SA Orthopaedic Journal

Is the same calendar day hip arthroplasty for everyone or a select few?

Communicate, collaborate and document: the pillars to avoid and manage complaints

Low dislocation rate one year after total hip arthroplasty at a tertiary hospital in South Africa

BACKGROUND: Total hip arthroplasty (THA) is one of the most performed and most researched procedures worldwide, and there is an ever-growing demand for THA in an already resource-constrained system in South Africa. Early dislocation after THA remains a serious and costly problem; however, few THA outcome studies have been performed locally. This study therefore aimed to calculate the incidence of dislocation after THA and to identify risk factors for dislocation after THA in a South African academic hospital METHODS: In this retrospective cohort review, files and radiographs of 543 patients were reviewed for dislocation during the first year after primary THA. The reason for the THA, the surgical data, the implant data, and whether and when dislocation occurred were recorded for each patient. Fisher's exact tests and independent t-tests were done to analyse the association between variables and a patient's odds of experiencing a dislocation after THA RESULTS: Twenty (3.7%) out of 543 THAs dislocated during the first year, 17 of these within the first three months. The surgical approach used was not shown to be a significant risk factor (p = 0.650) for dislocation, although the Hardinge approach had been used for all 20 cases of dislocation. Similar dislocation rates (p = 0.967) were found for THAs done for displaced neck of femur (NOF) fractures (3.6%) and for elective THAs (3.7%). Trauma THAs made up more than half (55%) of our study population. Femoral head sizes < 32 mm (p = 0.390 for neck of femur THA and p = 0.451 for elective THA) and a single mobility design (p = 0.494) both produced a higher dislocation rate, although this was not statistically significant. Surgeon experience did not prove to be significant for our study population (p = 0.570 CONCLUSION: The dislocation rate after THA at our institution is lower than rates reported in the literature for NOF THA and similar to rates reported for elective THA. This was found despite the dislocation rate for the Hardinge approach being nearly eight times higher than expected. Minimal surgeon experience, implant coupling and smaller femoral head size did not prove to be significant risk factors for dislocation after THA Level of evidence: Level 4

Functional outcome of free fibula grafting in benign non-reconstructable bone tumours involving the hand

BACKGROUND: Bone tumours involving hands are usually benign but can be locally aggressive. Several treatments have been described. Usual modalities of treatment include curettage and bone grafting. In more advanced stages when short bones of the hand are involved with more than 70% cortical destruction, or when such treatment option is not possible (as with non-contained tumours with cortical breaches, pathological fracture), only the resection or amputation of the affected segment can offer an effective cure. We studied the role of the free fibula graft (non-vascularised) in such types of benign non-reconstructable (by conventional methods) hand tumours. The aims and objectives were to study the functional outcome of free fibula grafting in benign non-reconstructable bone tumours involving the hand and to analyse the complications, if any, and assess the causes and solutions for them METHODS: We prospectively studied 15 patients with different types of benign, non-reconstructable bone tumours involving the hand operated by free fibula grafting. The study period ranged from January 2014 to December 2021. Follow-up ranged from 2 to 8 years (average of 4.26 years RESULTS: Results were analysed by the QuidkDASH-9 score system. There was no recurrence. One case of superficial infection was treated with antibiotics and dressing. All patients were happy with the treatment and resumed their normal duties and functional movements CONCLUSION: Use of the free fibula graft can be a good option for benign non-reconstructable bone tumours involving the hand to avoid amputation. The free fibula graft gives better results due to total excision of the lesion and strut graft support for good functional outcomes Level of evidence: Level 3

A subungual glomus tumour of the finger with five reappearances: a rare case report

BACKGROUND: A subungual glomus tumour is a rare benign neoplasm that develops in the distal portion of the finger from the glomus body. Hand surgeons are most significant in the diagnosis of this tumour CASE REPORT: We present an atypical case of a patient who experienced multiple recurrences of a subungual glomus tumour of the finger over a period of 26 years. A transungual approach was used to remove the nail during the surgical excision. Postoperatively, the patient was symptom-free DISCUSSION: The glomus body is the neuromyoarterial histological structure located in the stratum reticularis of the dermis of the skin and the subungual regions. Recurrences can be classified as early, delayed and ancient. Early recurrences may result from incomplete excision or a second tumour that develops within a year of the initial excision. A year following excision, delayed recurrences are thought to be caused by a new glomus tumour at the fingertip. A tumour that reappears more than three times after excision on the same fingertip in five years can be either a new or incomplete excised tumour, as in our case, and is considered an ancient recurrence. Surgical eye loupes should be use intraoperatively to improve complete tumour lesion excision CONCLUSION: To the best of our knowledge, this is the first case of a finger with five recurrences post excision. In the event that excision-related pain is significant, recurrence should be considered. Delayed and ancient recurrences are thought to be caused by a new glomus tumour at the fingertip that one cannot prevent with surgery Level of evidence: Level 5

A survey on the educational value of an mHealth referral app for orthopaedics in South Africa

BACKGROUND: A WhatsApp orthopaedic referral group (ORG) was created in 2017 by orthopaedic specialists at a district hospital to provide support to primary healthcare doctors in order to manage traumatic fractures and dislocations. This study assessed the educational value and user satisfaction of the ORG platform METHODS: An online, cross-sectional survey was conducted among ORG users from May to June 2021. Demographic information, user satisfaction, the educational value of ORG, and perceived improvement in managing closed fractures and dislocations were captured using descriptive and inferential statistics RESULTS: There were 80 respondents, with 50% females. The median age was 30 (interquartile range [IQR] 28-35) years, duration of practice was 5 (IQR 3-10) years, and length of ORG use was 10 (IQR 5-24) months. Seventy-two (90%) reported that ORG enabled them to receive timely advice for orthopaedic case management and 75 (93.8%) considered it an easy referral facilitation tool. Most (76.3%) felt that the advice, pictures, and videos shared on ORG helped novice doctors successfully complete fracture reduction. The percentage of participants who felt very capable in managing the following fractures increased after ORG membership: extra-articular distal radius fracture (12.5% to 45.0%, p < 0.001); bimalleolar ankle fractures (16.3% to 43.8%, p < 0.001) and shoulder dislocation (35.0% to 61.3%, p = 0.001 CONCLUSION: ORG is an easy-to-use and well-accepted platform for the management, referral facilitation and teaching of acute orthopaedic conditions. Similar platforms can be introduced in other settings where surgical specialists are scarce. Additional studies should measure the feasibility and effectiveness of these mHealth platforms Level of evidence: Level 3

Enhancing healthcare services in an orthopaedic department utilising a system dynamics and participatory action research perspective to optimise patient flow

BACKGROUND: The high burden of trauma in Durban results in longer elective surgery waiting periods, which exacerbates the in-patient hospital days and increases the average length of stay. Quantitative analyses of the data clearly demonstrate a growing list of elective patients awaiting surgery while the rate of acute trauma admissions continues to escalate. It has been demonstrated that interactions of patients between the various stages of care should be carefully studied in order for policymakers to identify limiting factors and leverage points Many public health interventions run aground and fail to actualise their initial objectives since the system is deconstructed and reduced to simplified autonomous components. A restorative undertaking to remedy this syndrome is to reconstitute the normative conventions of framing, mapping out and scrutinising deficiencies within healthcare systems. This paper explores a model of total patient flow through the orthopaedic service to test alternative major new structural options for relieving pressure on health services. METHODS: Qualitative data was collected using purposeful sampling to conduct 20 semi-structured interviews as well as including discourse analysis and ethnographic research. Participatory action research (PAR) was the main epistemological method driving the study under the auspices of a system dynamics framework RESULTS: Areas of potential improvements have been identified which can ameliorate the flow of patients between the different departments together with the challenges and uncertainties that are present in achieving this CONCLUSION: Efficient patient flow management is a cornerstone in optimising healthcare services; the failure of such a system burdens the entire health system Level of evidence: Level 5

Factors associated with dissemination and complications of acute bone and joint infections in children

BACKGROUND: Paediatric bone and joint infections remain common in low- and middle-income countries (LMICs) and may have devastating long-term sequelae. There is a paucity of data from LMICs where the true incidence might be underreported, and delayed presentation is common. Our study aimed to determine the complication rate and incidence of disseminated infection in paediatric bone and joint infections in an LMIC setting. Secondly, we aimed to elucidate factors associated with complications and disseminated disease METHODS: We retrospectively reviewed our paediatric orthopaedic database for children that presented with bone and joint infections between September 2015 and March 2019. Data were extracted from medical records, laboratory results and radiological investigations to identify factors that were associated with the development of complications and disseminated infection at a median follow-up of four months RESULTS: We analysed 49 children. The median age at presentation was 6 years (range 1 month to 12 years). Locally advanced disease, with combined acute haematogenous osteomyelitis (AHOM) and septic arthritis (SA), was present in 13 children (27%). The remaining 36 children were evenly divided (18/49 each, 37%) between isolated AHOM and SA, respectively. Disseminated disease was present in 16 children (33%) and was associated with locally advanced disease, an increase in the number of surgeries and an increased length of stay. Twenty-six complications were documented in 22 (45%) children. Chronic osteomyelitis developed in 15/49 (31%) cases, growth arrest in 5/49 (10%), and pathological fracture, DVT and septic shock in 2/49 (4%) each. Complicated disease was associated with locally advanced disease, a higher number of surgeries, disseminated disease and an increased length of stay. Staphylococcus aureus was the infecting pathogen in 65% of cases (31 MSSA, 1 MRSA), while 25% (12/49) were culture-negative infections. While the median time from admission to surgery was one day, the median time from onset of symptoms to surgery was seven days CONCLUSION: We found a high complication rate despite a short follow-up period. More than a quarter of patients had locally advanced disease, and this was associated with the development of complications and disseminated disease. Further studies are needed to be able to predict which children will have poor outcomes Level of evidence: Level 4

Intertrochanteric femur fractures: a current concepts review

Intertrochanteric fractures are common injuries around the hip, especially among the elderly. With the rising incidence of these injuries, they are expected to double by 2050. Incidence rates are higher in females than males and in white patients than black African patients. Osteoporosis weakens the local trochanteric anatomic support leading to an increased susceptibility to fractures. Disruption of the posteromedial calcar region results in fracture instability. Optimal lag screw position and fracture reduction are significant determinants for postoperative outcomes. The tip apex distance and reduction criteria determine lag screw cut-out risk and fracture reduction quality, respectively. A calcar-referenced tip apex distance is comparable if not better than the tip apex distance in predicting cut-out risk. Optimal reduction is in slight valgus, a positive medial cortex apposition and smooth anterior cortex apposition. High mortality rates are observed with non-surgical treatment. Surgical management is therefore the gold standard for intertrochanteric fractures. Treatment options are categorised into extramedullary fixation, intramedullary fixation and proximal femur replacement. They include the dynamic hip screw (DHS), cephalomedullary nails (CMN) and arthroplasty. Although still in use, the proximal femur locking plate is falling out of favour due to high complication rates. Fracture stability and pattern influence the treatment choice. There is, however, a growing use of CMNs which has been attributed to surgical training background. Modification of older CMN designs has improved treatment outcomes. Systematic meta-analyses of randomised controlled trials (RCTs) do not show superiority of one treatment option over another; therefore, there is no consensus on the best treatment choice. The proximal femur nail antirotation (PFNA) has better outcomes compared to other fixation options with respect to intraoperative blood loss and Harris hip scores. As a group, CMNs have a better 120-day postoperative quality of life compared to the DHS. No significant difference in complications has been found between treatment options. In light of the anticipated increased incidence of intertrochanteric fracture, more work is needed in planning national resource allocation, devising preventative methods and improving clinical interventions in South Africa. Level of evidence: Level 5

The management of postoperative pain after musculoskeletal surgery - a narrative review

Cost-effective care amidst the rapidly rising cost of medical services necessitates the implementation of a standardised multimodal analgesia plan to aid patient care. This review aims to address the physiology and pharmacological management of postoperative pain following musculoskeletal surgery.