Segmental endoprosthesis replacement in a resource-constrained setting

PURPOSE

Indications for the use of endoprosthesis have continued to expand over the years, especially as an alternative to ablative surgery. This mode of treatment which was initially limited to orthopaedic oncology is now being applied in complex trauma with significant bone loss and end-stage arthroplasty. However, use of endoprosthesis in a resource-constrained setting such as sub-Saharan Africa is limited by various factors. These factors include high cost of endoprosthesis, restricted availability of appropriate equipment and the requisite trained specialists in the field.

METHODS

Twelve patients who had segmental endoprosthetic replacement for various aetiologies were studied in this case series. Resection lengths, complications and functional outcomes were noted.

RESULTS

The resection length varied between 12 and 27 cm. Using the Henderson classification system, one patient (8.3%) had a Type 1A complication, one had a Type 3A complication (8.3%), and two patients had Type 4A complications (16.6%). Functional outcomes were graded using the MusculoSkeletal Tumour Society scoring system, and scores were good to excellent in ten patients, moderate in one and poor in one patient.

CONCLUSION

Early results indicate fair outcomes; however, factors limiting the use of endoprosthesis still persist. These include high cost of endoprosthesis, restricted availability of appropriate equipment and the requisite trained specialists in the field.

Femoral bone growth after extendible endoprosthetic replacement of the proximal tibia in skeletally immature patients

There is increasing preference for limb salvage techniques in the management of pediatric musculo- skeletal tumors. This study was aimed at evaluating femoral growth following proximal tibia resection (PTR) and placement of an extendible endoprosthesis with sliding stem. This was a retrospective study. The demographic and clinical data were collected. All the patients with malignant tumors were fully staged and commenced on appropriate chemotherapy. An expected discrepancy of > 3cm was considered sub- stantial enough to warrant extendible prosthesis. Twelve patients who had follow up full length scanogram of the lower limbs were included for the evaluation of femoral growth. The last available scanograms were used for growth comparison of the femur. The age at resection for all twelve patients ranged from 4-13 years. The commonest histological diagnosis was Osteosarcoma. In the twelve patients assessed for the growth of femur, the mean femoral length was 96% [89%-102%] of the unaffected femur. Distal femoral physeal growth continued after im- plantation of a sliding extendible prosthesis after resection of proximal tibia tumors.

Life or limb: an international qualitative study on decision making in sarcoma surgery during the COVID-19 pandemic

OBJECTIVES

The COVID-19 pandemic is unprecedented as a global crisis over the last century. How do specialist surgeons make decisions about patient care in these unprecedent times?

DESIGN

Between April and May 2020, we conducted an international qualitative study. Sarcoma surgeons from diverse global settings participated in 60 min interviews exploring surgical decision making during COVID-19. Interview data were analysed using an inductive thematic analysis approach.

SETTING

Participants represented public and private hospitals in 14 countries, in different phases of the first wave of the pandemic: Australia, Argentina, Canada, India, Italy, Japan, Nigeria, Singapore, Spain, South Africa, Switzerland, Turkey, UK and USA.

PARTICIPANTS

From 22 invited sarcoma surgeons, 18 surgeons participated. Participants had an average of 19 years experience as a sarcoma surgeon.

RESULTS

17/18 participants described a decision they had made about patient care since the start of the pandemic that was unique to them, that is, without precedence. Common to 'unique' decisions about patient care was uncertainty about what was going on and what would happen in the future (theme 1: the context of uncertainty), the impact of the pandemic on resources or threat of the pandemic to overwhelm resources (theme 2: limited resources), perceived increased risk to self (theme 3: duty of care) and least-worst decision making, in which none of the options were perceived as ideal and participants settled on the least-worst option at that point in time (theme 4: least-worst decision making).

CONCLUSIONS

In the context of rapidly changing standards of justice and beneficence in patient care, traditional decision-making frameworks may no longer apply. Based on the experiences of surgeons in this study, we describe a framework of least-worst decision making. This framework gives rise to actionable strategies that can support decision making in sarcoma and other specialised fields of surgery, both during the current crisis and beyond.

Femoral bone growth after extendible endoprosthetic replacement of the proximal tibia in skeletally immature patients

There is increasing preference for limb salvage techniques in the management of pediatric musculo- skeletal tumors. This study was aimed at evaluating femoral growth following proximal tibia resection (PTR) and placement of an extendible endoprosthesis with sliding stem. This was a retrospective study. The demographic and clinical data were collected. All the patients with malignant tumors were fully staged and commenced on appropriate chemotherapy. An expected discrepancy of > 3cm was considered substantial enough to warrant extendible prosthesis. Twelve patients who had follow up full length scanogram of the lower limbs were included for the evaluation of femoral growth. The last available scanograms were used for growth comparison of the femur. The age at resection for all twelve patients ranged from 4-13 years. The commonest histological diagnosis was Osteosarcoma. In the twelve patients assessed for the growth of femur, the mean femoral length was 96% [89%-102%] of the unaffected femur. Distal femoral physeal growth continued after implantation of a sliding extendible prosthesis after resection of proximal tibia tumors.

Spinal Malignant Peripheral Nerve Sheath Tumours in Nigerians

BACKGROUND

Spinal Malignant peripheral nerve sheath tumours (MPNSTs) are very rare aggressive tumours with poor prognosis. Little is known about these tumours in sub-saharan Africa.

OBJECTIVES

This study aims to evaluate the clinical profile and outcome of management of these tumours in a resource limited country.

METHODS

We retrospectively analysed data from the records of patients who had surgery for spinal MPNSTs at our center between January 2004 and December 2018.

RESULTS

There were four patients in this study (M:F= 1:1). The ages ranged from 27-53 years with a mean of 43.25 ± 11.84 years. The tumour was located in the thoracic region in 2 of the patients (50%), the lumbar region in one (25%) and thoracolumbar in the 4th patient. Three patients (75%) presented with back pain while limb weakness, sensory deficit and sphincteric dysfunction were present in all patients at presentation. The duration of symptoms were 2 months in 2 patients (50%) and 3 months in the other 2. None of the patients had neurofibromatosis. Gross total tumour excision was achieved in 2 patients (50%) and subtotal resection in the other 2. The tumours were high grade in three patients (75%) and low grade in one. Two patients had adjuvant radiotherapy. Two of the patients were dead within 6 months of the diagnosis, another one within 18 months while one patient is still alive 3 years after.

CONCLUSIONS

MPNSTs are very rare in our practice. Most of the tumours were high grade tumours and ran an aggressive course.

Tumor Necrosis Factor-Alpha and Interleukin-1 Alpha as Predictors of Survival in Peritonitis: A Pilot Study

Context:

Peritonitis induces an inflammatory response characterized by the elevation of various cytokine levels. Included in this cascade of cytokines are tumor necrosis factor-alpha (TNF-α) and interleukin-1 alpha (IL-1α). The outcome of patient care may be associated with the pattern of elaboration of these cytokines.

Aim:

The aim of this study was to describe the pattern of cytokine response (TNF-α and IL-1α) in the course of peritonitis and evaluate them as predictors of mortality in peritonitis.

Setting and Design:

This was a prospective study conducted in the Division of Gastrointestinal Surgery, University College Hospital, Ibadan.

Methods:

Consenting patients with clinical diagnosis of generalized peritonitis over a 6-month period (July to December 2015) were recruited. The serum samples of these patients were obtained at presentation, immediately after surgery, and 24 h and 48 h after surgery with a follow-up period of 30 days.

Results:

Twenty-six samples out of thirty could be analyzed. Serum TNF-α and IL-1α levels were both elevated at presentation in all patients. However, the patterns of change after intervention varied between the survivors and nonsurvivors.

Conclusion:

Peritonitis triggers a simultaneous increase in serum levels of TNFα and IL-1α. Lower serum level of TNF-α is associated with survival, while on the contrary, higher level of IL-1α is associated with survival.

Endoprosthetic replacement of distal femoral tumors in Nigeria: A case series

In this observational study, three consecutive patients who were treated for distal femur tumours using endoprosthetic replacement between June 2013 and June 2014 were studied. The patients were within the ages of 28-47 years at the time of surgery. All three patients had modular endoprosthesis fixation and were evaluated using the Musculoskeletal Tumour Society (MSTS) Scoring System. Numerical values from 0 to 5 points were assigned for each of the following 6 categories: pain, function, emotional acceptance, use of supports, walking ability and gait. These values were added and the functional score was presented as a percentage of the maximum possible score. The results for each patient were graded according to the following scale: Excellent - 75-100%; good - 70-74%; moderate - 60-69%; fair - 50-59% and poor - <50%. Of the 3 patients evaluated, 2 had a diagnosis of Giant Cell Tumour (GCT) of the distal femur; the third patient was diagnosed to have plasmacytoma. All underwent wide local resection with modular endoprosthetic distal femur reconstruction. The MSTS functional scores calculated were 70%, 78%, and 52% respectively. Complications noted included wound dehiscence in two patients and thrombosis of the Pulmonary artery needing an arterial embolectomy in one of these two patients. The same patient also had a post-operative loss of motor and sensory function below the level of the ankle.

Comparison of postoperative pain in diathermy and conventional scalpel Skin incision after mastectomy in Ibadan, Nigeria

INTRODUCTION

Pain control is a challenge after surgery. Inadequate control of acute postoperative pain in mastectomy patients may lead to chronic post mastectomy pain syndrome. The study aimed to compare the effect of diathermy incision with scalpel incision on the severity of acute postoperative pain after mastectomy.

METHOD

Sixty three females had mastectomy under general anaesthesia. Thirty two patients had skin incisions made with scalpel while 31 patients with diathermy. Both groups received intraoperative Fentanyl and Tramadol. Tramadol was also employed as postoperative analgesic while Paracetamol was given as the rescue analgesic. The outcome measures were pain scores using visual analogue score (VAS) and analgesic consumption within the twenty four hours postoperatively.

RESULTS

The mean VAS in the diathermy group versus scalpel group at 6th, 12, 18th and 24th hour post operatively were 11.84 +/- 6.15 mm versus 16.18 +/- 8.5 mm (p=0.001), 11.10 +/- 4.26 mm versus 15.84 +/- 5.12 mm (p=0.001), 11.07 +/- 4.15 mm versus 17.32 +/- 6.01 mm (p=0.001), 10.6 +/- 8.08 mm versus 19.19 +/- 8.7 mm (p = 0.001) respectively. The mean dose of Tramadol was 264 +/- 84 mg in the diathermy group versus 278 +/- 64 mg in the scalpel group p=0.189, three patients required rescue analgesic (paracetamol) in the diathermy group mean dose 1.5.7 +/- 0.54 g versus 7 patients in the scalpel group, mean dose 1.67 +/- 0.58 g p=0.75.

CONCLUSION

Diathermy can contribute to reduction in the acute postoperative pain in patients undergoing mastectomy.

Routine repeat radiographic examination post fracture fixation: is it necessary?

In spite of the widespread availability of image intensifier for fracture fixation and storage of images on a radiological computer system, routine check radiography is still a common practice. This is even so in situations with no clear indications such as fall or increasing patients' discomfort.

Surgical consideration for benign bone tumors

BACKGROUND

The surgical management of symptomatic benign bone tumor has been described in various manners in medical literature. However, there are few published reports on the presentation and surgical management of benign bone tumors in black African patients.

OBJECTIVES

To determine the pattern of presentation of benign bone tumors and evaluate the common indications for surgery in a Nigerian Orthopedic Center.

MATERIALS AND METHODS

This is a prospective study of 67 patients, surgically treated for benign bone tumors, over a three-year period, at the National Orthopedic Hospital, Lagos, Nigeria.

RESULTS

The common histological types include, osteochondroma, giant cell tumor, and the simple bone cyst. These tumors have varying anatomic locations, but are more commonly located around the knee joint. In this series, most of the patients have presented with an active or aggressive stage of the disease. The most common indication for surgery is painful swelling; other indications include a pathological fracture, restricted range of movement, and peripheral nerve compression. The surgical procedures performed are simple excision, curettage, and stabilization; and 1-stage and 2-stage wide resection with reconstruction. Patients with significant bone defects have autologous bone grafting or methylmethacrylate cement application. Further stabilization is achieved with intramedullary or compression plate and screw fixation. Amputation has only been necessary in one patient with a huge aneurysmal bone cyst. At the average follow-up period of 28.6 months, five patients showed recurrence. All were with a histological diagnosis of giant cell tumor.

CONCLUSIONS

The mode of presentation of benign bone tumors in this group of black African patients is heterogenous, demanding various surgical options. Limb sparing is a largely feasible option, but the recurrence rate is particularly higher for giant cell tumors. Increase in the number of patients presenting with giant cell tumors raises the possibility of an increase in the incidence of this condition in the black African population. Larger multicenter studies in the black African population may shed more light on the actual incidence of giant cell tumors and other bone tumors in this group of patients.

Risk factors for pressure ulceration in a resource constrained spinal injury service

STUDY DESIGN

Pressure ulceration and other complications constitute an encumbrance in the management of spinal cord injury in many services with limited resources in developing countries. These services undertake patients' care without adequate prehospital care, limited modern infrastructure and limited number of trained staff.

OBJECTIVES

To evaluate the associated risk factors for pressure ulceration in traumatic spinal cord injured managed in a resource constrained spinal injury unit in Lagos, Nigeria. A regional acute trauma and rehabilitation centre serving a population of >20 million.

METHODS

This is a prospective study in patients presenting with traumatic spinal cord injury between 1 October 2004 and 30 November 2006. The data collected include demographic characteristics, interval before admission in the unit, type of spinal cord injury and serum albumin. The incidence of pressure ulcers and the isolated organisms was recorded for patients who developed pressure ulcers on admission and during the period of stay in the unit. The length of hospital stay was also recorded for all the patients.

RESULTS

The overall incidence of pressure ulceration on admission was 57.1%. There was an average lengthening of hospital stay of 33.1 days in the group of patients with pressure ulceration compared to patients without pressure ulcers. The nutritional status on admission, interval before admission and the type of neurological injury were significant factors for the incidence of pressure ulcers.

CONCLUSION

The incidence of pressure ulceration was high, delay in admission and poor nutritional status may be significant factors in the incidence of pressure ulceration in spinal cord injury.