Scielo RSS <![CDATA[SA Orthopaedic Journal]]> http://www.scielo.org.za/rss.php?pid=1681-150X20180004&lang=es vol. 17 num. 4 lang. es <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>The <i>p</i>-value: <i>p </i>for problem</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2018000400001&lng=es&nrm=iso&tlng=es <![CDATA[<b>An audit of circular external fixation usage in a tertiary hospital in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2018000400002&lng=es&nrm=iso&tlng=es BACKGROUND: Circular external fixation is a well-known treatment modality in reconstructive orthopaedic surgery and is frequently used for deformity correction, limb lengthening, limb salvage, and complex diaphyseal and periarticular fractures. The current use of this treatment modality in the South African context remains largely unknown. This retrospective review aims to describe the indications, outcomes and complications of the use of circular external fixation in a tertiary hospital in South Africa. MATERIALS AND METHODS: We retrospectively reviewed the records of 480 patients treated with circular external fixation in a specialist limb reconstruction unit. We report on patient demographics, comorbidities, indications and outcomes. RESULTS: The final cohort consisted of 346 men and 134 women with a mean age of 35.5 years (SD 14.9, range: 5-73). Comorbidities were identified in 163 (34.0%) patients. These included diabetes in 14 (2.9%) patients and smoking in 102 (21%) patients. HIV infection was diagnosed in 120 patients (25%) with a mean CD4 count of 425 cells/mm³ (SD: 223, range: 82-1056). The mean time in external fixator was 24.6% weeks (SD: 15.3, range 4-159). The treatment objective was achieved in 441 patients (92%). The overall complication rate excluding pin-site infection was 26%. Pin-site infection occurred in 88 patients (18.3%) but had no impact on the outcome of treatment. CONCLUSION: Circular external fixation treatment objectives can be achieved in a high percentage of patients in the context of a South African specialist reconstruction unit. This study shows favourable outcomes in deformity correction, limb lengthening, limb salvage, and complex diaphyseal and periarticular fractures. Comorbid factors, including HIV, diabetes and smoking had no effect on achieving the planned outcomes, but smoking did increase the overall time in external fixator. Level of evidence: Level 4 <![CDATA[<b>Unstable intertrochanteric fracture in elderly patients: outcome of primary cemented bipolar hemiarthroplasty versus internal fixation</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2018000400003&lng=es&nrm=iso&tlng=es BACKGROUND: The aim of this study was to evaluate the outcome of internal fixation in comparison with primary cemented bipolar (PCB) hemiarthroplasty in elderly patients with unstable intertrochanteric fracture. METHODS: A prospective cohort multicentre study compared cemented bipolar (n=60) to osteosynthesis (n=57) in unstable intertrochanteric fracture (AO/OTA classification) in the elderly. Peri-operative mortality, complications and functional outcome were used as main outcome measures. RESULTS: The two groups were comparable in age, sex, comorbidity, mode of trauma, and classification of fracture. In hemiarthroplasty, 93.3% of patients were able to start partial weight bearing on post-operative day 1, while in the internal fixation group, 75.4% of patients started partial weight bearing after two weeks post-operatively. At the final follow-up, one year after surgery, the mortality rate did not differ between the two groups, but general and mechanical complications were more common in the internal fixation group. The mean Harris Hip Score at final follow-up was better in the hemiarthroplasty group (91.14 vs 74.33). CONCLUSION: Primary cemented bipolar hemiarthroplasty was superior to internal fixation in terms of lower complication rates and better functional outcome. Level of evidence: Level 4. <![CDATA[<b>The prevalence and risk factors for urinary tract infection in elderly patients presenting with proximal femoral fractures: a prospective observational study</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2018000400004&lng=es&nrm=iso&tlng=es BACKGROUND: Proximal femoral insufficiency fractures are increasingly common in the elderly population. Urinary tract infection (UTI) is the most common associated complication in this group of patients with these injuries and may add to an already severe morbidity and mortality. The incidence of patients presenting with an established UTI from home is unknown as most research focuses on UTIs that occur after hospital admission. The aim of the study was to determine the prevalence of UTIs on admission and to compare urine culture results and patient profiles of these patients. METHODS: Forty patients presenting with a proximal femoral insufficiency fracture were identified on admission to casualty. A urine specimen was taken according to a standard protocol and sent for microscopy, culture and sensitivity (MCS). The organism and sensitivity profiles were determined from all positive MCS samples. Risk factors and patient demographics were identified using a questionnaire. RESULTS: Twenty of the 40 patients (50%) had a positive culture from the urine MCS. The most common organism was Escherichia coli (55%) [CI = 33.2; 76.8%] and the most common antibiotic sensitivity was to amoxicillin/clavulanic acid. Most of the organisms identified were resistant to ampicillin/amoxicillin and trimethoprim/sulfamethoxazole. Significant risk factors associated with an increased prevalence were female sex and the age of the patient. CONCLUSION: The prevalence of UTI in elderly patients with proximal femoral fractures is underestimated. Higher risk patients for presenting with a UTI from home are the elderly female patients above 80 years of age. Screening for, diagnosing and treating UTIs earlier has clear benefits for this specific group of patients to potentially decrease overall morbidity and mortality. LEVEL OF EVIDENCE: Level 4. <![CDATA[<b>Functional outcomes following surgical treatment of chronically unreduced simple elbow dislocations: a retrospective review</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2018000400005&lng=es&nrm=iso&tlng=es BACKGROUND: Chronic elbow dislocations are rare injuries that present late for orthopaedic management. The delay in presentation is frequently due to patients not seeking treatment after the initial injury, poor access to health care, inadequate initial treatment of acute dislocation or initial missed diagnosis. Chronic simple elbow dislocations refer to dislocations that remain unreduced for more than two weeks and are not associated with fractures. This study aims to evaluate the outcome of surgically treated chronic elbow dislocations. METHODS: A retrospective review of all patients who were treated for chronic simple elbow dislocations between September 2009 and August 2014 was undertaken. Further information regarding return to function was obtained from the records or telephonic consultation with the patients. Nine patients were included for final analysis. RESULTS: Nine patients were eligible for the study. Three patients were employed, three were scholars and three were unemployed. All patients were able to return to premorbid function with minor limitations due to occasional pain. According to the Mayo Elbow Performance Index (MEPI) score, two patients had excellent outcomes, three good and three fair. One could not be scored as there was no recorded scoring on the file and telephonic contact was unsuccessful. The range of motion varied from 20° of extension to 140° of flexion. One patient developed a stiff elbow but was able to adapt to activities of daily living. CONCLUSION: Surgical treatment of chronically unreduced simple elbow dislocations offers satisfactory outcome with minimal complications and should be considered for all patients presenting with this condition. LEVEL OF EVIDENCE: Level 4 <![CDATA[<b>Spinal fusion for paediatric lumbosacral spondylolisthesis</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2018000400006&lng=es&nrm=iso&tlng=es BACKGROUND: Paediatric spondylolisthesis can range from a benign non-progressive asymptomatic condition to rapidly progressive slips with associated debilitating axial and radicular pain. We reviewed our experience as to the presentation, surgical management and outcomes following surgery of this relatively rare condition. METHODS: We identified 24 paediatric patients who underwent surgery for spondylolisthesis from 2006-2017. The cohort consisted of 17 females and seven males with a median age of 13 years (IQR 11-14) at the time of surgery. A case note and imaging review was conducted. Presenting history and examination, aetiology and degree of slip, surgical technique employed, complications and outcome were analysed. RESULTS: Most patients presented with a combination of lower back and radicular symptoms, with five having radiculopathy as a single complaint. Seventeen cases involved instrumentation and 18 interbody fusions, with interbody cages used in 14, and bone graft alone in four. All but the four uninstrumented interbody fusions were performed with an all-posterior approach. In 11 of grade 1 and 2 slip cases, the listhesis was completely reduced. Four patients were partially reduced and in six patients, including one spondyloptosis, fusion was in situ. All patients with radicular symptoms were decompressed surgically, along with those where the listhesis was reduced. All but one patient has complete resolution of presenting symptoms at latest follow-up. Four patients required re-operation for complications related to the surgery. CONCLUSION: Paediatric spondylolisthesis can be successfully managed employing a variety of techniques. For low grade slips, reduction and interbody fusion is a safe and reliable method of improving spinal sagittal balance and relieving symptoms related to nerve root compression and spinal instability. For higher grade slips, reduction was associated with instrumentation failure in two patients and in-situ fusion via a combined anterior and posterior approach had a better outcome in our patients. LEVEL OF EVIDENCE: Level 4 - Case series. <![CDATA[<b>A new prototype of a non-ferromagnetic non-invasive femoral extendable prosthesis for skeletally immature patients</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2018000400007&lng=es&nrm=iso&tlng=es BACKGROUND: Modern extendable endoprostheses allow for non-invasive extension procedures to maintain limb length equality. However, these devices are incompatible with normal diagnostic techniques due to ferromagnetic materials and require physician-facilitated extensions. The aim, therefore, is to develop an extendable implant, capable of carrying out daily minor extensions comparable to natural growth, as well as permitting monitoring of the surrounding soft tissue site through MRI or CT. METHODS: A biocompatible, non-ferromagnetic prototype device has been constructed for in-vitro testing. The titanium body of the device encloses a piezoelectric motor, a gearbox, a lead screw/telescopic shaft and an electronic circuit board. Testing has been performed to quantify the linear force developed by the device, the electronics' survival and behaviour after gamma radiation, the permeability of water through the seals, the rate of extension and the suitability for MRI and CT imaging. In addition, an external control unit was manufactured, and designed to be programmable by the physician, to control both the amount of daily lengthening and the number of extensions until the next assessment. This device transmits power to the receiver of the extendable device (designed for transcutaneous placement), by means of inductively coupled coils. RESULTS: The prototype device, through its driving mechanism of the piezoelectric motor (a non-ferromagnetic motor), gearbox and a lead screw, produced an extension at a rate of 5 |jm/min and generated the required force of 500 N for limb extension under non-invasive external control. Testing under a strong magnetic field of 3 Tesla, the MRI imaging produced a void in the area where the extendable device was placed, but it did not produce artefacts typical of those observed with ferromagnetic materials. The electronic circuitry, within the prototype, withstood the effects of 25 kGy gamma sterilisation (required for biomedical implants prior to implantation), and the lead cable and inductive coil maintained their flexibility. The device was submerged in water at 37 °C and 10 kPa pressure for a period of 72 hours and no fluid passed its seals into the motor and gearbox chamber. After concluding the mechanical testing, as well as the MRI and gamma radiation, the external control unit successfully transmitted (via the inductively coupled coils) the signals to the piezoelectric motor, which functioned normally. CONCLUSIONS: The preliminary testing proved that the prototype could be developed into a suitable extendable implant delivering sufficient force for limb lengthening. The external electronic control unit can be programmed by the physician to allow daily extensions of the limb at a rate of 5 jm/min. At this rate a maximum daily extension of 30 jim will take 6 min. Although MRI testing at 3 Tesla magnetic field strength was inconclusive, but produced no artefacts or scattering, literature suggests that at the recommended strength of 1.5 Tesla, the MRI will produce a sharp and clear image of the device in the patient's limb. LEVEL OF EVIDENCE: Level 5. <![CDATA[<b>Osteoid osteoma of the hallux: a case report and review of the literature</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2018000400008&lng=es&nrm=iso&tlng=es Osteoid osteoma (OO) of the phalanges of the foot is a rare occurrence, making it a diagnostic dilemma. Classically OO presents with localised pain, which is worse at night. This pain is often relieved by the use of nonsteroidal anti-inflammatory drugs (NSAID). In the foot however it does not exhibit the classic radiological picture. This makes it difficult to distinguish from a more common diagnosis like infection and inflammation. This diagnosis should be considered in patients with no obvious cause for chronic night foot pain. We present a case of a child with osteoid osteoma of the hallux. Level of evidence: Level 5. <![CDATA[<b>Letter to the editor</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2018000400009&lng=es&nrm=iso&tlng=es Osteoid osteoma (OO) of the phalanges of the foot is a rare occurrence, making it a diagnostic dilemma. Classically OO presents with localised pain, which is worse at night. This pain is often relieved by the use of nonsteroidal anti-inflammatory drugs (NSAID). In the foot however it does not exhibit the classic radiological picture. This makes it difficult to distinguish from a more common diagnosis like infection and inflammation. This diagnosis should be considered in patients with no obvious cause for chronic night foot pain. We present a case of a child with osteoid osteoma of the hallux. Level of evidence: Level 5.