Background: The suprascapular nerve, derived from the upper trunk of the brachial plexus passes through the suprascapular notch into the supraspinous fossa where it supplies the supraspinatus and then through the spinoglenoid notch to gain entry into the infraspinous fossa where it innervates the infraspinatus muscle. The nerve may be compressed at either of these two notches or injured in operations around the shoulder. Knowledge of the location of the nerve in these notches in relation to fixed bony landmarks around the shoulder is important in avoiding iatrogenic injury to the nerve or to locate it for release when it is compressed or for anaesthetic blockade. Objective: To determine the distances between the suprascapular and spinoglenoid notches and fixed bony landmarks in the shoulder i.e the acromion, the supraglenoid tubercle, the posterior edge of the glenoid rim and the tip of the coracoid process. Methods: The distances were measured using digital vernier callipers on dried unpaired adult scapulae that were grossly not deformed. The mean, minimum, maximum and standard deviation of the measurements was obtained. Results: Average distance to the suprascapular notch from the supraglenoid tubercle, anterolateral edge of the acromion and the tip of the coracoid process were 31.2mm, 65.6mm and 45.7mm respectively. Average distance to the spinoglenoid from the posterior glenoid rim was 16.3mm. Conclusion: Comparison with other populations shows variability in these distances. In order not to imperil the suprascapular nerve in the suprascapular incisure, a safe distance of less than 25.5mm from the supraglenoid tubercle should be observed. In the spinoglenoid notch, a safe distance of less than 13.1mm from the edge of the posterior glenoid rim should be maintained. Keywords: Suprascapular nerve, Suprascapular notch, Spinoglenoid notch, Acromion, Coracoid process

Background: Numerous studies have demonstrated that graduated compression therapy (GCT) is efficacious in the management of venous disorders, as well as in the prevention of venous thromboembolism (VTE). This study aimed to delineate GCT usage by surgeons in the region served by the College of Surgeons of East Central and Southern Africa (COSECSA). Methods: We conducted a cross-sectional study among surgeons attending the 17th COSECSA Annual Scientific Conference in Mombasa, Kenya, between 7 and 10 December 2016. Only surgeons practising in the COSECSA region were included. Participation was voluntary, and those who consented were asked to complete a pretested questionnaire. Results: Ninety-four surgeons of various specialities submitted complete questionnaires. General and orthopaedic surgeons (48% and 30% of respondents, respectively) saw the most patients with venous disorders and patients at risk of VTE. Considering the mean number of patients seen, respondents prescribed GCT infrequently. Orthopaedic surgeons were the least likely to report having prescribed GCT for patients who might have benefited from such therapy, only doing so 15% of the time. The commonest indications for GCT prescription were varicose veins and VTE prophylaxis. The most commonly reported challenge was availability. No respondent reported experience with serious adverse events associated with GCT, such as limb ischaemia or nerve injury. A majority of the surgeons (58%) reported that GCT is effective for the prevention of VTE as well as the treatment of various venous disorders. Conclusions: GCT is widely accepted as a useful tool in the prevention of VTE and management of various venous disorders among surgeons in the COSECSA region. However, GCT usage is low, owing to challenges such as availability. Keywords: graduated compression therapy; compression stockings; venous insufficiency; venous thromboembolism; deep vein thrombosis; varicose veins; Africa

Background : The coracoid process is widely used as a graft in patients with recurrent anterior shoulder instability with significant glenoid bone defects. However, no local studies have determined the coracoid dimensions and correlated them to the glenoid dimensions. Objective : To measure the widest anteroposterior (AP) diameter of the glenoid cavity, the length, width and thickness of the coracoid process, compare these with other populations, determine the amount of coverage the thickness and width of the coracoid process can afford in case of bony glenoid deficiency and the adequacy of the coracoid process to safely accommodate fixation screws used in the Latarjet and congruent-arc Latarjet procedures. Methods : The dimensions were measured using digital vernier callipers on dried scapulae that were not deformed. The ratio between coracoid thickness and width to the glenoid AP diameter was determined as the percentage cover that particular dimension can provide to the deficient glenoid. Results : A total of 26 scapulae were obtained. Average AP diameter and height of the glenoid was 25.1mm and 36.2mm respectively. Average coracoid length, width and thickness was 22.3mm, 13.3mm and 7.7mm respectively. There was no significant difference between the right and left sides in all the dimensions. The average coverage provided by the coracoid thickness (Latarjet procedure) was 30% with coracoid width providing average coverage of 50% (congruent-arc Latarjet procedure). The coracoid width could safely accommodate the 3.5mm and 4.5mm screws while coracoid thickness offered a very thin margin round the screws. Conclusion : The coracoid process can cover glenoid defects of between 30% and 50% and while it may safely accommodate the 3.5mm and 4.5mm screws if oriented for the classic Latarjet operation, care is needed especially if the congruent-arc Latarjet is planned as coracoid thickness may not be adequate to accommodate the fixation screws. Keywords : Coracoid process, Glenoid, Latarjet, Congruent-arc Latarjet

Background : Numerous orthopaedic procedures are carried out on the proximal femur. For optimal hip function, these procedures must restore the anatomy of the proximal femur to as near normal as possible. There are currently no local studies that have described in detail the normal anatomy of the proximal femur and its implications in operations on the proximal femur. Objective : The aim of this study was to determine the neck-shaft angle, femoral neck anteversion angle, femoral neck width and femoral head diameter in adult femora, compare the results with other studied populations and examine the implications of the same in operations on the proximal femur. Methods : Femoral neck anteversion angle and the neck-shaft angle were determined from digital photographs of 70 cadaveric femora using an open-source image analysis software, ImageJ®(National Institutes of Health, Bethesda, Maryland). Femoral neck width and femoral head diameter were determined by measurement using a digital vernier caliper. The dimensions of available implants were searched from local suppliers of the implants. Results : Mean femoral neck-shaft angle was found to be 129.21o, while the mean femoral neck anteversion angle was found to be 23.06o. Mean neck-shaft angle was found to be 128.67o on the left while on the right side, it was 129.03o. This difference was not statistically significant. Mean femoral neck anteversion angle was found to be 23.97o on the left side, and 23.03o on the right side, but this difference was not statistically significant. Mean femoral neck width was found to be 29.36mm, with mean width of the left side being 28.67mm and that of the right being 29.36mm. The difference was not statistically significant. Mean femoral head diameter was 42.6mm, with mean diameter of the left side being 41.2mm and that of the right side being 42.6mm. The difference was not statistically significant. Conclusion : The current study has shown that the femoral neck-shaft and anteversion angles in the Kenyan femora vary from those of other populations. The available implants have angles which may not be suitable for a significant proportion of the local population. It would be prudent to avail a range of implants with different angles to improve the choices available to the surgeon when faced with a patient who requires an operation on the proximal femur.

Background: No local study has been done to determine the anthropometric features of the distal femur, compared it with other studied populations and some of the total knee replacement implants available. Objective: To determine the Medio-Lateral (ML) width of the condyles of the femur, the anteroposterior (AP) diameter of the condyles and the intercondylar notch width, determine the relationship between length of the femur and the distal femur measurements, compare the results with other studied populations and the femoral components of widely used total knee replacement implants. Methods: The distances were measured using digital vernier calipers on dried femora which were grossly not deformed. The dimensions of the femoral components of widely used total knee replacement implants were obtained from respective product monographs. Results: A total of 62 grossly normal femora were used in the study, 29 from the right side, and 33 from the left side. Average femoral length was 46.12cm, average medio-lateral width of condyles was 68.44mm, with average anteroposterior width of the lateral condyle being 61.20mm, while that of the medial condyle was 58.01mm.There was no significant difference between the dimensions of the left and right sided femora. There was a positive correlation between length of the femur and the mediol-lateral and anteroposterior widths of the condyles. There was no correlation between length of femur and the intercondylar notch width. The distal femur dimensions were greater than those reported in studies on Indian, Chinese and Malay populations, but lesser than the dimensions reported in studies on Greek femora. Comparison with femoral components of eight total knee replacement implants showed that three of the components had dimensions that closely matched those of the femora. Conclusion: The dimensions of the distal femur of the adult Kenyan differs from other ethnic populations. Of the implants sampled, most had dimensions that did not closely match those of the femora studied. Local clinical studies are needed to determine the clinical significance of the mismatch on the outcome of total knee replacement. Keywords: Anthropomentry, Width of condyles, Aspect ratio, Total knee replacement

Background: The traditional clinical examination has fallen into disfavour on account of considerable inter-examiner variability. The OSCE is gaining popularity as it is perceived to be less prone to this. Objective: To establish whether inter-examiner variability is still a significant factor for the undergraduate orthopaedic clinical examination in our institution. Method: Thirty three final year students were randomly divided into two groups of 17 and 16 students. Two standardized OSCE questions were administered to each student by four examiners with each group being examined by one lecturer for each of the questions. For the first question, students in Group 1 were examined by Examiner A while those in Group 2 were examined by Examiner B. For the second question, students in Group 1 were examined by Examiner C while those in Group 2 were examined by Examiner D. The scores for each student were tabulated and the range, mean, and pass rate determined for each of the examiners. The Student’s t-test was calculated to determine if there was statistically significant interexaminer variability. Results: For Question 1, the mean score for students examined by Examiner A (Group 1) was 7.47 marks while that for Examiner B (Group 2) was 5.59 marks. The p-value was 0.01367 (95% confidence interval). For Question 2, the mean score for students examined by Examiner C (Group 1) was 7.32 marks while that for Examiner D (Group 2) was 8.625. The p-value was 0.001148 (95% confidence interval). Conclusion: There was statistically significant inter-examiner variability. We recommend that for all OSCE exams, examiners be paired with a deliberate attempt to pair a “Hawk” with a “Dove”. Statistical correction of biases is also recommended.

Background: There are currently no studies which have documented the anterior femoral curvature in Kenya or elsewhere in Africa, and compared it to the curvature of the available intramedullary nails. Objective: To determine the anterior femoral curvature in cadaveric femora and to compare this with the curvatures of locally available femoral intramedullary nails. Methods: We determined the radii of 66 cadaveric femora by the method described by Karakas and Harma. The radii of locally available femoral intramedullary nails were also obtained from the respective product monographs. Results: We found that the radius of the curvature ranged from 52.02cm to 165.82cm with a mean of 96.4cm and standard deviation of 25.61cm. The radii of locally available intra-medullary nails ranged from 127cm to 200cm. Conclusion: The radius of curvature of the adult femora in Kenyans is less than that of other populations. There was a large mismatch between the available intramedullary nails and the femoral curvature. Further study of the complications resulting from this mismatch and a review of the design of the nails for local use is recommended.

Background : There are no local guidelines for prophylaxis against Venous Thrombo-Embolism (VTE). In the absence of any guidelines, most of the information available has been provided mainly by the pharmaceutical industry which is an interested party. There have been publications in local journals that lean more on endorsing guidelines developed elsewhere. Unfortunately, such guidelines have not been embraced by everyone even in their countries of origin yet they are sometimes presented as the universally accepted standard of care. Objective : We sought to elucidate some of the reasons for the opposition to these guidelines in this article. Our aim is not to convince readers to change their practice but to provide information that may be useful to them as they make decisions on this matter. We also hope to stimulate debate on this issue and hopefully contribute to the development of a national guideline for and by the orthopaedic community. Data source : Publications from peer reviewed journals. Results : The assumed relationship between deep vein thrombosis and pulmonary embolism is erroneous. The “post-phlebitic limb” is not always post-phlebitic. Large studies comparing the morbidity and mortality prior to and after introduction of various VTE prophylaxis guidelines find that the measures proposed by various guidelines are not efficacious. Most early deaths occurring after orthopaedic procedures are not a result of pulmonary embolism. There exists a serious conflict of interest in many of the studies that support chemo-prophylaxis for VTE prevention. The risks from chemoprophylaxis for VTE are greater than the anticipated benefit. Conclusions : Evidence adduced in this article casts doubts on the rationale and efficacy of VTE chemoprophylaxis recommendations by various international guidelines and does not support their whole-scale adoption. Recommendations : Kenya Orthopaedic Association needs to put in place mechanisms to develop local guidelines based on the local data and spearheaded by the orthopaedic fraternity.

Acute compartment syndrome of the thigh is a rare complication of trauma to the thigh. It occurs less commonly than in other sites such as the leg and forearm. Because of its rarity, it is often not suspected and its diagnosis is frequently delayed with disastrous consequences. We report a patient who sustained blunt trauma to the thigh without a femoral fracture and subsequently developed acute compartment syndrome. The patient had initially been seen and sent home on oral analgesia but presented five hours later with worsening thigh pain. Then, a diagnosis of acute compartment syndrome was made and fasciotomy done. He recovered uneventfully.

Patella fractures are rare in children. Transverse fractures in particular are an uncommon pattern. We report a case of a transverse patella fracture in a ten year old boy. He presented with inability to actively extend his left knee, two months after a fall. On evaluation he was found to have a transverse fracture of his left patella. This was treated by tension band wiring. EAOJ ; Vol. 7: September 2013

Background : Locked intramedullary nailing is the standard of care for femoral and tibial shaft fractures. Correct placement of locking screws is often an ordeal followed at times by a tormenting wait for check radiographs to confirm whether or not the locking screws were correctly placed. Objective : We present a simple, inexpensive, fool-proof technique that confirms the correct placement of the locking screws on table thus allowing for revision at the time of surgery in case the locking screw missed the locking hole in the nail. Methods : The basis of this technique is that a screw or drill bit in the locking hole prevents advancement of a guide wire beyond the level of the screw or drill bit. The maximal length of wire that goes in is marked prior to locking. The most distal distal lock is placed first. If the lock is in place, then less of the guide wire will go in than what went in in the first instance. The length of wire that goes in up to the most distal lock is then marked and used to confirm the placement of the proximal distal lock. In the same manner, the distal proximal lock is placed followed by the most proximal lock in that order. Results : We have used this technique to confirm placement of locking screws in thirty nailing procedures and on all occasions, check radiographs confirmed that the locking screws were correctly placed as confirmed by this technique. Conclusion : This technique enables the surgeon to confirm correct placement of locking screws on table. It can be used with any cannulated nailing system. It is simple, in-expensive and foul-proof. As an adjunct during closed nailing under image intensification, the technique helps reduce operating time and exposure to radiation.