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   Table of Contents - Current issue
Coverpage
July-December 2019
Volume 18 | Issue 2
Page Nos. 35-76

Online since Monday, January 13, 2020

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REVIEW ARTICLE  

Spinal tuberculosis - Current management approach p. 35
John E Onuminya, Eghosa Morgan, Mutaleeb Ayodele Shobode
DOI:10.4103/njot.njot_25_19  
Broad narrative review. To review and summarise the current literature on the management of tuberculosis (TB) spine. A thorough review of literature was performed on the epidemiology, aetiology, pathophysiology, pathology, clinical features and management of TB spine. Spinal TB accounts for half of skeletal TB and remains a common cause of public health concern in the developing world. The thoracic spine segment is the most affected. Patient commonly present with back pain and gibbus. The diagnosis involves demonstrating Mycobacterium tuberculosis on microscopy or culture as well as characteristic histology findings. Magnetic resonance imaging is the gold standard imaging modality. Medical therapy with anti-TB agents is the mainstay of treatment. Surgery is supplementary and indicated in selected cases. Spinal TB carries a good prognosis when detected and treated early. Delays can be associated with the development of complications including difficult-to-manage deformities. Multi-drug anti TB chemotherapy remains the bedrock of treatment. Surgery is supplementary and when indicated, takes the form of abscess drainage, debridement and fusion with or without instrumentation.
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ORIGINAL ARTICLES Top

Functional outcome of calcaneal fractures treated by various methods p. 44
Vatsal Vishnu Khetan, Ishani Patel, Dhaval R Modi, Naitik Panchal, Nishant Bhavsar, Arpit Joshi
DOI:10.4103/njot.njot_8_19  
Introduction: Calcaneal fractures make up about 2% of all fractures. They account for 60% of major tarsal injuries. Anatomic restoration of the three-dimensional anatomy of the calcaneum and restoration of weight-bearing function is the goal of surgical management of calcaneal fractures. Over the years, various techniques have been developed to accomplish this goal. All these techniques have certain steps in common including disimpaction of the fragments, reduction of the displaced fragments either manually or percutaneously and protection of reduction with plaster pins and plaster, external fixation and open reduction and internal fixation. Materials and Methods: This is a retrospective study of 41 patients (50 fractures) with calcaneum fractures from 15 to 60 years of age, managed either conservatively or operated at our institution between 2012 and 2017, with regular detailed clinical and radiological follow-up for minimum of 6 months. Results: In this series, we have used American Orthopaedic Foot and Ankle Society score for assessment of our result. Ninety-three per cent fractures had good to excellent result in non-operative group and 77% fracture had good to excellent result in the operative group. In intra-articular fractures with joint depression pattern, 9 (69%) of the percutaneously fixed fractures had good to excellent results and 8 (66%) of the Open reduction and internal fixation (ORIF) group had good to excellent results. Eight (33%) with fair result had persistent heel widening and pain. One patient had loss of reduction, but all of them have returned to their original occupation. In intra-articular fractures with Tongue type fracture, all 7 (100%) fractures had good to excellent results, whether they were fixed percutaneously or via open fixation. Conclusion: In this retrospective study, we observe that there was no significant difference noted, with respect to the functional outcome, between the operated and non-operated group.
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Epidemiology of open fractures in a nigerian teaching hospital p. 48
Ifeanyi Charles Nwagbara, Francis Chukwudi Nwabueze
DOI:10.4103/njot.njot_9_19  
Background: The management of open fractures has been of great challenge to surgeons over the years, and these fractures are often associated with considerable patient morbidity and high socioeconomic consequences. Epidemiological studies are of great importance in the management of these conditions as the information obtained will be used to define priorities and enhance the understanding of this challenging subgroup of traumas. Objective: The aim of this study was to define the epidemiological profile of patients who were managed for open fractures of the long bones at a teaching hospital in South East Nigeria. Materials and Methods: This was a retrospective and descriptive epidemiological study involving open fractures of the long bones managed at a teaching hospital in the southeastern part of Nigeria over a period of 3 years, from January 2014 to December 2016. Data which were collected from patients' case notes were subjected to descriptive analysis, and the results were presented with simple frequency tables, percentages and charts. Results: Seventy patients with 73 fractures were treated for open fractures within the period of the study. The male to female ratio was 4.3:1, and the peak age incidence was 20–29 years (30%). The most common cause of the injury was motor vehicle accidents (82.9%), of which 64.3% of cases were as a result of motorbike accidents. The leg bones were the most affected site (63%) while the Gustilo type III fractures were the most common injuries (67.1%). The average time interval from injury to presentation was 10 h. Wound infections were the most frequent complications observed, followed by delayed union. Conclusion: Open fractures are challenging conditions which affect mainly the young and active males in our society. The victims often present late which affects the management outcome. The burden of open fractures can be minimised in our society by efforts aimed at reducing the menace of motorbike operators, the latter being the most common cause of the injury.
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Open femoral shaft fractures in a developing country: Pattern of presentation and outcome of treatment p. 54
Henry Chinedum Ekwedigwe, Amechi Uchenna Katchy, Richard Chukwunonye Ezeh, John Kene Anieze
DOI:10.4103/njot.njot_14_19  
Background: The femur is one of the principal load-bearing bones of the lower extremity. Femur fractures are among the most common fractures encountered in orthopaedic practice. Open femur fractures are always as a result of high-velocity injury and almost invariably associated except for isolated gunshot injuries with multiple traumas. The aim of the study is to determine the pattern of presentation of open femur shaft fractures, associated injuries and outcome of treatment. Patients and Methodology: A 10-year retrospective study done at National Orthopaedic Hospital, Enugu, from 2007 to 2016. Patients' folders were retrieved from the Medical Records Department; patients' biodata, cause of the injury and other relevant information were collated from the folders and their management followed up for 1 year. Data analysis was done with Statistical Product and Services Solution Version 22. Results: A total of 62 cases were reviewed. Treatment outcome of 50 patients that completed their management was analysed. The age range with the highest frequency was 21–30 years. Associated injuries were recorded in 77.4% of the patients. Thoresen's combined excellent and good outcome was observed in 63.3% of the patients at a minimum of 1-year follow-up. Conclusion: Open femoral shaft fractures are more common in the younger age groups and usually associated with high frequency of associated injuries. The outcome of treatment of these fractures in our environment is good despite the limited resources usually encountered in a developing nation like ours.
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A 2-year review of the rotary-supported ponseti Clubfoot Clinic in Lagos, Nigeria p. 60
Oladipo A Adewole, Matthias O Shoga, Omolara M Williams, Olawale S Famude, Michael O Kayode, Samuel O Idowu
DOI:10.4103/njot.njot_20_19  
Background: The Ponseti method is generally acknowledged to be the gold standard for congenital clubfoot treatment, worldwide. Although this treatment is considered to be cheap and effective, some patients in less affluent climes are unable to afford the treatment, which includes wearing of braces until the age of 4 years. Objectives: This study documents the experience of running a clubfoot clinic with the financial support from three rotary clubs for 2 years and aims to review the impact of the sponsorship and recommend a replication of this model in similar settings. Materials and Methods: This is a retrospective study of patients treated in our clubfoot clinic adopted by the rotary clubs from 20th September 2017 to 20th August 2019. Age at presentation, sex, laterality, Pirani score, number of casts to correction, brace compliance and complications were recorded prospectively in the International Clubfoot Registry hosted by The Center for Bioinformatics and Computational Biology at the University of Iowa, USA, and analysed using Microsoft Excel software. Results: A total of 136 patients were treated, 81 (60%) of which had bilateral deformities, totalling 217 feet. There were 71 males and 65 females, with a male-to-female ratio of 1:0.9. The age at first visit ranged from 0 to 10 years. The largest number, 74 patients (54.4%), was aged between 0 and 3 months, but only one was aged above 10 years, at presentation. Using the Pirani score, 71% had severe deformities (Pirani score of 4 and above). The tenotomy rate was 29%. The average number of casts to correction was 4.6. Sixty-eight patients received braces at subsidised rates of 50% of the cost. Only 5% of the feet relapsed after correction. Conclusion: The rotary club intervention in our clubfoot clinic was associated with an increase in the annual number of patients attending the clinic, but the relapse rates remained the same as with previous studies.
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Management of the Wound in Type IIIB Open Tibiofibular Fractures: The Role of Improvised Vacuum-assisted Closure Dressing p. 65
OM Babalola, Oni Nasiru Salawu, BA Ahmed, GH Ibraheem, JO Mejabi
DOI:10.4103/njot.njot_21_19  
Background: The negative pressure used in vacuum-assisted closure (VAC) dressing helps to suck out fluid and bacteria from the wound and enhances granulation tissue formation and wound contraction, thus causing wound healing. Aim: The aim of the study is to demonstrate the effectiveness of VAC in extensive wound management when using local materials. Methods: This was a prospective study in which all consented patients who met the inclusion criteria within the study period were included in the study; suctioning machine, rubber tube, foam and cling film were adapted to make the local VAC which was used to manage the wound. The results were analysed by IBM SPSS Version 22. Results: Thirty-two wounds were managed with VAC, there were 28 males and four females, the mean age of patients was 33.7 ± 9.6 years, the mean length of wound managed was 10.6 ± 2.9 cm and the average number of dressing was five times. All wounds were culture positive at the beginning of the management, with Staphylococcus aureus being the most common organism. At the end of VAC treatment, 90.6% of the wound were negative for culture. Healing by secondary wound intension occurred in 50% of the wound, secondary suturing was done in 31.2% of the wound, while 18.8% of the wound had split-thickness skin grafting. The complications noted during the treatment are pain in 9.3% of the patients and skin excoriation in 3.1% of the patients. Conclusion: VAC method of wound management using local materials is effective in the treatment of extensive wound, and it is associated with less frequent dressing to achieve the desired result.
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CASE REPORTS Top

Complex primary total hip replacement in a patient with sickle cell disease and contralateral poliomyelitis: A case report and review of literature p. 69
Charles Ayekoloye, Ajibola Babatunde Oladiran, Ajibade Babatunde Omololu
DOI:10.4103/njot.njot_13_19  
Sickle cell haemoglobinopathy (SCH) and neurological sequelae of childhood poliomyelitis are still relatively common in this environment. The non-paralytic limb in polio patients is subjected to abnormal stresses due to excessive weight-bearing load, leg length discrepancy, pelvic obliquity and abnormal gait mechanics. We present this case to highlight the challenges of managing such a case and present our experience. A 47-year-old female with SCH presented with left-sided avascular necrosis (AVN) of the head of the femur and right-sided post-polio paralysis. Limb length discrepancy was 1.5 cm with a longer left lower limb. Oxford hip score (OHS) = 25 and SF12 = 16. Packed cell volume (PCV) was 20%. Radiographs revealed a destroyed left hip with secondary osteoarthritis, partial collapse, lateral subluxation and metaphyseal sclerosis. She had non-cemented left total hip arthroplasty via Hardinge approach. One-month post-operative scores were OHS = 38, SF12 = 24. Three-month follow-up scores were OHS = 46 and SF12 = 30. AVN poses a major burden. Combination with post-polio paralysis and the risk of infection with encapsulated organisms create a complex interplay of challenges. Peri-operative management requires meticulous monitoring, care and prevention of sickling crisis. Uncemented implants gave better results with fewer complications. Limb shortening at arthroplasty increases dislocation risk; so, length should be maintained. Coexisting post-polio paralysis and SCH is rare but challenging. The non-paralytic limb is subjected to excessive abnormal forces. Excellent results and low complication rates are achievable if meticulous peri-operative management, appropriate choice of cementless implants and maintenance of length are done. Ensuring adequate fixation of implants at surgery reduces risk of loosening. Rehabilitation must take the risk of falls into account. Pre-operative planning and optimisation, meticulous surgical technique and cementless implants are keys to success.
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Metallic object within the knee joint: A consequence of abnormal sitting position in a tricycle p. 74
Oni Nasiru Salawu, AO Kolade
DOI:10.4103/njot.njot_23_19  
The use of tricycle as a means of transport is becoming more popular across the rural and urban areas in Nigeria. This article reports a case of a 34-year-old woman who sat with her right knee protruding outside the body of the tricycle; while it was on motion, she hit her knee against part of metallic scraps being pushed in opposite direction. X-ray confirmed the presence of the object around her knee joint, she had surgery to remove the object and she recovered fully from the injury after the surgery. Proper sitting position while inside tricycle is very essential to prevent some avoidable injuries.
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