed the best overall effect based on body weight gain, intestinal mucosal growth and adaptation, evidenced by increased in residual bowel Villi height (27.71µm), Villi weight (14.51µm), Crypt depth (11.25µm), and Villi density (3.40µm). Glutamine showed a better result than honey with a significant increase in villi height (38.08µm), width (8.48µm) and crypt depth (40µm). Histologically, an improved villi branching was observed with glutamine/honey combination. Our results showed that honey/glutamine combination had comparative therapeutic advantage over glutamine or honey and may be a preferred treatment for short bowel syndrome patients.

Management of mandibular chronic osteomyelitis using Belfast technique

Chronic osteomyelitis is still common in developing countries like Nigeria due to the fact that conditions associated with the lowering of resistance to infections like malnutrition, malaria, anaemia, and acute eruptive fever are still prevalent in our society. Various operative techniques have been described for the treatment of chronic osteomyelitis with various outcomes. A case of chronic osteomyelitis of the mandible managed using the Belfast technique is presented. The Patient was followed up for 2 years with no evidence of recurrence of infection and a repeat radiograph at the end of follow-up revealed new bone formation. The Belfast technique is effective in the treatment of chronic osteomyelitis of the mandible and is recommended in the management of this condition.

Predisposing factors and outcome of treatment of non-union of long-bone fractures in Ibadan, Nigeria

AIMS AND OBJECTIVES

This study was done to find out factors that contribute to development of Non-union of long bone fractures in this environment and the outcome of operative intervention. This is a prospective hospital based study.

PATIENTS AND METHODS

All patients with Non-union of long bone fracture that presented in the hospital since January 1997 were recruited into the study. The data included causative factors, treatment given before presenting in the hospital, type of surgical procedure and result of treatment. The study was completed in December, 2005.

RESULTS

78 patients presented with 87 Non-union of long bones. A male, female ratio of 1.6:1 was encountered while 69.2 per cent of the patients were below the age 55years. Road Traffic Accident accounted for 68 fractures (78.2 per cent) while duration of injury before presentation varies from 6 months to 22 months. Atrophic non-union occurred in 60 cases (69.0 per cent) and hypertrophic non-union in 21 cases. Non-union of the femur occurred in 33 cases (37.9 per cent) humerus in 24 cases (27.6 per cent), tibia in 16 cases (18.4 per cent), radius and ulna in 14 cases (16.1 per cent). The initial treatments of the fresh fracture in the 78 patients with nonunion were by the traditional bonesetters in 51 patients (65.4 per cent) while the remaining fractures were treated by plaster of paris in hospital. Open reduction and internal fixation using plate and screws with bone grafting was the most common procedure for treating the non-union in most cases. Union was achieved in the entire patients following surgical intervention.

CONCLUSION

Important factor that appears to contribute to non-union of long bone in this environment is soft tissue interposition between the fracture ends of the bone, which is found in all fractures with more than one diameter displacement. Another factor is interference with periosteal blood supply from disruption of soft tissue envelope as a result of high energy injuries which is also responsible for the displacements that were observed in these fractures. The treatment by traditional bone setters which entails daily massage of the fracture creating a macro movement at the fracture site is also an important contributing factor.

Intra-tumoral ligation and the injection of sclerosant in the treatment of lingual cavernous haemangioma

INTRODUCTION

Haemangiomas are developmental vascular abnormalities and more than 50% of these lesions occur in the head and neck region, with the tongue, buccal mucosa, lips and palate most commonly involve. They are considered as harmatomas rather than true neoplasms Factors such as patient's age, size and site of lesion and the proximity of lesion to vital structure are paramount in the determination of the therapeutic approach 7 surgical excision, cryotherapy, injection of feeder vessels with sclerosants and embolization of the blood vessels.

CASE REPORT

We report the management of cavernous haemangioma of the tongue in a 38 year old man using intra-tumoral ligation (The Popescu Procedure) and injection of sclerosant under general anaesthesia.

RESULT

The efficacy of this method lies in the fact that it obstructs the vascular channels to and from the entire tumour mass leading to progressive atrophy of the vascular endothelia, fibrous hyperplasia and the substitution of the angiomatous tissues by a fibroconnective tissue mass which initially appears excessive but remodels and produces an acceptable appearance which can be further improved by plastic surgery.

CONCLUSION

The procedure was well tolerated and the patient made excellent recovery. It is recommended in our centre where facilities for technologically demanding methods are not available.

Back school: the development of a Nigerian urban model

BACKGROUND

Back Schools are health education and behaviour modifying programmes for care of the back and prevention of back injuries, usually available as video documentary. They are often developed with consideration for the environment and the practices of the people they serve. Although back schools are available in many parts of the world, none has been developed for the Nigerian environment.

OBJECTIVE

To develop a back school model for the Nigerian urban setting.

METHODS

The Nigerian Back School (NBS) was developed from two existing video documentaries and series of focus group discussions. The focus group discussions suggested how to adapt these documentaries to the Nigerian environment and cultural practices. A hand book containing illustrations on wrong and correct postures was also developed.

RESULTS

The NBS comprises 30-minute video documentary and a 24-page handbook. The first part of the video documentary provides information on the epidemiology and causes of back pain, structures and functions of the back while the second and third parts consist of demonstrations of wrong and correct resting and working postures assumed during everyday life activities and simple exercises for the prevention or alleviation of back pain or its recurrence respectively. The NBS handbook consists of illustrations on wrong and correct postures assumed at rest and during activity of daily living

CONCLUSION

A back school (video documentary and handbook) with considerations for the Nigerian urban environment and the peoples' practices was made available.

Pattern of the cases seen in the accident and emergency department in a Nigerian Tertiary Hospital over a period of twelve months

INTRODUCTION

There is a dearth of information on emergency medical services in Nigeria. This study was conducted to determine the age, sex distribution and the pattern of patient presentation in the Accident and Emergency Department of a Nigeria teaching hospital.

METHODS

A retrospective study of all cases seen at the accident and emergency department of the University College Hospital in 2003 was carried out. The information extracted from the records includes age, sex, and diagnosis, department to which the patient was referred, the month of presentation and the outcome within the first twenty four hours of presentation.

RESULTS

A total of 4674 patients attended the casualty, with a male: female ratio of 1.2:1. The third decade was the peak age distribution. There was a predominance of surgical cases (61%). In the treatment outcome, 52.1% were referred to other departments while there were ten (0.2%) mortalities. Trauma related cases constituted 45.1%. Road traffic accidents were the commonest cause of trauma.

CONCLUSION

The largest proportion of patient were in the active third decade of life. Trauma is the commonest cause of presentation in the Accident and Emergency Department. A significant proportion of patients do not require admission. The doctor in the Accident and Emergency Department must be skilled in basic trauma care.

The use of thromboembolic prophylaxis by surgeons: A multicentre Nigerian study

BACKGROUND

Despite the well known contributions of deep vein thrombosis and pulmonary embolism to perioperative deaths, these major causes of morbidity and mortality appear not to be given adequate attention by surgeons in our environment.

OBJECTIVE

To study the practice of thromboembolic prophylaxis among surgeons in some sub-specialties in three Nigerian tertiary institutions.

MATERIALS AND METHODS

A structured questionnaire was used to collect information from consultants in the surgical sub-specialties on the use of thromboembolic prophylaxis in their practice.

RESULTS

Fifty nine adequately completed questionnaires were returned. Of this, only 28 (47.5%) used prophylaxis routinely in major surgeries. Use was most frequent in orthopaedics and least in ophthalmology and otorhinolaringology. Subcutaneous heparin was the most commonly employed agent and the most important indication for prophylaxis was a previous history of thromboembolism.

CONCLUSION

The results obtained suggest low use of prophylaxis. Evidenced-based guidelines are available on antithrombotic and thrombolytic therapy with the benefits outweighing risks, burdens and costs. Therefore greater attention should be paid to antithrombotic measures by all the surgical sub-specialties and patients stratified according to risk.

Pattern of congenital orthopaedic malformations in an African teaching hospital

BACKGROUND

Congenital Orthopaedic malformations are common malformations that are usually unacceptable to the common populace in the West African sub-region. There is paucity of knowledge about the common types of Orthopaedic congenital malformations in our environment This study was undertaken to determine the pattern of congenital Orthopaedic malformations in a Teaching Hospital.

STUDY DESIGN

This was a prospective study of all the Orthopaedic congenital malformations seen in our surgical outpatient departments and the inpatient referrals from the wards between January 1995 and December 2003.

RESULT

There were 284 patients in total with a male to female ratio of 2:1 and age range between two days to nine years. Clubfoot (CTEV) accounted for 52.8% of all the malformations while Congenital knee dislocation (CDK) and calcaneovalgus deformity accounted for 8%. Congenital hip dislocation (CDH) accounted for only 2.2% of all the cases.

CONCLUSION

Congenital talipes equinovarus deformity is the most common congenital orthopaedic malformation in this environment while congenital hip dislocation (CDH) is rare when compared with the Caucasians.

Double blind clinical trial comparing the safety and efficacy of nimesulide (100mg) and diclofenac in osteoarthrosis of the hip and knee joints

BACKGROUND

Osteoarthritis of the hip or knees is a very disabling condition in both Caucasians and Africans. A lot of medical drugs have been in use with their corresponding side effects, hence the search for newer drugs with fewer side effects.

STUDY DESIGN

A double blind clinical trial comparing the safety and efficacy of nimesulide and diclofenac was carried out in the University College Hospital Ibadan. All patients referred to the outpatients department of the orthopaedic division with osteoarthritis of the hips and knees who met the criteria for inclusion in the study were used for the study.

RESULTS

There were a total number of sixty-seven (67) patients. 70.6% of the nimesulide patients had only mild pain in the involved joint on completion of the eight weeks trial compared to 50% of the diclofenac group. A significant proportion of the patients in the diclofenac group (50% vs 17.6%) had break through pain that warranted the use of at least two tablets of 500mg of paracetamol per week in contrast to the nimesulide group. There was a statistically significant difference in the frequency of side effects between the patients in the diclofenac group and the nimesulide group (p<0.05).

CONCLUSION

Nimesulide was found to be more effective in relieving pain in osteoarthritis of the hip and knees and with less side effects than diclofenac.

The ultrastructure of the peri-articular osteophytes - an evaluation by scanning electron microscopy

OBJECTIVE

Osteophytes are intra-articular osteochondral tissues, which are usually found at the margins of degenerating synovial joints. The aetiology or pathogenesis of this tissue has been a subject of protracted debate. The aim of this study was to offer a possible aetiology and or pathogenesis of this expendable yet important osteochondral tissue using the scanning electron microscopy to evaluate the structure of the cartilage mantle of osteophytes and the relationship of this mantle with that of the adjoining normal articular cartilage.

METHODS

Sections of periarticular osteophytes and osteophyte-normal articular cartilage composite tissues were obtained during total knee replacement for osteoarthritis (OA). These sections were routinely processed and examined using the scanning electron microscope with emphasis on the osteophytic cartilage mantle and the merger of the osteophyte and the adjoining normal articular cartilage.

RESULTS

The cartilage mantle of osteophytes was found to be thinner but continuous with that of the adjoining normal articular cartilage. However, a longitudinal bar of acellular tissue was found to separate the subchondral bones of both tissues. The cellular (chondrocyte) arrangement in the osteophytic cartilage was similar to that of the adjoining normal articular cartilage. In addition, in the superficial layer, there was looping of collagen fibres between the normal articular cartilage mantle and that of the osteophytic tissues.

CONCLUSION

The continuity between the cartilage mantle of osteophytes and the adjoining normal articular cartilage may suggest that in the formation of osteophytes, the chondrocytes from the adjoining normal articular cartilage greatly influence the mesenchymal tissue precursor of osteophyte to differentiate along a chondrocytic pathway initially. With subsequent vascular invasion probably from the periosteum, the neocartilage develops a bony core with a completely separate blood supply from that of the adjoining subchondral bone.

The surgical management of severely displaced supracondylar fracture of the humerus in childhood

A total of 28 children with severely displaced supracondylar fractures of the humerus were operated between January 1997 and December 2001 using the posterior approach raising a tongue of triceps and stabilisation of the fractures with two crossed Kirschner wires. All the supracondylar humeral fractures were extension type. The mean age was 6.9 years with male/female ratio 1.5:1. Fall at home accounted for 85.7% of the cases while 67.9% presented with injury to the left elbow. In 92.9% of the children the triceps muscle power was grade 5, 71.4% could flex the elbow joint beyond 120 angle and only 10.7% had 15 degrees of extension lag at the elbow joint at six months. All had within normal carrying angle with 64.3% having carrying angle between 0 degrees - 10 degrees. The scar was cosmetically acceptable in 27 patients (96.4% ) at six-months.

Femoral head diameter in subcapital fracture of the femur in Ibadan, Nigeria

Subcapital fracture of the femur is common in the elderly patients though the incidence is less in our environment than in the western world. Primary prosthetic replacement is the method of treatment in the majority of the patients. To facilitate this, a foreknowledge of the femoral head diameter is necessary. To determine the diameter of the femoral head and its magnification on radiograph among patients with hip fractures seen in South-West Nigeria, all patients with subcapital fracture of the neck of femur seen between March 1997 and February 2002 were included in the study. The femoral heads were measured on the radiographic film using a transparent ruler and after extraction of the femoral head during surgery using callipers. There were 25 patients in all, the mean age of patients was 73.2 years. Fall at home accounted for 70% of the cases. The femoral head diameter was between 42 mm and 50 mm in 92% of patients while magnification of femoral head diameter on radiograph was 10-14% in 92% of cases. The usaof 10-14% magnification of femoral head on radiograph would help the surgeon determine the size of prosthetic head before commencement of surgery.

Traditional bonesetters in south western Nigeria--friends or foes?

OBJECTIVE

To highlight the dangers inherent in the practice of traditional bone setting in south western Nigeria as evidenced by the preventable complications that accompany treatment of fractures, joint dislocations and limb deformities by traditional bonesetters (TBS).

METHOD

Twenty-five consecutive patients with fractures, dislocations and limb deformities who had been previously managed by TBS and who subsequently presented to the University College Hospital, Ibadan (on account of complications from treatment at the TBS) between 15 October 1999 and 31st March 2000 were evaluated.

RESULT

Fourteen patients had fracture non-union or malunion necessitating open reduction and internal fixation. Two patients with wet gangrene of the extremities had amputations.

CONCLUSION

Traditional bone setting is an ancient trade practiced in Nigeria and most developing countries without government regulations and they lack guidance. The complications that accompany these practices are unacceptable and it is imperative that there should be legislation to curb their activities and save the unsuspecting public from further harm or even death.

Normal values of knee angle, intercondylar and intermalleolar distances in Nigerian children

There is little data on the range of variation of knee angle, intermalleolar and intercondylar distances in African children. Such measurements are needed to assist determining whether a child legs are normal or not. Knee angle intermalleolar and intercondylar distances were measured in 2166 Nigerian children aged one year to 10 years to establish normal values for these measurements. In the study we discovered that knees were maximally bowed at ages 1-3 years and reduced to neutral of 0 degrees at age five (5 years) in girls and age seven (7) in boys. Both sexes had no bowing after age (7 years) in boys. Both sexes had no bowing after age of 7 years. The valgus angle was found to be constant at about 11 degrees between ages 1-10 years in both sexes. Mean intercondylar distance was 0.2 cm at 1 year of age and did not vary significantly at 10 years of age. The greatest intermalleolar distances of 2.5 cm and 2.2 cm were noted between the ages of 2 and 4 years. Normograms of these measurements are presented as diagnostic aids in clinical settings.

Infective lumbar discitis in a sickler--an occult 'typhoid' spine?

Pyogenic infection of the intervertebral disc (discitis) is a rare infection and the diagnosis often depends on a high index of suspicion. The cases of infective discitis described in the modern literature are similar to, if not identical with what was described as 'typhoid spine'. Salmonella infection of the musculoskeletal system on the other hand is more common in patients with sickle cell anaemia. This case report highlights the bizarre presentation of infective lumbar discitis in a sickler (HbSS) and calls attention to the need for a thorough evaluation of low back pain in these patients.

Management of open tibia fracture--Anderson and Hutchins technique re-visited

Prior to September 1995, most open tibia fractures seen at the University College Hospital, Ibadan had hitherto been managed by the application of plaster-of-Paris after limited wound debridement. The outcome of this form of treatment was found, from the outpatient clinic follow-up records, to be associated with a high rate of complications including chronic osteomyelitis and joint stiffness. In most hospitals in the developed and developing countries, majority of these injuries are best managed by the use of various types of external fixators. However, these external fixator devices are by no means cheap and often times most patients in our environment are unable to afford them since the country operates a health care system where the patients are solely responsible for their health care needs. In this study, the Anderson and Hutchins technique (Steinmann's pins threaded through bone and incorporated in plaster-of-Paris) was used in the management of thirty-four open tibia fractures between September 1995 and August 1999. Seventy-nine percent of these were severe or Type III open fractures. The time to radiological union was 21 weeks and pin tract infection occurred in 15 percent of the patients, mainly in the proximal (tibia) pins. The use of a single stout proximal (tibia) transfixing Steinmann's pin was found to offer a stable fixation.

Hip fractures in a tropical teaching hospital

The pattern of hip fractures, treatment, outcome of treatment, and complications of forty-four consecutive patients treated over a five-year period were retrospectively studied. This represents 3.5% of the hospitalised patients in orthopaedic services. The male:female ratio was 1:1.3. Seventy percent of the fractures occurred in those over 65 years of age. The fractures were the result of low energy trauma in 81.8% of patients. Intracapsular (cervical) fractures accounted for 79.5% of the total cases. Only two patients had associated injuries on admission. Austin Moore hemiarthroplasty was the choice of hip replacement for intracapsular fractures, while ORIF (Open reduction and internal fixation using fixed angle blade plate) was done for patients with (extracapsular) trochanteric fractures. Anaesthesia (general or regional) was uneventful. Non-fatal pulmonary embolism occurred in one patient post-hemiarthroplasty while in the hospital. This study shows that hip fractures are not uncommon in our environment although far less common than what obtains in the Caucasians.

The Belfast technique for the treatment of chronic osteomyelitis in a tropical teaching hospital

From September 1995 to August 2001, we treated 25 patients with chronic osteomyelitis of long bones by a two-stage technique. This consisted of the radical removal of all infected bone and soft tissue and immediate provision of soft-tissue cover. This was supplemented when necessary with delayed autogenous bone grafting. The average follow-up was 46 months (range: 19-80 months). One patient with haemoglobin sickle cell disease (HbSS) died after the second stage of surgery. There were four recurrences, one of which followed a myocutaneous flap that became necrotic. Ankylosis occurred in five patients.

Domiciliary treatment of femoral shaft fracture in children

A total of 20 children presenting in Accident and Emergency (A&E) Department of University College Hospital, Ibadan, Nigeria with femoral shaft fracture treated with straight leg fixed traction in a domiciliary setting is presented. The male:female ratio is 3.2 with fall accounting for 65% of the cases. There was satisfactory correction of overriding and angular deformity following the application of the fixed traction in all the patients. There was good Callus formation at six weeks with no vascular, neurological or soft tissue complication.

Major limb amputation in Ibadan

A prospective study of patients who had major limb amputation at the University College Hospital Ibadan over a 5-year period is presented. One hundred and one major limb amputations were performed within this period (71 Males, 30 Females, M:F = 2.3:1). Trauma accounted for 48% of the cases followed by diabetes in 26%, soft tissue infection in 13% and tumours also in 13%. The major post-op complication was wound infection. In accordance with the findings in other centers, a higher proportion of the amputations (69%) were carried out in the lower limbs. Patient's refusal to accept amputation resulted in a delay in amputation in 49 patients. This delay (before surgery) ranged from 1 day to 150 days, with a mean of 15.49 (SD 9.V). From this study, we found that a reduction in vehicular accidents and increasing emphasis on efficient foot care (and glycaemic control) in the diabetic may significantly reduce the rate of amputations in our environment.

Haematoma block in reduction of distal radial fractures

A total of 35 patients who presented in the Accident and Emergency Department of University College Hospital with displaced distal radial fracture between January 2000 and March 2001 had reduction of the fracture under haematoma block using 10ml of 2% lignocaine. There was significant reduction of the pain following infiltration of the fracture site with lignocaine and significant pain reduction during manipulation compared to pain score at presentation. All the patients had satisfactory reduction of the fracture. The fracture was mobilised in Plaster of Paris 6 weeks in patients with Collens' fracture and 3 weeks in patients with distal radial epiphyseal injury. All patients had good range of movement at 8 weeks after removal of Plaster of Paris and patients expressed satisfaction with this method. We recommend the use of Haematoma block for patients of 15 years and above with displaced distal radial fracture in the Accident and Emergency Department.

The complications seen from the treatment by traditional bonesetters

Traditional bone setters are rampant in the West African subregion but the atrocities committed by them have never been reported hence the need for this article that deals with the menace caused by them. All patients referred to the University College Hospital between 1996 and 2001 were included in this study. Only a few number of the patients have been selected just to illustrate the menace caused by the traditional bonesetters in so many African societies. The deformities, financial loss and amputations resulting from the management by traditional bonesetters have been highlighted. Suggestions are made on how to improve awareness in the way of adequate communications through televisions, radio and the press. Much need to be done in the society as it was found in the study that poverty or lack of education alone is not the major cause of the society seeking the help of the traditional healers, but probably the culture and traditional beliefs of the society.

Traumatic dislocation of the hip joint--pattern and management in a tropical African population

Traumatic dislocation of the hip is an orthopaedic emergency for which early reduction is indicated. This article describe our experience of the pattern and choice of management of traumatic dislocation of the hip joint in a tropical African population. Majority of the dislocation (87%) were Thompson and Epstein's grades I and II which were easily managed by closed reduction following the administration of titrated intravenous analgesic and intravenous diazepam. This treatment option is cheap and readily administrable to avoid undue delays in the management of this orthopaedic emergency. All the close reduction were carried out in the accident and emergency room except for one patient with bilateral posterior hip dislocation who had his reduction on the ward. Early diagnosis and treatment of traumatic hip dislocation are essential to reduce the morbidities that are commonly associated with delay in reduction.

Congenital dislocation of the knee in Ibadan, Nigeria

Between January 1996 and December 2001, 41 congenital dislocations of the knee joints (30 patients) were reduced with closed methods by immediate reduction without anaesthesia and serial casting in plaster of Paris immobilization for a period of six to eight weeks. The patients' age ranged from the age of one week to four weeks with a male to female ratio of 1.5:1. The right knee was involved in 46.65% the left in 16.6% and bilateral involvement in 36.65% of patients. Routine check of the hip did not reveal any patient with hip instability. All the patients followed up after 2 years showed excellent results. We conclude that congenital knee dislocation when discovered early and without any other congenital malformation can be managed conservatively with excellent results.

Microbial isolates in open fractures seen in the accident and emergency unit of a teaching hospital in a developing country

In this prospective study, superficial and deep swabs of all open fractures seen at the accident and emergency unit of our hospital between January and June 2000 were taken (before wound debridement was done or anitibiotics commenced). Routine microscopy, culture and sensitivities for aerobic and anaerobic organisms were carried out on these specimens. The organisms were cultured and identified using standard techniques and the antibiotic sensitivity testing was carried out using the disc diffusion method of Stokes. Within six hours of injury, single-organism isolates were commonly found whilst after 48 hours a mixed or poly-microbial organism load were isolated. In 90% of the positive isolates, the organisms isolated form the superficial and the deep swabs were the same. The antibiotic sensitivity pattern of all the isolates shows that pefloxacin, ciprofloxacin and ceftriaxone were more effective compared to cefuroxime and amoxycillin which had substantial resistance to most of the isolates. 41 fractures were followed to union and 4 (9.7%) developed osteomyelitis.

Primary malignant bone tumour in a tropical African University teaching hospital

Bone tumours are relatively rare tumours as compared with all other tumours. The relative frequency has not been well documented in this environment. The aim of the study was to define the frequency of primary malignant bone tumours in an African University teaching hospital in Ibadan. The medical records of 114 patients with malignant bone tumours recorded in the Cancer Registry of the University College Hospital, Ibadan, Nigeria between January 1977 and December 2000 were reviewed retrospectively. Primary malignant bone tumours represented 0.53% of all the 21390 cancers seen in the teaching hospital in the period studied, with a male female ratio of 1.4:1. About 45% oftumours occurred among patients < 20 years of age. Osteogenic sarcoma was the most common primary malignant bone tumour while the mandible was the most commonly affected bone. In contrast to previous studies, Burkitt's lymphoma affected the mandible more commonly than the maxilla. The relative frequency of primary malignant bone tumours is low in our environment as observed in other developing countries.

Limb conservation using non vascularised fibular grafts

This paper highlights the use of non-vascularised fibular graft in limb reconstruction from bone loss due to trauma and infection. Bone loss can occur from severe high velocity injuries due to road traffic accidents, severe neglected infections, and osteolytic tumours. In majority of cases, the surgeon is left with the only option of an amputation especially where there is no access to microvascular surgery and microvascular bone grafting devices. This is a major problem in the West African subregion hence the need for this article. We present illustrative cases of limb conservation in an adult involved in a high velocity trauma and a child with a destructive osteolytic infection culminating in bone loss. The patients are still been followed up in our surgical outpatient clinics.

Microbial isolates in chronic osteomyelitis--a guide to management

Between August 1995 and December 1999, sixty patients with chronic osteomyelitis had the effluent from the discharging sinuses and bone biopsies cultured aerobically and anaerobically. 47 positive isolates were obtained and the organism commonly isolated both in the single- and two-organism isolates was Staphylococcus aureus. The sensitivity patterns of these isolates were carried out with the available antibiotic discs. 30 per cent of the organisms isolated were sensitive to ceftriaxone (Rocephine) and gentamycin.

The choice of antibiotic in open fractures in a teaching hospital in a developing country

Open fracture wounds may be contaminated, and the use of an appropriate antibiotic in the early stages of management reduces the risk of osteomyelitis developing. Environmental factors influence both the type of micro-organisms that are isolated from these wounds and the antibiotics that are chosen to manage the wounds. Before this study, the choice of antibiotic in the management of open fractures in our hospital was based on tradition and 'best guess' antibiotics. In a prospective study of 52 open fractures seen in the accident and emergency unit of University College Hospital, Ibadan, between January and June 2000, the positive bacterial culture yield was more than 70%. Staphylococcus aureus was the commonest microbial isolate, accounting for 37.5% of total isolates. The antibiotic sensitivity pattern revealed high efficacies for pefloxacin, ciprofloxacin and ceftriaxone against the isolated micro-organisms. In comparative costs, these antibiotics are cheaper than the combination of the 'best guess' antibiotics that were used previously. On the strength of this finding, we have suggested a change in the antibiotic policy of the hospital with regard to the antibiotic regimen to be used to complement the surgical management of open fractures.

Management of chronic osteomyelitis in a developing country using ceftriaxone-PMMA beads: an initial study

Chronic osteomyelitis is a debilitating disease that is fairly common in developing countries. Various operative techniques have been adopted in the management of this disease but there have been few reports of their use in Africa. In this report, we present our experience of the use of a modified two-staged Belfast operation in patients with chronic osteomyelitis in Ibadan, Nigeria. An important modification of the procedure was the substitution of gentamicin beads (Septopal) with ceftriaxone-polymethylmethacrylate (PMMA) beads at the saucerised segment of bone at the first stage. Thirty-four patients with chronic osteomyelitis had the two-stage Belfast operation in 35 long bones; of these, 32 patients had ceftriaxone-PMMA antibiotic beads inserted at the saucerised segment of bone at the first stage, while the other two patients had gentamicin beads inserted. One of the two patients who had gentamicin beads had a residual collection of pus at second stage surgery but, following a repeat debridement, the cavity was rid of infection. There was recurrence of infection in three patients (8.6%) who had a suction drain inserted at the first stage and in six patients (17.1%) who had no suction drain at the first stage. The locally produced ceftriaxone-PMMA beads were found to be as efficient as the commercially available gentamicin beads in eluting antibiotics locally, thereby eliminating the residual infection in the bone cavities after the first stage. Another important outcome was a fourfold saving in cost in choosing to use ceftriaxone-PMMA beads rather than gentamicin beads.

The management of metastatic bone pain in a developing country: the role of radiotherapy as an adjunct to weak opioids

Bone pain secondary to metastatic cancer is the commonest intractable pain and is a major concern in most oncology units the world over. Cancer pain management is multidisciplinary in approach, so there is no universal or singular modality of treatment. In a developing country like Nigeria, only external radiotherapy and adjuvant weak opioids are readily available, so it is of interest to review the response of these patients to this management option. This is a retrospective review of 92 patients aged 16-80 years with radiologically confirmed metastatic bone disease associated with pain who received external radiotherapy and weak analgesics. The results showed that 23 (25%) patients had a complete response and 67 (73%) had a partial response within four weeks of treatment. Total response was over 90%, which suggests external radiotherapy has an effective palliative role. The study also demonstrated the pattern of bony involvement among the common cancers seen in our environment. The availability of strong opioids (e.g. morphine and pethidine) will obviously consolidate the gains achieved with external radiotherapy in the management of metastatic bone pain in our environment.

Further characterization of storage-related alterations in immunoreactivity of archival tissue sections and its implications for collaborative multicenter immunohistochemical studies

Storage of unstained paraffin slides may lead to the deterioration of specimens and failure to detect cellular proteins immunohistochemically. Although the implication of age-induced alterations on multicenter immunohistochemical studies would be considerable, they have not been investigated previously. The current study was undertaken to examine the effect of this factor further and to explore new ways of overcoming the resultant shortcomings. The authors now report on the immunodetection of a host of antigens in similarly preserved unstained serial paraffin slides obtained from three centers using a panel of eight antibodies. Staining of recently prepared sections from the authors' centers resulted in similar strong patterns in seven of eight antibodies, with one antibody demonstrating variable immunoreactivity. However, storage of unstained paraffin sections at room temperature resulted in a variable but progressive decrease in expression of several tissue antigens. Although the loss in antigenicity was proportional to the length of storage, the effect was reversible if super antibody concentrations were used. The authors conclude that recently prepared paraffin sections from centers with similar fixation protocols have similar immunoreactivity and are suitable for use in comparative multicenter studies. However, in view of the delays that may attend tissue transportation during these projects, the authors suggest that test systems should be checked for age-induced antigen degradation by incubating sections with higher antibody concentrations.

Quadriceps tendon rupture in an adolescent

Quadriceps tendon rupture is said to be rare in patients younger than 40 years of age. We report a case of quadriceps tendon rupture in a 13 year old athletic boy.