Local corticosteroid injections: Rational use in common orthopaedic problems

The use of local corticosteroid injections in orthopaedic practice is common due to their antiinflammatory and analgesic effect. However, the use may result in local or systemic complications. Moreover, the conflicting reports on their benefits versus side effects, throws the average user in confusion or fear. This review highlights the need for utility in only those conditions with clear outcomes

Early outcome of vascular lower limb amputations at a National Referral Hospital in Kenya

BACKGROUND: Majority of lower limb amputations performed in the African setting have been reported to be mainly due to trauma and neoplasms. These affect mainly young and therefore, fit individuals with lower risks of complications. Recent local studies show an increase in the incidence of cardiovascular diseases including peripheral vascular diseases. These are associated with higher rates of both systemic and amputation stump-related complications. There is however little published data in Africa on the outcomes of vascular lower limb amputations. OBJECTIVE: To determine the early outcome of vascular lower limb amputations. DESIGN: Descriptive prospective study, conducted between July 2003 and June 2004. SETTING: The Kenyatta National Hospital, the largest referral and teaching hospital in Kenya. SUBJECTS: All patients with gangrene of the lower limb due to occlusive peripheral vascular disease not caused by trauma or inappropriate limb splintage who were amputated at Kenyatta National Hospital during the study period were included. OUTCOME MEASURES: These included the wound healing time, number of stump revisions, number of conversions to a higher amputation level, the thirty-day post-operative mortality and the hospitalization period. CONCLUSION: While the findings of this study compare with other series, the prolonged hospital stay is of concern considering the younger average age of the patients

Morphology of the Sacral Hiatus in an African Population – Implications for Caudal Epidural Injections

Background The sacral hiatus exhibits variations in morphology which differ among populations. These variations may influence the success of caudal epidural injections for anaesthesia. This study describes the morphological and morphometric characteristics of the sacral hiatus in an adult Kenyan population. Study design A descriptive cross-sectional study. Materials and methods Eighty eight dry human sacra obtained from the Department of Osteology, National Museums of Kenya, Nairobi were used. The shape of the sacral hiatus was described as inverted-V, dumb-bell, inverted-U or irregular. The distance of the hiatal apex from the lower limit of S2 vertebra, the inter-cornual distance and the apical antero-posterior diameter were measured and tabulated. Results The inverted-V was the most common (32.1%) shape. The apex of the sacral hiatus was at the level of 4th sacral vertebra in 62% of cases. Mean distance of the hiatal apex from the S2 level was 43.1 + 12.9mm whereas antero-posterior diameter of the sacral hiatus at the apex was 6.4 + 3.1 mm. The sacral hiatus was absent in 1.2% of cases. Conclusion The level of the sacral hiatus in the African population implies minimal risk of dural puncture during caudal epidural injections

Gender-associated violence at a women's hospital in Nairobi, Kenya

Objective: To describe the pattern of gender-associated violence amongst adult survivors. Design: Descriptive case analysis of prospectively collected data. Setting: The gender violence and recovery centre (GVRC), a shelter and violence treatment facility for the gender-associated violence at the Nairobi Women\'s hospital (NWH). Subjects: Data on 663 consecutive adult patients who presented to GVRC between February 2003 and April 2004 were evaluated. Results: The patients age ranged from 18 to 74 years (mean 27.7 years). Four hundred and eight patients (61.5%) presented following sexual assault. Most of assaults were perpetrated at night. A stranger was the assault perpetrator in 75.1% and 2% of sexual and non-sexual assault respectively. An intimate partner was the perpetrator in majority (86.5%) of nonsexual violence. Most physical injuries were minor bruises and swellings. The rate of positive spermatozoa from high vaginal swabs was only 15.9% in cases of sexual assault. Sexual assault was significantly associated with single status of the victim and assault by more than one assailant. Conclusions: Violence against women is a common public health problem in the city of Nairobi. Women are vulnerable both in and out of the home. More efforts, including massive public education, are needed to protect this vulnerable population. East African Medical Journal Vol. 85 (7) 2008: pp. 347-35

Anatomical Measurements of the Distal Clavicle in a Kenyan Population

Anatomical measurements of the distal clavicle are important in the design of clavicular implants for fixing clavicular fractures and reconstruction of the coraco-clavicular complex in acromio-clavicular joint dislocations. These measurements show population variations however, little data exists from the African population and none for the Kenyan one. One hundred and eighty unpaired dry adult human clavicles were obtained from the Department of Human Anatomy, University of Nairobi. The length of clavicle and distance of conoid and trapezoid tuberosities from the distal end were measured using a ruler. The superoinferior thickness of the distal end was measured using a vernier caliper. The mean clavicle length was  148.57±12.63mm. The left clavicle was longer (150.4mm) than the right one (146.8mm). Conoid tubercle (CT) and trapezoid tuberosity (TT) were 39.52±5.93mm and 17.96±3.42mm respectively from the lateral edge of clavicle. These distances correlated positively with the  length of clavicle and occupied 0.3 and 0.15 of total clavicular length respectively. The supero-inferior thickness of the lateral edge was 10.09±2.36mm. The distance of CT and TT positively correlated with clavicular length. The CT lies at a junction of lateral one third and medial 2/3 while the TT is midway between CT and lateral end. Designers of clavicular implants should consider these measurements and surgeons involved in fixation of acromoclavicular joints fractures.Key words: Clavicle, conoid tubercle, trapezoid tuberosity

Pattern of Innervation of the Upper Gluteus Maximus Muscle: Implication in Prosthetic Hip Dislocation

Background: Dislocation is one of the most common complications after total hip arthroplasty. The posterolateral approach avoids disruption of the abductor mechanism but may denervate gluteus maximus as a basis for associated higher dislocation rates.Objective: To determine the pattern of innervation of gluteus maximusStudy design: Descriptive cross-sectional studyMaterials and methods: Twenty four cadavers for routine dissection in the Department of Human Anatomy, University of Nairobi were used. Having exposed the gluteus maximus, the muscle was transected close to its distal attachment and refl ected superiorly to expose the entry of the neurovascular structures into it from the greater sciatic foramen. The pattern of distribution of the inferior gluteal nerve to the muscle was noted and the left and right in the same cadaver comparedResults: In all the 48 cadaver sides, the inferior gluteal nerve exited the pelvis via the infra-piriformic compartment of the greater sciatic foramen. In majority (43, 89.6%) of gluteal regions this nerve funned out in multiple equal branches to the GM. Only one branch crossed the upper border of piriformis muscle. In 5 cases, this single branch that crossed theupper border of piriformis was a major trunk almost equal in size to theparent nerve. One such case was bilateral.Conclusion: A major branch of the inferior gluteal nerve to the upper partof GM, when present, could be injured in the posterior approaches to thehip to signifi cantly weaken the upper part of this muscle increasing therisk of prosthetic hip dislocation

Anatomical variations of the carotid arteries in adult Kenyans

Objective: To describe the topography and anatomical variations of the carotid arteries among Kenyans. Design: A descriptive cross-sectional study. Setting: Department of Human Anatomy, University of Nairobi. Subjects: Eighty carotid arteries of forty cadavers were dissected. Results: The bifurcation of the commonest carotid artery was high (above the reference points) in 63.8% of vessels and the external carotid was antero-lateral to the internal carotid artery in 30% of the vessels. A linguo-facial trunk was the most common variation of the external carotid artery. The origin of the right common carotid artery was high and low in 10% and 2.6% of vessels respectively. Conclusion: The carotid arteries show important variability and thus emphasise caution for clinicians during surgical procedures in the neck. East African Medical Journla Vol. 85 (5) 2008: pp. 244-24

Variations in the formation of supraclavicular brachial plexus among Kenyans

Objective: To describe the pattern and prevalence of variations that occur in the supraclavicular part of the brachial plexus in a Kenyan population. Study design: Descriptive cross-sectional study. Materials and methods: Ninety-four brachial plexuses from forty-seven formalin fixed cadavers were displayed by gross dissection. Results: The presence of at least one variation from the classical anatomy was observed in 73 (77.7%) of the 94 plexuses. The roots and trunks were involved in 32 (34%) of the plexuses . Preand postfixed roots were present in 23 (24.7%) and 3 (3.2%), respectively. The presence of four trunks, and trunks passing between the scalene medius and posterior were also noted. The long thoracic nerve was variant in 51 (54.3%) of the plexuses. Unusual relations of the phrenic nerve to scalene muscles and the subclavian vein were encountered. Conclusion: The presence of four trunks and an accessory phrenic nerve passing through the subclavian vein are probably described and reported for the first time. However, most of the variations of the BP among Kenyans are similar to those reported in the other populations

Efficacy and safety of two neutralising monoclonal antibody therapies, sotrovimab and BRII-196 plus BRII-198, for adults hospitalised with COVID-19 (TICO): a randomised controlled trial

BACKGROUND: We aimed to assess the efficacy and safety of two neutralising monoclonal antibody therapies (sotrovimab [Vir Biotechnology and GlaxoSmithKline] and BRII-196 plus BRII-198 [Brii Biosciences]) for adults admitted to hospital for COVID-19 (hereafter referred to as hospitalised) with COVID-19. METHODS: In this multinational, double-blind, randomised, placebo-controlled, clinical trial (Therapeutics for Inpatients with COVID-19 [TICO]), adults (aged ≥18 years) hospitalised with COVID-19 at 43 hospitals in the USA, Denmark, Switzerland, and Poland were recruited. Patients were eligible if they had laboratory-confirmed SARS-CoV-2 infection and COVID-19 symptoms for up to 12 days. Using a web-based application, participants were randomly assigned (2:1:2:1), stratified by trial site pharmacy, to sotrovimab 500 mg, matching placebo for sotrovimab, BRII-196 1000 mg plus BRII-198 1000 mg, or matching placebo for BRII-196 plus BRII-198, in addition to standard of care. Each study product was administered as a single dose given intravenously over 60 min. The concurrent placebo groups were pooled for analyses. The primary outcome was time to sustained clinical recovery, defined as discharge from the hospital to home and remaining at home for 14 consecutive days, up to day 90 after randomisation. Interim futility analyses were based on two seven-category ordinal outcome scales on day 5 that measured pulmonary status and extrapulmonary complications of COVID-19. The safety outcome was a composite of death, serious adverse events, incident organ failure, and serious coinfection up to day 90 after randomisation. Efficacy and safety outcomes were assessed in the modified intention-to-treat population, defined as all patients randomly assigned to treatment who started the study infusion. This study is registered with ClinicalTrials.gov, NCT04501978. FINDINGS: Between Dec 16, 2020, and March 1, 2021, 546 patients were enrolled and randomly assigned to sotrovimab (n=184), BRII-196 plus BRII-198 (n=183), or placebo (n=179), of whom 536 received part or all of their assigned study drug (sotrovimab n=182, BRII-196 plus BRII-198 n=176, or placebo n=178; median age of 60 years [IQR 50-72], 228 [43%] patients were female and 308 [57%] were male). At this point, enrolment was halted on the basis of the interim futility analysis. At day 5, neither the sotrovimab group nor the BRII-196 plus BRII-198 group had significantly higher odds of more favourable outcomes than the placebo group on either the pulmonary scale (adjusted odds ratio sotrovimab 1·07 [95% CI 0·74-1·56]; BRII-196 plus BRII-198 0·98 [95% CI 0·67-1·43]) or the pulmonary-plus complications scale (sotrovimab 1·08 [0·74-1·58]; BRII-196 plus BRII-198 1·00 [0·68-1·46]). By day 90, sustained clinical recovery was seen in 151 (85%) patients in the placebo group compared with 160 (88%) in the sotrovimab group (adjusted rate ratio 1·12 [95% CI 0·91-1·37]) and 155 (88%) in the BRII-196 plus BRII-198 group (1·08 [0·88-1·32]). The composite safety outcome up to day 90 was met by 48 (27%) patients in the placebo group, 42 (23%) in the sotrovimab group, and 45 (26%) in the BRII-196 plus BRII-198 group. 13 (7%) patients in the placebo group, 14 (8%) in the sotrovimab group, and 15 (9%) in the BRII-196 plus BRII-198 group died up to day 90. INTERPRETATION: Neither sotrovimab nor BRII-196 plus BRII-198 showed efficacy for improving clinical outcomes among adults hospitalised with COVID-19. FUNDING: US National Institutes of Health and Operation Warp Speed

Short communication: Does the pattern of innervation of brachialis by the musculocutaneous nerve influence the presence or absence of the radial nerve contribution?

The innervation of brachialis muscle by the musculocutaneous nerve has been described as either type I or type II and the main trunk to this muscle is rarely absent. The contribution by the radial nerve however ranges from 30 to 100%. It is not clear if the presence or patterns of supply to this muscle by either nerve are interdependent. The aim of this study was to determine the pattern of innervation of brachialis by the nusculocutaneous nerve and relate it to the presence and contribution from the radial nerve. Fifty seven arms (25 male and 4 female); 29 right and 28 left from formalin-fixed adult cadavers were used. The pattern of musculocutaneous branch to brachialis was recorded based on the classification by Yang et al. into either type I or II. The presence and number of branches by the radial nerve to the same muscle were determined and related to the pattern from brachialis. The musculocutaneous nerve supplied brachialis in all (100%) of the cases while the radial nerve did so in 33 arms (57.9%). Type I was the predominant pattern in both left and right arms (91.2%) with no correlation between the type of innervation by musculocutaneous nerve and the radial nerve contribution.Keywords: Brachialis, radial nerve, musculocutaneous nerve