Scielo RSS <![CDATA[SA Orthopaedic Journal]]> vol. 16 num. 3 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>Orthopaedic surgery as a business - getting it right</b>]]> <![CDATA[<b>The radiological outcome of uncemented femoral stems in rheumatoid patients undergoing total hip arthroplasty: results at minimum eight years</b>]]> BACKGROUND: Rheumatoid arthritis is a multi-systemic disease which affects all synovial joints. Compromised bone quality may have a negative impact on prosthesis incorporation after total hip replacement, resulting in an increased risk of aseptic loosening and early implant failure. MATERIALS AND METHODS: Between 2002 and 2007, 49 patients (age 29-80 years) underwent total hip replacement. Radiographs were evaluated for signs of loosening or failure. RESULT: Of the 49 hips, there was one case of stem subsidence, and one case of aseptic loosening. There were no revisions in the current series. Complications included eight (16.3%) intra-operative calcar fractures, which healed uneventfully. CONCLUSION: We report satisfactory radiological results, and revision rate in a group of rheumatoid patients at mid-term review following total hip replacement with uncemented femoral stems. <![CDATA[<b>Tapered uncemented HA-coated femoral stems: a radiological study</b>]]> INTRODUCTION: Numerous national joint registries demonstrate a trend towards the use of uncemented femoral components in total hip arthroplasty. While the results of first-generation uncemented, and some of the second-generation uncemented implants have been unacceptably poor, others, including the fully hydroxyapatite (HA) coated femoral stems, have been excellent with survival rates of greater than 95% at 20 years. Component longevity is largely related to robust stem fixation to native bone. Adequate stem fixation to the native bone can be determined by clinical assessment and radiological signs of osteointegration. The absence of these radiological signs might be an indication of early loosening. With this in mind, we performed a radiological analysis of the osteointegration of uncemented fully HA-coated femoral stems inserted at our arthroplasty unit. MATERIALS AND METHODS: We performed a retrospective chart and radiological review of patients who had undergone total hip replacement with an uncemented fully HA-coated femoral component over a five-year period. Between March 2003 and March 2008, 80 patients met the criteria used, and radiological changes around the femoral stem were analysed. The mean patient age at the time of surgery was 59 years, and the most common presenting pathology was avascular necrosis (43%). The immediate post-operative, six-week, six-month, one-year and five-year radiographs were evaluated. RESULTS: There were no revisions for stem-related complications. The earliest radiological signs of osteointegration, which included remodelling and trabecular bone formation, were noticed as early as six weeks post-operatively in 4%. At six months and one year, these had increased to 63% and 100% respectively. Thereafter, the radiographs demonstrated minimal change and maintained so-called 'radiological silence'. CONCLUSION: Osteointegration of fully HA-coated stems occurs in a predictable manner, and is noted in radiographs as early as the six-week follow-up period. Signs of osteointegration can be used as reliable indicators of solid femoral stem fixation after total hip replacement <![CDATA[<b>Bipolar hemiarthroplasty for stage III sickle cell-related avascular necrosis of the femoral head</b>: <b>a successful alternative to total hip replacement</b>]]> INTRODUCTION: The purpose of this study is to bring to the fore a simple, less expensive, biomechanically sound means of treating a devastating complication of sickle cell disease (SCD). SCD is a neglected haemoglobinopathy which is the most common cause of morbidity and mortality due to a genetic disorder. Avascular necrosis of the femoral head seen in sicklers is treated by total hip replacement which is expensive and fraught with complications of infection and revision in sickle cell patients. The simple bipolar hemiarthroplasty is easier to perform, less expensive, and relieves the patient of pain and limitation of movement. METHODS: All patients seen by one of the contributors with stage III Ficat and Arlet avascular necrosis of the femoral head (AVNFH) were assessed for pain and limitation of movement using the numeric rating scale (NRS) for pain and walking distance in metres. These were recorded. Patients were then operated on the hip via the anterolateral approach of Watson Jones. A bipolar endoprosthesis is inserted and the hip repaired. Post-operative NRS for pain and walking distances were measured and recorded. Complications such as infection, protrusion acetabula, and dislocation were also noted. RESULTS: The mean pre-operative walking distance was 172 metres with the highest being 400 and the lowest 50 metres. The mean post-operative walking distance was 614 metres indicating a more than three times improvement in the ability to walk long distances. The improvement was gradual and increased with time. The mean pre-operative NRS for pain was 6 with a range of 5 to 9. The average post-operative NRS was 3 indicating a two-fold decline in intensity of pain when sitting or walking. CONCLUSIONS: Bipolar hemiarthroplasty is a useful, successful modality of treatment for stage III osteonecrosis of the femoral head in SCD patients in low income countries. <![CDATA[<b>The anatomy of the anterior approach: a cadaver study</b>]]> BACKGROUND: This research investigated the anatomy underlying minimally invasive total hip arthroplasty when the anterior approach was used. METHODS: Ninety hips were dissected and in one cadaver, a complete hip replacement was performed. Simulations of the anterior approach surgical incisions were carried by the orthopaedic surgeon in order to see if injury to the lateral femoral cutaneous nerve (LFCN) could be avoided, when the correct anatomical landmarks were palpated. RESULTS: The data analysis revealed significant differences for the mean distances from the pubic tubercle to the straight head of the rectus femoris muscle. Statistical significance was detected for comparisons between males and females, for weight ranges and BMI categories. CONCLUSION: The study findings prove that the concerns relating to the course and distribution pattern of the LFCN and the lateral circumflex femoral artery (LCFA) using the anterior approach, could be overcome when the anatomy of the hip joint and the thigh is understood. However, it is important to note the possible variations in the course of the LFCN and the branching pattern of the LCFA In order to avoid intra-operative bleeding and possible thigh numbness post-surgery. <![CDATA[<b>The management of fragility fractures of the hip: a quality assessment project</b>]]> Fragility fractures of the hip (FFH) constitute the most serious complication of osteoporosis, carrying a mortality rate of up to 30% in the first year after injury. Less than 50% of affected patients will regain their pre-injury activity level. Surgical fixation of the hip fracture within 48 hours of injury, multimodal pain management, deep vein thrombo-prophylaxis, early physical therapy and simultaneous management of osteoporosis and frailty in a multidisciplinary approach constitute the standard of care for FFH to keep the mortality and morbidity rates as low as possible and prevent future fragility fractures. AIM: To assess the standard of care of FFH at our institution and determine areas of management which require more attention and improvement. METHODS: A retrospective review of clinical and radiographic records of all patients admitted at our institution for FFH from 1 January 2014 to 31 December 2014. The waiting time from admission to surgical fixation of the hip fracture, pain control and thrombo-prophylaxis strategies, rate of geriatric referrals and extent of osteoporosis management were assessed. RESULTS: One-hundred-and-thirteen FFH were admitted from 1 January to 31 December 2014; 98 clinical records and 98 pelvis radiographs were included in the study. The other 15 clinical records were incomplete and were therefore excluded. The average waiting time from admission to surgery was 49 hours (range 9-120). All patients received low dose morphine, paracetamol and tramadol for perioperative pain control. Low molecular weight heparin and compression stockings were prescribed for thrombo-prophylaxis in all patients. Only two (2.04%) patients had some osteoporosis investigations ordered and none of the patients were referred to the geriatric department, and none were formally treated for osteoporosis. CONCLUSION: While the waiting time from admission to surgery was largely within the recommended time frame, there were no signs of a multidisciplinary approach to the management of FFH at our institution, leaving osteoporosis and frailty largely untreated. <![CDATA[<b>Intramedullary nailing of subtrochanteric femur fractures caused by low velocity gunshots</b>]]> BACKGROUND: Subtrochanteric femur fractures remain challenging injuries to treat. There is paucity of literature evaluating their outcomes and complications following low-velocity civilian gunshots. The purpose of this study is to evaluate the results of intramedullary nailing of subtrochanteric femur fractures secondary to low-velocity gunshots. METHODS: A retrospective review of clinical and radiological data was performed on all patients who sustained subtrochanteric femur fractures (AO type 32C3) caused by low-velocity civilian gunshots treated at a single institution between March 2008 and December 2014. Data was analysed to determine the time to union, post-operative complication rates and patient outcomes. Radiographic evidence of healing was defined as bridging callus on three of four cortices on two orthogonal views. RESULTS: Fifty-one patients (48 men and two women) were identified. Mean age was 28 years (range 16-50 years). The predominant method of fixation was a cephalomedullary nail in 43 patients (84%), and eight patients had locking into the lesser trochanter. Thirty patients with a mean follow-up period of 3.3 weeks (0-6 weeks) were lost to follow-up. Twenty-one patients had adequate radiographic and clinical follow-up data suitable for analysis. The mean follow-up period was 24.8 weeks (range 2-40 weeks) for this group. The average time to union was 17.2 weeks (7-40 weeks). Seven fractures (37%) had delayed union. None of the patients required additional surgery. Union was achieved in all cases and no implant failure occurred. CONCLUSION: This study demonstrates that intramedullary nail fixation of subtrochanteric femur fractures caused by low-velocity civilian gunshots is an acceptable option for the treatment of these injuries with good union rates and low complication rates. <![CDATA[<b>Outcome of bilateral circular fixators in complex lower limb fractures</b>]]> Circular external fixators are increasingly being used for complex lower limb trauma. When these injuries are sustained to both lower limbs, the ideal management is unclear. We present the results of 25 consecutive patients who were treated with bilateral circular external fixators for complex tibial trauma. The final cohort consisted of 23 men and two women with a mean age of 31.8 years (range 21-62 years) and a median follow-up was 16.4 months (range 6-37 months). Bony union was achieved in 96% (48 out of 50) of the tibia fractures. The mean time to union was 26 weeks (range 13-71 weeks). Serious complications included chronic osteomyelitis that developed in one patient following a high-grade open fracture and unilateral non-unions in two patients. Bilateral circular external fixators are a viable treatment option for patients who sustain bilateral complex lower limb trauma. <![CDATA[<b>Outcomes of treatment of displaced midshaft clavicle fractures in adolescents using titanium elastic nails</b>]]> BACKGROUND: Literature on the functional outcomes following the treatment of closed, displaced midshaft clavicle fractures in adolescents is fairly limited. These fractures have traditionally been treated non-operatively; however, recent literature in adults shows improved outcomes with operative treatment, and it has been suggested that these results may translate to adolescents. STUDY OBJECTIVE: To assess the effectiveness of titanium elastic nailing in the treatment of displaced midshaft clavicle fractures in adolescents. METHODS: Adolescent patients (age 13 to 17 years) with closed, displaced midshaft clavicle fractures sustained between 2008 and 2015, were treated operatively with a titanium elastic nail inserted in an unreamed fashion from the sternal end of the clavicle by a single surgeon. Post-operatively, patients were immobilised in a sling for six weeks and attended scheduled follow-up visits at two, six and 12 weeks. The nail was removed from 12 weeks onwards in all cases. All patients were assessed by the surgeon with regard to the radiological outcome, Constant shoulder score, scar quality and complications RESULTS: Fifteen patients, 12 males and three females with a mean age of 14.9 years, were assessed. Fourteen patients went on to complete union by 12 weeks and the remaining one united by 20 weeks post-surgery. The difference in Constant shoulder scores between the affected and unaffected shoulders for 14 patients was below 11 at 12 weeks' follow-up and all patients were satisfied with their scar after 12 weeks. Two patients developed complications - one an iatrogenic perforation of the posterior cortex of the lateral fragment and one a haematoma after re-injury. CONCLUSION: Operative treatment with a titanium elastic nail is a safe, minimally invasive and reliable treatment method for displaced, uncomminuted midshaft clavicle fractures in adolescents. Level of evidence: Case series; Level IV evidence. <![CDATA[<b>Standardised post-operative radiographs for volar radial plate fixation: the '22/11 X-ray'</b>]]> BACKGROUND: The current standard post-operative radiographs for patients who have had volar locking plate fixation for a distal radius fracture may give the impression of intra-articular screw placement due to the normal anatomic inclination of the radiocarpal joint. Our aim was to determine: 1) if anatomically tilted post-operative radiographs increased the observer's confidence with regard to assessment of screw position, and 2) the intra- and inter-observer reliability of these radiographs. METHODS: Thirty patients' standard and tilted (11 ° postero-anterior and 22° lateral) post-operative radiographs were assessed by an orthopaedic intern, registrar, consultant, and a radiologist on two occasions. Single and combined views were analysed. RESULTS: There was no difference in confidence of assessment, but there was a significant change of assessment of actual screw position with fewer intra-articular penetrations reported with the tilted PA view. There was low intra-observer reliability except for the consultant orthopaedic surgeon. Inter-observer reliability was substantial when the intern's observations were excluded. CONCLUSIONS: The routine acquisition of the tilted PA radiograph can assist senior health professionals with important patient management decisions. LEVEL OF EVIDENCE: Level II. <![CDATA[<b>Intraosseous suture technique with K-wire stabilisation for fixation of mallet fracture with DIPJ volar subluxation</b>]]> BACKGROUND: Mallet fracture with distal interphalangeal joint (DIPJ) subluxation remains a challenging problem, with numerous techniques proposed for repair of this fracture. METHODS: The authors present a modified approach to mallet fractures with volar subluxed DIPJ by K-wire fixation and intraosseus suture of the avulsed extensor tendon. RESULTS: The described technique resulted in successful clinical management of 12 patients with isolated mallet fractures with volar subluxation with 1/12 patients having a complication of stable non-union CONCLUSIONS: The intraosseous suture technique with K-wire stabilisation offers a simple and reproducible technique of fracture reduction and stabilisation of volar subluxed DIPJ mallet fractures. <![CDATA[<b>An atypical large ulcero-budding type nodular fasciitis of the hand: a case report</b>]]> BACKGROUND: Nodular fasciitis is a benign soft-tissue tumour mimicking a sarcoma. It is generally subcutaneous and small in size. CASE PRESENTATION: The authors report an exceptional case of a large ulcero-budding proliferative nodular fasciitis located on the hand of a 15-year-old boy. CONCLUSION: This exceptional case focused on the effect of repetitive microtrauma on a nodular fasciitis. <![CDATA[<b>New Code to help harmonise medical and business ethics</b>]]> BACKGROUND: Nodular fasciitis is a benign soft-tissue tumour mimicking a sarcoma. It is generally subcutaneous and small in size. CASE PRESENTATION: The authors report an exceptional case of a large ulcero-budding proliferative nodular fasciitis located on the hand of a 15-year-old boy. CONCLUSION: This exceptional case focused on the effect of repetitive microtrauma on a nodular fasciitis.