East African Orthopaedic Journal

Sciatic nerve variations around the piriformis muscle and bifurcation level: An anatomical study

S. Habumuremyi — 2024-11-08

Background: The ventral rami from the fourth lumbar to the third sacral spinal nerves form the Sciatic Nerve (SN). SN exits the pelvis through the greater sciatic foramen at the inferior border of the Piriformis Muscle (PM), and then it bifurcates into the common fibular and tibial nerves in the popliteal fossa, however it may present different patterns.

Objectives: To identify the SN relation to the PM and the level of bifurcation.

Method: Twenty-two lower limbs were dissected to expose the SNs, then the SN position to the PM were studied, and then the levels of the SN bifurcation from the inferior border of the PM were measured and compared to the thigh lengths.

Results: SN patterns to PM were as follows: 4% were type B in which one component of the SN passed under the PM, while the other component passed through the piriformis muscle. Twenty three percent were type G in which the divided SN components pass under the PM, and 73% were type A in which the undivided SN passed under the PM. SN bifurcated at the following levels: 18% in pelvic region, 14% in the upper 1/3 of the thigh, and 4% in the middle 1/3 of the thigh. Two SN (9%) showed different patterns where one bifurcated in the pelvis, reunited in mid-thigh, and bifurcated again in the inferior 1/3 of the thigh. Another one bifurcated in the gluteal region at the inferior edge of the piriformis muscle, reunited in upper one third of the thigh, and then bifurcated again in popliteal fossae. The remaining 12 (55%) SN bifurcated in the popliteal fossae.

Conclusion: Knowledge of the variants of the SN is needed for the accuracy and the safety of the procedures in this area.

Orthopaedic surgical treatment waiting time for acute musculoskeletal trauma patients attended at Muhimbili Orthopaedic Institute, Dar-Es-Salaam

E. Godfrey — 2024-11-08

Background: Waiting time for acute musculoskeletal trauma surgery has been used as a measure of institutional efficiency. Delay in operating on trauma patients leads to increased morbidity, mortality and reports have shown negative impacts and additional costs for the hospitals besides inconvenience to patients and their families.

Objectives: To determine the extent and causes of delay of orthopaedic surgical treatment among acute musculoskeletal trauma patients at Muhimbili Orthopaedic Institute.

Methods: A cross- sectional study on two hundred and eighty patients who met the inclusion criteria. Modified Lankester tool was used to assess the patients from the emergency department and classified into A or B according to the urgency of their surgery. Data was analysed using predictors of surgical delay beyond 24 hours were identified by logistic regression analysis.

Results: The mean age of these trauma patients was 28±15 years of whom a large proportion (79.6%) were male. Lankester group A accounted for 77.5% of the patients recruited. The mean waiting time for orthopaedic surgery for Lankester A and B respectively was 9±5 and 12±6 hours whereby 65.4% of Lankester group A and 9.5% of Lankester B had missed their optimal target time.

Conclusion: Only about a third (34.6%) of emergency patients were operated in less than 6 hours after admission. The most common cause of this delay was lack of theatre slots while the presence of comorbidities predicted delay of more than 24 hours.

Recommendations: There should be more theatres allocated for emergency surgeries and there should be a physician present in the emergency on-call team to manage the co-morbid conditions to reduce their waiting time.

Indications and early outcome of total hip arthroplasty in young adults at Muhimbili Orthopaedic Institute, Tanzania

D.P. Ngunyale — 2024-11-08

Background: Total hip arthroplasty is an effective surgical procedure in patients with advanced hip pathologies. The newer techniques, implants and improved functional outcomes have increased demand for the procedure in young adults. The indications for primary and revision total hip arthroplasty, early outcome and its associated risk factors in young adults are not well known at Muhimbili Orthopaedic institute.

Objectives: To determine the indications, early outcome and associated risk factors for total hip arthroplasty among young adults operated at Muhimbili Orthopaedic Institute.

Methods: A descriptive retrospective cross-sectional study, involving 341 patients who underwent total hip arthroplasty. Data was retrieved from total joint registry, verified from patient’s files and hospital management information system and analyzed using Statistical Package for Social Sciences version 20.

Results: A total of 341 patients were enrolled in the study, with a mean age of 40 ± 12 years with a slight male predominance of 54.4%. The leading indication for primary total hip arthroplasty was osteoarthritis (48.2%). Other indications included avascular necrosis (27.2%), femoral neck fracture (14.4%), neglected dislocation (4.9%), acetabular fracture (3.3%) and developmental dysplasia of the hip (1%). In majority (85.6%) of patients the implant of choice was uncemented, whilst the hybrid was used in 9.2% and cemented implants in 4.3% of the patients. Thirty six patients (10.6%) had early complications including hip dislocation (5.3%), aseptic loosening (2.1%), peri-prosthetic fracture (1.2%), implant malposition (1.2%) and surgical site infection (0.9%). The reoperation rate within one year was 6.2%.

Conclusion: Total hip arthroplasty is becoming increasingly common among young adults. Osteoarthritis is the leading indication for primary total hip replacement. Early complications within one year included hip dislocation, aseptic loosening, periprosthetic fracture, implant malposition and surgical site infection. The risk factors for reoperations within one year were associated with advanced age and male gender.

External fixation followed by cast immobilization in the management of gustilo-anderson iiia and iiib open tibial fractures

I.N. Nze — 2024-11-08

Background: The ideal method for definitive management of open tibia fractures has been a subject of debate. Several techniques have been tried with mixed results.

Objectives: To describe and present our experience using external fixator interrupted by cast immobilization in the management of Gustillo-Anderson IIIA and IIIB open tibia fractures guided by the radiographic union scale of tibia fractures.

Methods: Patients with Gustillo-Anderson IIIA and IIIB tibia fractures admitted into Nnamdi Azikiwe University Teaching Hospital had debridement and stabilization with external fixators. Subsequently, fracture healing was monitored with radiographs while wounds were cared for with dressings. At Radiographic Union Scale for Tibial Fractures (RUST) score of 4, external fixators were taken down and above knee plaster of Paris cast applied. Partial weight bearing was commenced at RUST 6 (cast still in place). Cast was removed at RUST 11 and full weight bearing commenced at RUST 12. Outcome of this method was assessed.

Results: Gustillo-Anderson IIIA accounted for 43.1% while IIIB accounted for 56.9%. Mean presentationintervention interval was 41.5 hours ±3.3. Mean time to partial weight bearing was 14.2 weeks ±1.8 (GA IIIA) and 15.6 weeks ±2.6 (GA IIIB). Mean duration on cast was 12.4 weeks (GA IIIA) and 17.5 weeks (GA IIIB). Union occurred at a mean time of 29.9 weeks (GA IIIA) and 35.6 weeks (GA IIIB). Polymicrobes were seen in both classes. Non union rate was 17.6%.

Conclusions: Management of open tibia fractures with external fixator and conversion to cast immobilization results in good healing. Presentation-intervention interval of close to 48 hours does not significantly affect pin tract infection rates. RUST is a useful guide for safe graduation of patients with tibia fractures across the stages of treatment rehabilitation.

Factors associated with favourable short-term non-operative treatment outcomes among patients with degenerative cervical spine disease at Muhimbili Orthopaedic Institute

M.C. Mutagwaba — 2024-11-08

Background: Non-operative treatment of cervical degenerative spine disease involves pharmacotherapy and physical therapy. Favorable Short-term treatment outcomes include pain reduction and sensory-motor recovery, with an eventual return to normal daily activities as a longterm outcome. Several factors have been attributed to early pain relief and sensorimotor recovery; these include early diagnosis and combined therapy.

Objective: This prospective study was carried out from June to December 2022 and was carried out to determine factors associated with favourable short-term treatment outcomes among patients with degenerative cervical spine disease treated non-operatively at Muhimbili Orthopaedics Institute (MOI).

Methods: This prospective study involved 78 individuals diagnosed with chronic degenerative cervical spine disease, undergoing six weeks of non-operative treatment. Patient data, including gender, age, occupation, and symptoms, were collected via a questionnaire. Disease severity and treatment outcome were assessed using the Copenhagen Neck Functional Disability Scale (CNFDS) and the modified Japanese Orthopaedic Association scale (mJOA).

Results: Out of 78 patients, most were female (71.79%) and over 60 years old. Axial neck pain and radiculopathy were common clinical presentations, with moderate severity at presentation predominating. Combined therapy was frequently used and showed better pain reduction than pharmacotherapy alone (p = 0.002) also initial disease severity significantly influenced pain reduction (p = 0.02).

Conclusion: The study findings indicate that non-surgical treatments at MOI can notably alleviate initial pain in degenerative cervical spine disease patients, with initial severity significantly influencing short-term outcomes. However, sensorimotor improvements from non-operative methods were insufficient, warranting additional research for validation.

A comparison of MRI and arthroscopic findings of intraarticular soft tissue injury of the knee at Kenyatta National Hospital, Kenya

M. Abdullahi — 2024-11-08

Background: Musculoskeletal system disorders rank as the second most common cause of disability universally contributing to 169,264,000 Disability-Adjusted Life Years (DALYs). The knee joint is particularly susceptible to injury especially of the ligaments and menisci. A comparison between MRI and arthroscopic findings will help determine the reliability of MRI reports in knee injury patients and guide their management in our setting.

Objective: To compare the MRI and arthroscopic findings of patients with intra-articular soft tissue injury of the knee at Kenyatta National Hospital, Kenya.

Methodology: This was a retrospective cross-sectional study from January 1st 2018 to December 31st 2022. Seventy two participants were recruited for the study and the nature of injuries on MRI and at arthroscopy were analyzed.

Results: MRI had a sensitivity of 83.8%, 87.5%, 100% and 50% for medial meniscal, lateral meniscal, ACL and PCL tears respectively. It had a specificity of 77.1%, 85%, 96.6% and 98.5% for the same. Accuracy was highest for ACL injury detection by MRI (97.2%), followed by PCL injury detection (95.8%), and lateral meniscal tear detection (86.1%). The accuracy of MRI was lowest for medial meniscal injury detection (80.5%).

Conclusion: Overall, MRI and arthroscopy have comparable diagnostic effectiveness for detecting intra-articular soft tissue injuries of the cruciate ligaments as well as high sensitivity, specificity, and accuracy for detecting medial and lateral meniscal tears. These findings suggest that MRI is a useful diagnostic tool in the evaluation of knee injuries and should be carried out in patients presenting with intra-articular soft tissue injuries of the knee.

Levels of evidence of therapeutic studies published in the East African Orthopaedic Journal

K.C. Lakati — 2024-11-08

Background: The East African Orthopaedic Journal has published clinical scientific papers since 2007.

Objective: This study aimed to assess the levels of evidence of therapeutic studies published in the journal by using the Journal of Bone and Joint Surgery-American (JBJS-Am) level-of-evidence rating system.

Methods: All clinical therapeutic studies published in the journal from 2007 to 2023 were reviewed. Historical notes, editorials, cadaveric studies, case reports and literature reviews were excluded. Therapeutic studies were rated according to the JBJS-Am Level of Evidence (LOE) grading system as Level I, II, III, IV, or V.

Results: A total of 218 original studies were published in the journal, out of which 65 were therapeutic studies, representing 30% of the published papers. Level IV studies were the most predominant representing 69% of the therapeutic studies and 21% of the studies published. Level II studies represented 20% of the therapeutic studies and 6% of studies published. Levels 1 and III studies were the least predominant, both accounting for 5% and 6% respectively of the therapeutic studies and 1.4% and 1.8% of all the studies respectively. Level IV studies predominated over the years with little improvement in Level I, II and III studies.

Conclusion: Most studies published in the East African Orthopaedic Journal are Level IV studies. There has been no significant increase in Level I and II studies since inception of the journal.

Closed reduction of a hip dislocation following total femoral replacement using a traction table: A case report

K. Ekwe — 2024-11-08

Hip dislocations are relatively common complications following arthroplasties. In majority of cases closed reduction is the first option for treating this significant complication. Regular reduction techniques place a great strain on the surgeon physically and also significant strain on the implants. We present an easier option for closed reduction with traction table under image guidance that may be useful in difficult cases. A 72 year old, obese lady presented with an infected distal femoral replacement and had a total femoral replacement. This was done in two stages 12 weeks apart. An unconstrained liner was used. She suffered recurrent hip dislocations (4 episodes) afterwards within 5 months of the surgery. Each episode was reduced successfully by closed reduction using a traction table under C arm guidance. With physiotherapy and better patient education she is currently community ambulant with a walking stick and has not dislocated in the last 27 months. Reduction of hip dislocation especially following an arthroplasty or femoral replacement can be effected successfully using a traction table. This can be one of the options for closed reduction of dislocation following arthroplasty.

The future of orthopaedic training in Kenya

P.K. Oroko — 2024-11-08

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