Scielo RSS <![CDATA[SA Orthopaedic Journal]]> vol. 17 num. 3 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>Teaching philosophy</b>]]> <![CDATA[<b>Sham surgery: justified but practical? A systematic review of sham surgery trials in orthopaedics</b>]]> BACKGROUND: An increasing trend for sham surgery trials in minor orthopaedic procedures has been observed. Trial outcomes have changed the practice landscape of these procedures. However, there has been no sham surgery trial in a major orthopaedic procedure. The aims of this systematic review were to consider the ethics of sham surgery trials; to describe orthopaedic sham surgery trials conducted to date; and to consider the challenges that will need to be overcome in order to conduct sham surgery trials for major orthopaedic procedures in the future METHODS: A systematic review of the literature and clinical trial registries was undertaken. Trials with a published main findings paper underwent a risk of bias assessment using the Cochrane Collaboration risk of bias tool, in addition to an ethical assessment based on the work of Horng and Miller RESULTS: We identified 22 sham surgery trials for minor orthopaedic procedures that have been completed, terminated, or are currently in process. Among the ten trials with a published main findings paper, only one was free from risk of bias; all others were at risk of bias. According to the ethical assessment, the benefits of a sham control were outweighed by the risks in all but two of the ten trials. Across the 22 trials with published and unpublished main findings, participant recruitment within reasonable timeframes, as well as the low threshold for crossover from the sham were recurring challenges CONCLUSIONS: Researchers are obliged to carefully consider the feasibility of conducting a sham surgery trial in a major orthopaedic procedure, before drawing on limited research funds. Exploring the conditions under which patients and surgeons would find participation in a sham surgery trial acceptable, and simulating trial costs based on patient and surgeon preferences may assist funders, assessors and ethics boards to determine whether to support the conducting of future sham surgery trials in major orthopaedic procedures Level of evidence: Level 1 <![CDATA[<b>Mortality following hip fractures managed with hemiarthroplasty in the elderly in South Africa</b>]]> BACKGROUND: Limited studies are available documenting the demographics and mortality of hip fractures following surgery in South Africa and in Africa. The aim of this study was to evaluate short- and long-term mortality following displaced intracapsular femur neck fractures managed in the elderly with cemented hemiarthroplasty surgery at our institution METHODS: Data was collected from 561 patients who were treated from 1 May 2001 to 30 April 2014. Mortality was confirmed with the National Population Register RESULTS: The mean age was 77.96 years (SD=9.76) with more female (69.2%) compared to male (30.8%) patients. Male patients presented at a younger age (mean=74.6) than female patients (mean=79.4; p < 0.0001). The incidence of the affected side was similar, with right-sided hip fractures (49%) almost equalling left-sided hip fractures (51%). The overall cumulative all-cause mortality rates for patients were: 12.5% 30 days post-surgery, 22.7% 90 days post-surgery, 27.9% six months post-surgery and 34.3% one year post-surgery, respectively CONCLUSION: The results from this study showed a high mortality rate in comparison to international studies. Future research is required to identify risk factors associated with early mortality following hip fractures and this might help improving outcomes in our elderly patient population Level of evidence: Level 4 <![CDATA[<b>Fixation of extra-articular distal humerus fractures with a single posterolateral plate</b>]]> BACKGROUND: Our study aimed to establish that use of a single posterolateral plate for the open reduction and internal fixation of extraarticular metaphyseal humerus fractures resulted in consistent fracture healing, good functional outcomes and low complication rates. METHODS: A retrospective study was conducted at the Department of Orthopaedics, Northdale Hospital, Pietermaritzburg. A review of case X-rays and patient files from 1 January 2015 to 30 November 2017 of all patients who underwent operative intervention for extra-articular metaphyseal distal humeral fractures was undertaken. Standardised radiographs, functional assessment criteria (Quick Disabilities of the Arm, Shoulder and Hand Score - QuickDASH Score) and post-operative complications recorded in the patients' charts were analysed. RESULTS: Fifteen patients were included in the study. Ten male patients and five female patient's charts were analysed. The mean age of the participants was 33.13 years. All 15 patients showed adequate fracture healing on X-ray involving three or four cortices of the fracture site. There was no post-operative loss of fracture fixation. The mean humeral metaphyseal-diaphyseal angle was 84°, mean humeral-ulnar angle was 18°, mean shaft condylar angle was 40.4°, and the mean percentage of the capitellum anterior to the anterior humeral line was 49.3 per cent. The mean duration of surgery was 95.4 minutes. The mean QuickDASH score was 19.39. CONCLUSION: The use of a single posterolateral plating system for the fixation of extra-articular distal humeral fractures provides a viable alternative to dual plating. This method of fixation provided adequate stability of fracture fixation, good functional outcomes, low complication rates, shorter surgical times and less soft tissue dissection. This study supports current published evidence in this regard. Level of evidence: Level 4. <![CDATA[<b>Outcomes of segmental tibia fractures treated with circular external fixation at a single centre in a developing world setting</b>]]> BACKGROUND: Segmental tibia fractures historically are treated with special consideration due to their complexity, high complication rate and the propensity for associated injuries. Circular external fixators (CEFs) offer several potential advantages in this situation due to their modularity and minimally invasive application. These advantages have been demonstrated in several developed countries but not as yet in the developing world. This analysis aimed to evaluate if these beneficial outcomes are reproducible in a developing world environment. METHODS: We retrospectively assessed the data pertaining to skeletally mature patients who sustained segmental tibia fractures and were treated with CEFs between January 2008 to December 2015. These cases were performed in our tertiary hospital and overseen by a consultant with limb reconstruction experience. Union rates, time to union and complications encountered over a median of 10 months (range 6-20 months) follow-up period were among the outcomes measured. RESULTS: Fourteen male and three female patients with a median age of 34 years were included. Sixteen patients (94%) were injured as a result of high energy trauma, nine patients (53%) had associated injuries, fourteen cases (83%) were compound injuries and there were no cases of compartment syndrome. Fifteen patients (88%) united with the use of the initial CEF at a median of 25 weeks (16-52 weeks), the two cases of non-union were treated with adjustments to the CEF and distraction across the affected fracture site with ultimate union. Two cases (12%) of superficial pin infection were encountered and one case (6%) of deep infection occurred after union of the fractures necessitating removal of the CEF. Three cases (18%) developed malunion. CONCLUSION: Circular external fixators used for segmental tibia fractures, when applied in a developing setting by clinicians with limb reconstruction experience, display a satisfactory union rate and acceptable complication frequency, as compared to that achieved in developed countries. Level of evidence: Level 4. <![CDATA[<b>Sacroiliac joint involvement in spinal tuberculosis</b>]]> BACKGROUND: A discussion of the incidence and pathogenesis of tuberculosis of the sacroiliac joint and a description of an association with spinal tuberculosis. METHODS: A retrospective chart review was conducted in the spine unit on all inpatients admitted between 1 July 2014 and 30 June 2015. Patients with confirmed tuberculous spondylitis and/or sacroiliitis, who underwent adequate radiological examination of their sacroiliac joints, were included in the study. Available clinical and radiological investigations including plain X-rays, CT and MRI scans, were scrutinised to actively exclude sacroiliac joint involvement. RESULTS: Sixty-six patients with tuberculous spondylitis and one patient with isolated tuberculous sacroiliitis were included in the study. Seventeen patients had multilevel (>2 levels) contiguous involvement, while 14 patients had multilevel non-contiguous lesions. Thirty-four patients had associated iliopsoas abscesses. Thirteen patients (19.4%) were identified as having involvement of their sacroiliac joint(s). Six had bilateral involvement, five with right-sided and two patients with left-sided involvement. Eleven of the patients identified had associated iliopsoas abscesses, two of whom had gluteal and iliopsoas abscesses. The patient with isolated sacroiliac joint involvement had a gluteal abscess. CONCLUSION: Concurrent radiographic evidence of sacroiliac joint involvement is not uncommon in patients with spinal tuberculosis, more so when abscess formation is associated, and should be actively looked for and excluded in such cases. Level of evidence: Level 4. <![CDATA[<b>The FC Orth(SA) final examination: how effective is the written component?</b>]]> BACKGROUND: To determine the pass rate of the final exit examination of the College of Orthopaedic Surgeons of South Africa [FC Orth(SA)] and to assess the correlation between the written component with the clinical and oral component. METHODS: Results of candidates who participated in the FC Orth(SA) final examination during a 12-year period from March 2005 through to November 2016 were assessed retrospectively. Pass rates and component averages were analysed using descriptive and inferential statistics. Spearman's rho test was used to determine the correlation between the components. RESULTS: A total of 399 candidates made 541 attempts at the written component of the examination; 71.5% of attempts were successful and 387 candidates were invited to the clinical and oral component, of which 341 (88%) candidates were certified. The second-attempt pass rate for those candidates who wrote the written component again was 42%. The average annual increase in the number of certified candidates was 8.5%. The overall certifying rate increased by 1.5% for this period. Invited candidates who scored less than 54% for the written component were at significant risk of failing the clinical and oral component. The written component showed weak correlation with the clinical and oral component (r=0.48). CONCLUSION: While the written component was found to be an effective gatekeeper, as evidenced by a high eventual certifying rate, the results of this component of the FC Orth(SA) final examination did not correlate strongly with the performance in the clinical and oral component. This finding confirms the value of the written component as part of a comprehensive assessment for the quality of orthopaedic surgeons. Level of evidence: Level 4. <![CDATA[<b>HOST Study — HIV in Orthopaedic Skeletal Trauma Study: protocol for a multicentre case-cohort study</b>]]> BACKGROUND: Human immunodeficiency virus (HIV) and antiretroviral therapy (ART) have both been shown to reduce bone mineral density, mineralisation and bone turnover. Our study group and other researchers have suggested that HIV may impair fracture healing, based on extrapolation from basic science. These observations prompted this study as the true effect of HIV and highly active antiretroviral therapy (HAART) on bone healing is very poorly understood and has not previously been investigated METHODS: HOST Study is a multicentre case-cohort study being undertaken at two orthopaedic trauma centres in Cape Town, South Africa. All adult patients older than 18 years with fresh (within 2 weeks of injury), closed and open, tibia and femur fractures who undergo intramedullary (IM) nailing for fracture fixation will be eligible for the study. Participants will be recruited over 24 months and undergo a baseline questionnaire, HIV testing and assessment of their bone mineral density (BMD). They will be followed up at 2 and 6 weeks, and at 3, 6, 9 and 12 months. All adult patients who develop delayed bone union at the 6-month follow-up will be considered cases. Adult patients who show evidence of radiological union at 6 months or less will be considered controls. We will then determine if HIV is a risk factor for the development of delayed bone union. HIV prevalence levels in the cases and controls will be summarised using IRR (incidence rate ratio) statistics with their 95% confidence intervals. Negative binomial regression methods will be used to adjust the IRR estimates for the possible effects of confounding factors and/or important covariates RESULTS: Outcomes from the primary manuscript will be disseminated through publications in academic journals and presentations at relevant orthopaedic conferences. We will communicate trial results to all participating sites. Participating sites will communicate results with patients who have indicated an interest in knowing the results Trial registration number: NCT03131947 Site of study: Groote Schuur Hospital and Tygerberg Hospital, Cape Town, South Africa