Aetiological Patterns of Major Limb Amputations and Their Complications in Zaria, Nigeria

Background: Amputation is an unwanted but necessary ablative surgical procedure that is usually carried out as a last resort in an individual whose life is endangered by a disease condition. It is an ancient procedure that dates back to over 2500years during the time of Hippocrates. In the earlydays, the procedure was carried out crudely by removing a limb rapidly from the patient without anaesthesia.Haemostasis was only achieved by dipping the stump in boiling oil or crushing. Surgical amputation has very devastating psychological, social as well as economic effects on the patient and the family. It also has a downturn play on the economy of the society as most of the victims are the young and middle aged individuals who constitute the major work force in the community.Materials and Methods: Case records of all patients at Ahmadu Bello University teaching hospital who had amputation were retrospectively reviewed over five years. The period studied was between 2009 and 2013. The demographic data of the patients, the etiological factorsleading to the amputation, degree of tissue damage, level of amputation, the length of amputation stump and complications were studied. These complications include infection, flap necrosis, wound dehiscence and anemia.Patients included in the study were those that had majorlimb amputation and have traceable records and had a minimum follow up of one year.Results: One hundred and nineteen patients had major limb amputation. Eighty-one of them (68%) were males and 38 (31.9%), females with M:F = 2.1:1. Mean age of the patients was 35.99( 21.8) years. Seventy-nine (66.4%) of the patients were below the age of 40years and 40 (38.6%), above40years of age. The commonest indication for amputation was post traditional Bonesetter gangrene of the limb (31.1%) followed by Diabetic foot gangrene (24.4%) and crush injury (11.8%). There were more lower limb amputations (81.7%)than upper limb amputations (18.3%). Postoperative stump wound infection was the commonest complication (26.1% of total and 44.9% of all complications) followed by anemia. There were 3(2.5%) records of mortuary.Conclusion: Traditional bone setters' (TBS) gangrene and Diabetic foot gangrene were the commonest indications for major limb amputations in our center. Most of the amputations could have been most likely avoided if the patients with trauma presented to the hospital directly wheresalvage measures would have been implemented, and diabetic foot gangrene would be prevented by close observation and institution of preventive measures. Adequate attention paid to predisposing factors will go a long way to reduce the indications for as well as the complicationsof amputation

Management of civilian gunshot injuries to the extremities in Nigeria-an overview

There is an increasing incidence of missile injury attributable to improved technology, and increased crime and conflict rates in both developing and developed nations of the world. We undertook a review of civilian gunshot injuries to the extremities in Nigeria. The pathology of these injuries aswell as their implications for management are presented. The peculiar challenges they present to the orthopaedic surgeons in the management of gunshot injuries in a resource depleted country are highlighted. Community based socially and culturally acceptable conflict resolution mechanisms,control of fire arms and revision of the treatment guidelines are recommended as preventive and management strategies of gunshot injuries in Nigeria

Trauma intensive care in a terror-ravaged, resource-constrained setting: Are we prepared for the emerging challenge?

Introduction: Trauma in developing countries has been on the increase, a situation perpetuated by rising road traffic collisions, terrorism and firearms proliferation. Some of the victims of trauma are left with life threatening conditions requiring urgent surgical intervention and/or intensive care. The objectives of this study were to determine the pattern of major trauma needing intensive care in the region, and to determine the outcome of major trauma admitted to intensive care unit. Methods: A six-year retrospective cohort study of trauma patients needing intensive care, set in the Intensive Care Unit of Ahmadu Bello University Teaching Hospital, Zaria, North-West Nigeria. Subjects were major trauma patients admitted into the intensive care unit of the institution, identified via an admission register kept in the unit. The main outcomes measured were length of stay and mortality. Results: Trauma admissions represented 25.1% of the all intensive care admissions. Severe traumatic brain injury accounted for 32.1% of the trauma admissions, while burns accounted for 23.2%. Of the injuries, 15.5% were sustained in bomb blasts, and 8.3% were firearm injuries. The majority of the patients stayed for no more than seven days from admission. Burns patients had the worst outcomes, with 82.1% mortality. Conclusion: Major trauma contributes significantly to local intensive care admissions, with terrorism- related trauma now an emerging challenging cause of major trauma in our region. The observed poor outcomes in this study are a reflection of the quality of available intensive care, and lends credence to the concept of appropriately resourced, specialised intensive care units for optimisation of care. Keywords: Trauma admissions, Intensive care, Terrorism, Outcom

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

Primary Total Knee Replacement in a Patient with failed High Tibial Corrective Osteotomy: A Case Report

Background: Cases of elderly patients presenting with nonunion following high tibial osteotomy for genu vaum are now very rare. This is because corrective osteotomy around the knee in middle age and elderly has lost its importance over the years due to successes of total knee replacement.For the very few that present, several options of treatment, such as revision plating, intramedullary nailing or illizarov compression osteosynthesis exist. These are however not without limitations such as the need for prolong immobilization, development of joint stiffness, soft tissue contractures, recurrent nonunion and subsequent worsening of osteoarthritis of the adjacent joint (knee). We report primary total knee arthroplasty in a patient presenting with nonunion following failed high tibial osteotomy, using diaphyseal engaging stem (DES) in form of tibia extension rod. To the best of our knowledge we have not come across similar report in the country.Method: K.S is sixty two year old woman who presented with inability to walk. Prior to her presentation, she underwent high tibial corrective osteotomy for medial unicompartmental osteoarthritis of the right knee 3 years ago. She developed nonunion necessitating revision surgery (replating) a year and 7 month after first operation (2016), which resulted in nonunion again. Diagnosis of Post Osteotomy High Tibial Nonunion with bone loss was made. She was optimized and underwent total knee replacement with tibia extension rod.Result: She was able to mobilize on the 7th day post operative with the aid of walking frame and was discharged on the 14th day. At 11 month follow up, she mobilises comfortably and pain-free without aid with radiological union at fracture site.Conclusion: Semi constrained Total Knee Replacement with extension rod may be an option for treating failed high tibial corrective osteotomy coexisting with moderate to severe ipsilateral knee osteoarthritis. Keywords: Total Knee Arthroplasty, Tibial Extension Rod, Failed High Tibial Osteotomy

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