Scielo RSS <![CDATA[SA Orthopaedic Journal]]> http://www.scielo.org.za/rss.php?pid=1681-150X20160003&lang=en vol. 15 num. 3 lang. en <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>Internal fixation with solid fusion and late recurrent lumbar spine pain</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2016000300001&lng=en&nrm=iso&tlng=en <![CDATA[<b>Civilian gunshot wounds of the spine: A literature review</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2016000300002&lng=en&nrm=iso&tlng=en The incidence of gun-related violence continues to rise, although accurate statistics are difficult to obtain. Up to 17% of spinal cord injuries are gunshot related. The recent literature pertains to the management of high velocity/energy gunshot wounds as encountered in war scenarios such as Iraq, Afghanistan, etc. The treatment of civilian gunshot wound injuries to the spine has not been clearly stipulated, and many treatment modalities are adopted from the treatment of war injuries, which is a completely different scenario. AIM: To evaluate the available literature pertaining to civilian gunshot wound injuries of the spine and the treatment thereof with regard to the indication for bullet removal, antibiotic prophylaxis, lead poisoning, the use of imaging modalities and fracture stability CONCLUSION: Although the literature is often conflicting and published case series are outdated, there is consensus that not all bullets or fragments need to be removed; the majority of fractures are stable; MRI is a safe imaging modality; lead poisoning is extremely rare; and extended antibiotics prophylaxis is not needed The indications for bullet removal is deteriorating neurology, intra-canal bullets between T12 and L4 with incomplete neurology, sepsis and lead poisoning should it occur. <![CDATA[<b>Short-term results of grade III open tibia fractures treated with circular fixators</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2016000300003&lng=en&nrm=iso&tlng=en Grade III open tibia fractures have previously been shown to have high infection and non-union rates, and the optimal treatment remains controversial. We present the short-term results of 94 consecutive Gustilo-Anderson grade III open tibia fractures, definitively treated with circular external fixators in this retrospective study. A total of 94 patients (80 males and 14 females), with a mean age of 36.5 years (range 8-73) were followed up for a mean period of 12 months (range 6-52). Deep infection occurred in four patients (4.3%) and non-union in three patients (3.2%). The mean time to union was 23 weeks (range 11-79). The prevalence of HIV infection was 32.9% and no statistically significant association between HIV infection and an increased risk of deep infection (p = 0.601) or nonunion (p = 0.577) could be demonstrated. Pin-site infection occurred in 16% with the majority being low-grade infections. The management of grade III open tibia fractures with definitive circular external fixation delivered promising short-term results with low complication rates in terms of infection and non-union. <![CDATA[<b>Open reduction and internal fixation of calcaneus fractures through a sinus tarsi approach</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2016000300004&lng=en&nrm=iso&tlng=en INTRODUCTION: The wound complication rate for open reduction and internal fixation of calcaneus fractures through the extensile approach is 30%. Due to this high rate of wound complications, many surgeons prefer conservative management. If post-traumatic arthritis develops, the clinical results of a subtalar fusion are better if the posterior facet is reduced and the shape of the calcaneus restored. The sinus tarsi approach utilises a much smaller incision and indirect reduction techniques limiting the need for a large incision while still providing good exposure of the posterior facet for anatomic reduction The purpose of this study is to present the technique for open reduction and internal fixation through a sinus tarsi approach, to assess the adequacy of reduction and the complication rate. METHODS: A retrospective chart and X-ray review was performed of all patients who had an open reduction and internal fixation of the calcaneus performed since 2013. We report on the interim results of the adequacy of reduction and maintenance thereof and the incidence of wound complications. Follow-up was for a minimum of 6 weeks RESULTS: Twelve procedures were performed in this time. The Bohler's angle improved from a median of 12° pre-operatively to 28.5° (p=0.002) post-operatively. The angle of Gissane improved from a median of 125° to 110° (p=0.0001). Two patients had minor wound complications, both of which were managed without surgery, using dressings for 10 to 12 days CONCLUSION: Open reduction and internal fixation of calcaneus fractures through a sinus tarsi approach allows adequate reduction with a low incidence of wound complications <![CDATA[<b>Amputation rate following tibia fractures with associated popliteal artery injuries</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2016000300005&lng=en&nrm=iso&tlng=en BACKGROUND: Patients with fractures or dislocation about the knee are at increased risk of vascular injury and subsequent limb loss. Our objectives were to: a) determine the amputation rate; and b) identify risk factors in patients with proximal tibial and diaphyseal fractures and associated popliteal artery injuries. METHODS: We conducted a retrospective case-control study of 30 patients with popliteal artery injuries with ipsilateral tibia fractures at a level 1 trauma centre. Primary and delayed amputation rates were determined. Risk factors tested for significance (Fischer's Exact) included: mechanism of injury, limb viability, compartment syndrome, fracture pattern, surgical sequence, and time delay from injury or presentation to revascularisation. RESULTS: Primary amputation was performed in seven and delayed in ten patients (overall rate 57%). The 'miserable triad' of a proximal tibia fracture (OTA 41) with signs of threatened viability, and delay to revascularisation > 6 hours from injury or >2 hours from presentation was predictive of amputation (p = 0.036 and p = 0.018 respectively), and almost quadrupled the amputation rate. CONCLUSIONS: We should aim to intervene within 6 hours following injury or 2 hours following presentation to reduce the risk of amputation. This provides a target for trauma teams even with uncertain time of injury. <![CDATA[<b>Radiological analysis of component positioning in total hip arthroplasty using the anterior approach</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2016000300006&lng=en&nrm=iso&tlng=en BACKGROUND: The direct anterior approach for total hip replacement is gaining popularity among surgeons and patients alike, as it is a minimally invasive technique, and a true muscle-sparing operation. Reported advantages of this approach include decreased post-operative pain, faster post-operative mobilisation and a low incidence of hip dislocation. Optimal component positioning is vital for the longevity of total hip replacements. Poor positioning leads to increased dislocation rates, accelerated bearing wear, limited range of motion and higher rates of revision surgery. Minimally invasive surgery strives for smaller incisions, and muscle-sparing dissection. This may result in poor acetabular exposure, and subsequent sub-optimal component positioning. The direct anterior approach is generally done supine on a traction table with/without the use of intra-operative fluoroscopy. This study describes the surgical technique performed with the patient in the lateral decubitus position, without the use of traction, and without intra-operative imaging. We then report on the radiographic outcomes and complications using this approach. METHODS: We retrospectively reviewed 150 patients who had total hip replacements done via the direct anterior approach. Clinical notes were evaluated for patient demographics, body mass index, and post-operative complications. The post-operative radiographs were analysed for acetabular component position inclination and anteversion. RESULTS: The radiographic analysis showed a mean cup inclination of 41.1° (range 27.9-61.1°) and anteversion of 18.33° (range 11.2-25.3°). A total of 95.97% (95% CI) of the components were within the safety zones, as described by Lewinnek, (inclination 40 ± 10°, anteversion 15 ± 10°).23 There were five outliers with regard to cup inclination. Three had excessively abducted cups, which were noted to be in patients with increased BMI >35 kg/ m². The remaining two were excessively adducted. There were no outliers with regard to cup anteversion There were no dislocations, deep infections or femoral nerve palsies. Two patients required re-operation: one for a periprosthetic fracture and another for a greater trochanter fracture with late displacement. There were six cases of thigh swelling which resolved on discontinuation of oral anti-coagulation, four episodes of soft tissue inflammation responding to physiotherapy, four clinically observed leg length discrepancies, two minor stitch abscesses, and two transient lateral cutaneous nerve palsies. CONCLUSION: The direct anterior approach, done in the familiar lateral decubitus position, as described in this study, is safe and reliable, with an acceptable complication rate. The radiographic results for acetabular component placement are comparable to other surgical approaches, as well as to the direct anterior approach using a fracture table and intraoperative imaging. <![CDATA[<b>Lower limb deep vein thrombosis as a complication of posterior dislocation of a total hip replacement: A case report</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2016000300007&lng=en&nrm=iso&tlng=en CASE: A 56-year-old woman who developed deep venous thrombosis 6 weeks after dislocating her ipsilateral total hip replacement is presented. She was found to have an organising haematoma in her psoas and iliacus muscles compressing the common femoral and external iliac veins proximal to the thrombus on imaging. The haematoma was considered to have been caused by abrasion of the muscles against the sharp edge of the acetabular shell. CONCLUSION: Deep venous thrombosis should be considered a cause of ipsilateral lower limb swelling in a patient who has recently had a posterior total hip replacement dislocation. <![CDATA[<b>Periarticular local anaesthetic in knee arthroplasty: A systematic review and meta-analysis of randomised trials</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2016000300008&lng=en&nrm=iso&tlng=en BACKGROUND: This systematic review and meta-analysis aimed to quantify the effect of adding peri-articular local anaesthetic infiltration or infusion to an analgesic strategy in patients undergoing knee arthroplasty. METHODS: A literature search of six data bases was performed. Randomised controlled trials comparing periarticular local anaesthetic infiltration/infusion against other analgesic strategies in adult patients undergoing knee arthroplasty were included. The primary outcome was resting Visual Analogue Scores 24 hours after surgery. RESULTS: In the review, 396 potential studies were identified, of which 35 full text articles were assessed for eligibility. A total of 770 patients from 12 trials were included in the final meta-analysis. Local anaesthetic addition significantly improved pain control (mean difference -0.95 [95% CI -1.68 to -0.21]); however, there was significant heterogeneity (I²: 88%). CONCLUSION: Our analysis suggests that peri-articular local anaesthetic infiltration/infusion improves resting pain scores 24 hours after knee arthroplasty. However, the heterogeneity of these findings urges caution in their interpretation. <![CDATA[<b>Focal fibrocartilaginous dysplasia (FFCD) in the proximal femur causing coxa vara: A unique case report and review of the literature</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2016000300009&lng=en&nrm=iso&tlng=en BACKGROUND: Focal fibrocartilaginous dysplasia (FFCD) is an uncommon developmental defect of bone, where cortical bone is replaced by fibrous tissue. The condition has most commonly been reported in the upper tibia causing tibia vara. Several other sites have also been described including the distal femur, ulna, humerus, radius and phalanx. METHODS: We report a unique case of FFCD of the upper medial femur that caused coxa vara. The diagnosis was suspected on X-ray and confirmed on MRI and histology. Treatment included valgus subtrochanteric proximal femoral osteotomy, intralesional biopsy and curettage of the lesion. A literature review using PubMed/Medline and Google Scholar was completed to identify previous publications on FFCD up to February 2015. RESULTS: This is the first report of FFCD associated with coxa vara in the proximal femur. Eighteen cases of FFCD in the distal femur have previously been reported. The disorder is most commonly reported in the proximal tibia. CONCLUSION: FFCD should be considered in the differential diagnosis of a cortically based lytic lesion associated with bony deformity in growing bone. Further research is needed to define the aetiopathogenesis and natural history of the disorder. Treatment guidelines are needed for atypical locations. Level of evidence: Level V (case report). <![CDATA[<b>The relationship of the size of the footprint of the fibular graft to the surface area of the vertebral endplate in the reconstruction of the anterior column of the spine</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2016000300010&lng=en&nrm=iso&tlng=en INTRODUCTION: The anterior column of the spine is often destroyed by trauma, infection or tumours. It is reconstructed by using an autograft, allograft or synthetic cages. The fibular autograft provides good strength, incorporates quickly and has less risk of disease transmission, which is a big advantage in communities with a high incidence of HIV. Various authors cite that its major drawback is the size of its footprint because of the possibility of subsidence. We could not, however, find any literature that measures its size. AIM: To measure the size of the footprint of the fibular graft in relation to the surface area of the vertebral endplate. The clinical relevance is that it may guide the surgeon in deciding how many struts of the fibular graft to use in reconstructing the anterior column, and also quantifies the statement that the fibular strut has a small footprint. Material and method: CT angiograms are done frequently for peripheral vascular diseases. These angiograms show CT scan images of the lumbar and thoracic vertebrae, and fibulae of the same patient. We retrospectively examined 60 scans done during the years 2012 and 2013. From the CT scans, we measured the surface area of the endplates of the vertebral bodies of T6, 8, 12, L2, and the surface area of the cut surface of the proximal 10 cm, 20 cm and 30 cm of the fibular graft, all in square millimetres (mm²). We then compared the areas of the vertebral measurements to the area of the fibular graft measurements. RESULTS: The middle third of the fibular graft had the biggest axial surface area. The ratio of the fibular graft surface area to that of the thoracic vertebral endplate is 1:3-6. These ratios suggest that more than one fibular strut graft is required to reconstruct the anterior column in the thoracic spine. CONCLUSION: The results show that the fibular graft is better suited for reconstruction in the upper thoracic spine. Below that more than two struts are required. <![CDATA[<b>Treatment of chronic anterior shoulder dislocations: Limited goal surgery</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2016000300011&lng=en&nrm=iso&tlng=en BACKGROUND: Chronic anterior shoulder dislocations are encountered relatively frequently in KwaZulu-Natal, South Africa. Various surgical options exist to treat these injuries; however, the reported results of such interventions are not uniformly favourable. There remains the opinion that such cases are perhaps best treated with 'skilful neglect'. METHODS: We present a combined case series of chronic anterior shoulder dislocations treated surgically. Patients were identified retrospectively using departmental databases and their case files, available X-rays, CT scans and MRI scans were reviewed. Surgical outcome was assessed using range of movement, change in pain severity, the Oxford Shoulder Instability Score, the Rowe and Zarins score, as well as a patient satisfaction score. RESULTS: Twenty-six patients were included in the study. The average duration of dislocation was 9 months (range 2 weeks to 7 years). The most common reason for chronicity was delayed presentation to clinic or hospital (nine patients). A Hill-Sachs lesion was present in 20 patients, and a pseudo-glenoid was often encountered in dislocations present for more than 4 weeks (16 of 23 patients). Three supraspinatus ruptures and four biceps tears were encountered, while neurological injury was uncommon (two patients). Surgical treatment included open reduction (one patient), open reduction and Latarjet (15 patients), hemi-arthroplasty (two patients), hemi-arthroplasty and Latarjet (three patients) and reverse total shoulder arthroplasty (five patients). Eighteen patients were available for clinical review. Regardless of the type of surgery done, postoperative range of motion and surgical outcome scores were generally poor. Despite this, most patients (16 of 18 patients) were satisfied with their outcome due to reduction in pain. Two patients were dissatisfied, due to re-dislocation. CONCLUSION: Surgical treatment of chronic anterior shoulder dislocation results in limited improvement in range of motion and overall shoulder function. However, high patient satisfaction levels and significant improvement in pain levels can be expected. Patients should be counselled pre-operatively regarding this 'limited goal surgery'. <![CDATA[<b>Expert opinion on published articles</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2016000300012&lng=en&nrm=iso&tlng=en BACKGROUND: Chronic anterior shoulder dislocations are encountered relatively frequently in KwaZulu-Natal, South Africa. Various surgical options exist to treat these injuries; however, the reported results of such interventions are not uniformly favourable. There remains the opinion that such cases are perhaps best treated with 'skilful neglect'. METHODS: We present a combined case series of chronic anterior shoulder dislocations treated surgically. Patients were identified retrospectively using departmental databases and their case files, available X-rays, CT scans and MRI scans were reviewed. Surgical outcome was assessed using range of movement, change in pain severity, the Oxford Shoulder Instability Score, the Rowe and Zarins score, as well as a patient satisfaction score. RESULTS: Twenty-six patients were included in the study. The average duration of dislocation was 9 months (range 2 weeks to 7 years). The most common reason for chronicity was delayed presentation to clinic or hospital (nine patients). A Hill-Sachs lesion was present in 20 patients, and a pseudo-glenoid was often encountered in dislocations present for more than 4 weeks (16 of 23 patients). Three supraspinatus ruptures and four biceps tears were encountered, while neurological injury was uncommon (two patients). Surgical treatment included open reduction (one patient), open reduction and Latarjet (15 patients), hemi-arthroplasty (two patients), hemi-arthroplasty and Latarjet (three patients) and reverse total shoulder arthroplasty (five patients). Eighteen patients were available for clinical review. Regardless of the type of surgery done, postoperative range of motion and surgical outcome scores were generally poor. Despite this, most patients (16 of 18 patients) were satisfied with their outcome due to reduction in pain. Two patients were dissatisfied, due to re-dislocation. CONCLUSION: Surgical treatment of chronic anterior shoulder dislocation results in limited improvement in range of motion and overall shoulder function. However, high patient satisfaction levels and significant improvement in pain levels can be expected. Patients should be counselled pre-operatively regarding this 'limited goal surgery'.