Posterior Hip Dislocation with Ipsilateral Femoral Neck Fracture: Case Report

Dislocations of the hip associated with fractures of the neck of femur are rare entities. We report a case of a 23 year old man involved in a road traffic crash and sustained a posterior hip dislocation of the right hip with an associated fracture of the neck of femur. This is a rare case but may occur in high energy injuries. He was managed by bipolar hemiarthroplasty as opposed to total hip athroplasty due to financial constrains. This case highlights the challenge of treatment of posterior hip dislocation in the setting of associated femoral neck fracture, late presentation and resource constraint

Patterns of spine surgeries at Mulago Hospital

Background: Spine surgery is a specialised area of orthopaedics that is still in its formative stages in Africa. It may be done to relieve symptoms, or stabilise the spine to allow rehabilitation of patients. This review analyses spine surgeries done in the period 2005-2009 in a National Referral Hospital. Objectives: Patterns of spine surgeries. Design: A retrospective review of patients who underwent spine surgeries. Setting: Mulago National Referral Hospital, Uganda. Methods: Data was collected from theatre logs and the patient files retrieved for perusal. The data was then analysed. Results: Spine surgeries have been increasing in number over the years with a marked increase in 2009. Male patients were predominantly due to trauma while females were usually due to degenerative causes. Conclusion: Trauma especially that caused by road traffic accidents needs a holistic approach to adequately manage. There is need to facilitate surgeons with training and equipment so that their output may increase. Trauma still predominates as an indication for spine surgery. Outcome may be affected by delays in referral to the spine unit. The spine surgeon is increasingly being called upon to managed degenerative and developmental conditions. East African Orthopaedic JournalVol. 4: March 201

Clinical trials in Surgery

Editoria

Audit of prophylactic antibiotic use in orthopaedic surgery in Mulago Hospital

Background: Prophylactic antibiotics are entrenched in implant orthopaedic surgery. We conducted a study to determine the use of prophylactic antibiotics in clean implant orthopaedic surgery in Mulago hospital.Methods: We prospectively recruited patients undergoing ORIF, Athroplasty and Foot and Ankle surgery. We obtained information on antibiotic use and observed surgeries to determine the timing of administration.Results: Antibiotics were not used in 17.3% of patients and over half of the patients received the antibiotic after the skin incision had been made. The antibiotics were administered about 11 minutes from incision.Conclusion: Majority of patients either did not receive antibiotics or received them after the skin incision had been made. The use of a third generation cephalosporin may be associated with increased complications and drug resistance. Antibiotic prophylaxis is in variance with literature and may result in adverse outcomes

Incidence of early post operative surgical site infection after primary total hip athroplasty in the African setting

Background: Implant orthopaedic surgery is associated with a risk of post operative Surgical Site Infection (SSI). This can have devastating consequences in the case of arthroplasty. Due to the less than ideal circumstances under which surgery is conducted in Africa, there are concerns that the risk of SSI may be high.Objective: To determine the incidence of post operative SSI after primary total hip arthroplasty.Design: A retrospective cohort study.Methods: All primary total hip arthroplasties done from 1998 to 2011 were reviewed. The incidence of infection was determined on follow-up of the patients. The study was approved by the hospital ethics committee.Results: The overall incidence of post operative SSI was 1.5%. Co-morbidities identified were not associated with an increased risk of infection. Increased duration of surgery and increased body weight were also not found to increase the risk of post operative SSI.Conclusion: The risk of post operative SSI after total hip arthroplasties is low in the African setting. Further investigation is recommended to identify modifiable risk factors that may increase the risk of SSI.Key words: Post operative, Surgical site infection, Arthroplasty, Primary total hi

Incidence of Early Post Operative Infection after Primary Total Knee Arthroplasty at an East African Centre

Introduction: Surgical site infections (SSI) may occur after orthopedic surgery and are associated with increased costs, more surgical procedures and death. Various techniques have been developed to reduce this risk. Operation theatres in Africa are not as sophisticated as those in the west and one may expect higher rates of infection after primary Total Knee Replacement Arthroplasties (TKRA). We conducted a study to determine the incidence and risk factors for the development of post operative SSI after primary TKRA at a hospital in Africa over a fourteen year period.Methodology: A retrospective cohort study was conducted of all TKRA patients. The incidence of infection was determined for the first thirty days after surgery. The study was approved by the institution ethics committee.Results: The incidence of early postoperative SSI was 6.49%. We did not identify any risk factors for the development of SSI. Conclusion: There may be an increased risk of early SSI after primary TKRA in our region. Larger studies are needed to identify the modifiable risks factors.Keywords: Total Knee Replacement Arthroplasty, Infection, East Afric

Injury to presentation delays among musculoskeletal trauma patients in Uganda

Background: Injuries are a common cause of morbidity and mortality in the developing world with road traffic crashes being especially prevalent. Kampala has no organised pre hospital rescue service and this causes delays in presentation to hospital with possible adverse outcomes. Objective: The study sought determine the time it took patients to arrive in the hospitals and document the various factors associated with delays in presentation to hospital. Design: Prospective study. Setting: Accident and Emergency Department, Mulago Hospital , Kampala, Uganda Methods: All musculoskeletal injury patients presenting to Mulago Hospital were prospectively enrolled and details of the injury including times of injury and presentation to hospital recorded. Data analysis was done and the Man-Whitney U test and chi square tests used for statistical tests. Results: The median delay in presentation was 3.5 hours. Factors associated with delayed presentation included being managed as an outpatient, having an upper limb injury, being less than 18 years of age and being involved in a road traffic crashes RTC. Conclusion: The delay in presenting to hospital was comparable to other sites in East Africa though significantly longer than in the developed world. The prevalence of traditional bone setters and the lack of an organised pre hospital rescue service may be influencing the delay in presentation to hospital

Clinical Assessment of the Palmaris Longus – Accuracy of common tests

Background: The Palmaris longus is a small vestigial muscle that isused as a tendon graft by surgeons. There are several tests describedto detect the presence of the muscle clinically and there are variableopinions about which test is better. We set out to determine which often common tests brings out the tendon better.Methods: We conducted a prospective study and subjected all participantsto 10 tests to detect the presence of the Palmaris Longus. A negative test on all tests was judged to mean absence of the tendon while a positive result on any test was judged to be positive. Participants provided written informed consent and assent was sought from the next of kin in the case of those aged below 18 years. The study was approved by the hospital ethics board and permission was granted by the school authorities.Results: The Standard test described by Schaeffer was the most accuratewhile the open hand sign described by Bhattacharya was the least accurate.Conclusion: Tests that incorporate wrist flexion, thumb abduction,opposition and finger flexion are best at bringing out the Palmaris tendon.Clinicians should be aware of this as they counsel patients who need tendon grafts. Studies aiming at detecting the presence of the Palmaris longus would be more accurate were they to use these test

Surgeon Administered Regional Anaesthetic Blocks For Hand Surgery In Resource Limited Areas

Introduction: The axillary block was described more than sixty years ago and has since been used in a variety of scenarios. Recently it has been described with the use of ultrasound and nerve stimulators. These facilities are not available in resource limited areas.Methods: We describe the simple, but effective, perivascular axillary block technique we have used for regional anaesthetic blocks for hand surgery. We also undertook a prospective cohort study of all patients undergoing hand surgery under this regional block technique at Mulago Hospital. We abstracted the drug and dosage used, delay in onset of action and  duration of action data for each patient. We excluded patients younger than 12 years. All cases with attempted blocks were included.Results: The success rate of the procedure was 77.8%. The mean delay in onset of action was 20 minutes with an average duration of action of 99 minutes. The commonest drug used was Mepivacaine with a mean dosage of 333.3mg.Discussion and conclusion: This technique is reliable with a high success rate. It has few complications and can be used in areas without ultrasound or nerve stimulators

Blood Loss and Influencing Factors in Primary Total Hip Arthroplasties

Introduction: Orthopaedic surgery results in significant blood loss. There are no studies that can aid the surgeon in the African region estimate the  expected blood loss after total hip replacement. We conducted a study to quantify the blood loss following total hip arthroplasty and to determine the factors associated with this blood loss.  Methods: We conducted a cohort study of primary total hip arthroplasties and estimated the mean blood loss using a predetermined formula.Results: The mean blood loss was estimated to be 4.3g/dl and was  associated with higher pre operative haemoglobin concentration and  increasing duration of surgery. Conclusion: Total hip arthroplasty is associated with high levels of blood loss. The reduction of surgical time and pre operative autologous blood donation may reduce this loss and potentially reduce the need for post operative allogeneic blood transfusion.Key Words: Total hip arthroplasty, Blood loss, Blood transfusio