Scielo RSS <![CDATA[SA Orthopaedic Journal]]> vol. 19 num. 1 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>Surgery of state patients in private hospitals - a free lunch?</b>]]> <![CDATA[<b>Femoral lengthening in children</b>]]> BACKGROUND: We evaluated the outcomes following femoral lengthening by distraction osteogenesis in children. Additionally, we determined the incidence and nature of complications, the management thereof and factors associated with the development of complicationsMETHOD: A retrospective review was performed of all patients who underwent femoral lengthening as an isolated procedure at our institution. Data regarding presenting details and clinical course were collected and X-rays analysed. The healing index (HI) and the percentage lengthened were calculated. Complications were defined as deep sepsis, joint contracture, fracture and neurological injuryRESULTS: Fifteen patients underwent 16 femoral lengthenings from 2008-2018. Nine patients had congenital short femur or proximal focal femoral deficiency, three patients had sequelae of meningococcaemia and four had various other pathologies. The median age at time of surgery was 9 years (6-13). Median follow-up was 1.6 years (0.5-6.6). The median HI was 32 days/cm (20-60). Leg lengths were equalised to <2.5 cm in 11 patients; length achieved was as planned in all but three patients. Eight patients sustained fractures on average six days (2-57) after frame removal, Ave through the regenerate. Four required surgery. Thirteen patients developed joint contractures of which six required additional procedures to address this. Two deep infections required surgery. Two patients developed neurological symptoms of which one recovered fully. Higher percentage length gained (&gt;20%) was associated with increased fracture and joint contracture rate. Diaphyseal osteotomy, as opposed to metaphyseal, was associated with increased risk of fracture (71% vs 25%). A diagnosis of congenital short femur was associated with increased fracture rate. Spanning the knee did not prevent joint stiffness in 4/5 patients but did prevent subluxationCONCLUSION: Femoral lengthening using external fixation can be successful in achieving leg length equality, but complications are common and often require additional surgery. Limiting lengthening to less than 20% of the original bone length and performing the osteotomy through the metaphysis decreases the risk of fracture and joint contractureLevel of evidence: Level 4 <![CDATA[<b>An epidemiology of paediatric cervical spine injuries at the Red Cross War Memorial Children's Hospital over a ten-year period</b>]]> BACKGROUND: Paediatric cervical spine injury (CSI) is rare compared to adult CSI. Very little has been published regarding the epidemiology and outcome of CSI in children in South Africa. The objective of this retrospective study is to characterise the epidemiology and report on the outcome of CSI in children <13 years at a tertiary referral centre for paediatric traumaMETHODS: We performed a retrospective study of CSI at our hospital over a ten-year period. The Picture Archiving and Communication System (PACS) of our institution was searched for patients with CSIs. Search terms included: cervical spine fracture, subluxation, dislocation, contusion, SCIWORA (spinal cord injury without radiographic abnormality) and retroclival haematoma. Demographic and clinical data were obtained from hospital records. Injury-related variables were compared for children <8 and &gt;8 years due to anatomical and biomechanical differences observed. Outcome was assessed using the Frankel gradingRESULTS: Sixty-six children were identified with a cumulative incidence of 0.1%. The median age was 7 years (inter-quartile range 4-8.8) and 65% were male. All injuries were caused by blunt trauma. Passenger motor vehicle injury (MVA) accounted for 52% of injuries. Injuries due to physical abuse, and recreational and sporting activities did not occur. Children <8 years of age incurred more injuries than those &gt;8 years (74.2% vs 25.8%). Ninety-eight per cent of injuries occurred in the upper cervical spine (C1-C4) of children <8 years. Of the 13 (19.6%) children with neurologic injury, Ave (7.5%) had complete spinal cord injury, four (6%) had incomplete neurology, and three (4.5%) died. SCIWORA occurred in six (9%) children with variable outcome. Seven patients (10.6%) were operated for instability. An injury severity score (ISS) of 25 (13-34) was associated with poor outcome. The mortality rate was 4.5% and all children who died were <8 years with upper CSIs and closed head injuries (CHIs) related to MVACONCLUSION: CSI occurred in 0.1% of patients evaluated following trauma. MVAs, either pedestrian or passenger, were responsible for the majority of these injuries. Children <8 years were more frequently injured and sustained injuries to the upper cervical spine. The majority of paediatric CSIs are stable injuries that can be managed conservatively; however, urgent surgical stabilisation is indicated for unstable injuries. CSI with associated CHI caused by MVAs in young children is associated with death. Even though our patients are referred from high violence communities, no CSIs were attributed to physical abuse or penetrating injuryLevel of evidence: Level 4 <![CDATA[<b>18F-FDG PET/CT as a modality for the evaluation of persisting raised infective markers in patients with spinal tuberculosis</b>]]> AIMS: The aim of the study was to investigate the differences in participant characteristics between positive and negative, positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography (18F-FDG PET/CT) activity at the spinal tuberculosis (TB) site following 12 months of the appropriate chemotherapy therapy for spinal Tb. A secondary aim of the study was to determine whether erythrocyte sedimentation rate (eSr) levels could be used as a reliable marker of TB activity and/or treatment success of spinal TB, especially in a high HIV-positive populationPATIENTS AND METHODS: All patients who were treated for spinal TB and underwent an 18F-FDG PET/CT scan were considered for inclusion. PET/CT positive patients underwent a spinal biopsy which was sent for microscopy, Gram staining, Gene Xpert (GXP) polymerase chain reaction (PCR) and histology. Patients in the PET/CT positive group underwent a repeat MRI scan and biopsy at the completion of treatment to investigate the potential presence of resistance or ongoing active spinal TB.RESULTS: A total of 18 patients were included in the study: Ave patients were allocated to the PET/CT positive group and 13 to the PET/CT negative group. The PET/CT negative group was significantly older (p=0.016) and had significantly fewer TB-infected vertebrae (p=0.010) than the pEt/CT positive group. Two patients, one in each group, were found to have drug-resistant spinal TB. At the 12-month follow-up visit, two patients (40%) in the PET/CT positive group and three patients (30%) in the PET/CT negative group were still complaining of back pain. All smear microscopy results of the PET/CT positive patients who underwent a repeat biopsy were negative after the conclusion of treatment; culture results (n=4/4) were also negative. GXP PCR results were positive in four and negative in one case. Only one of four samples showed classic Tb signs on histologyCONCLUSION: This study is the first to report on biopsies done from a PET/CT positive site, after 12 months of anti-tubercular treatment. It is not unlikely that PET/CT is over-sensitive and can show metabolic activity in areas of sterile inflammation, and future studies are necessary to evaluate thisLevel of evidence: Level 3 <![CDATA[<b>The accuracy of pre-operative digital templating in total hip arthroplasty performed in a low-volume, resource-constrained orthopaedic unit</b>]]> AIMS: Total hip arthroplasty (THA) is considered one of the most successful surgical procedures in modern medicine. The success of THA is well documented, and includes high patient satisfaction rates, low morbidity rates and cost-effective surgery. Most publications come from THA performed in high-volume arthroplasty units, done in high-income countries. Limited data is available on THA performed in low-volume, low-income countries. The aim of this study was to evaluate the accuracy of digital templating in a low-volume, resource-constrained orthopaedic unit from 2016 to 2017. We introduced a standardised hip radiography programme, followed by a stepwise pre-operative templating method. We compared the implant sizes inserted during tHa with the templated sizes determined pre-operatively. This was to deduct whether digital templating in a low-volume arthroplasty unit is accurate and of the same value as digital templating done in a high-volume unitMETHODS: A descriptive retrospective study was conducted on all patients who received elective primary uncemented THA in a low-volume, resource-constrained orthopaedic unit. Pre-operative radiographs were done according to guidelines published by Scheerlinck followed by pre-operative templating using the Impax Orthopaedic tools® software and a stepwise technique described by Bono. Implanted prosthesis sizes, as recorded in operation notes, were retrospectively compared to pre-operative templatingRESULTS: A total of 56 participants were included (30 females, 26 males), with a mean age of 55.5 (32-78) years. On the acetabular side, in 71% (n=40; p<0.001) there was a cumulative difference of one implant size between the templated cup size and the actual cup size used. On the femoral side, in 79% (n=44; p<0.001) there was a cumulative difference of one implant size between the templated stem size and the actual stem size used. Oversizing of the implants was more prevalent, with 20% (n=11) of the acetabular components oversized by two or more sizes and 13% (n=7) of the femoral components oversized by two or more sizesCONCLUSION: With the introduction of a standardised radiology programme and a stepwise templating technique, the benefits and accuracy of pre-operative templating done in a low-volume, resource-constrained orthopaedic unit is comparable to published data done in high-volume arthroplasty unitsLevel of evidence: Level 4 <![CDATA[<b>Surgical anatomy of the sciatic nerve and its relationship to the piriformis muscle with a description of a rare variant</b>]]> AIMS: Variation of the sciatic nerve may increase the risk of iatrogenic injury during total hip arthroplasty or arthroscopy, result in failure of peripheral blocks, or be associated with piriformis syndrome. Studies from Africa are scarce, with none to date from South Africa. Thus, the aims were to document the relationship between the sciatic nerve and piriformis muscle, variation in the bifurcation level and in the length of the nerve. Any significant differences between sexes and sides were also investigatedMETHODS: The lower limbs of 42 cadavers (84 limbs) were dissected and the relationship between the sciatic nerve and piriformis classified according to the patterns described by Beaton and Anson. The region of sciatic nerve bifurcation was documented, and the length of the nerve was measured in individuals with bifurcation in the thighRESULTS: The normal relationship between the sciatic nerve and piriformis muscle was present in 64 limbs (76.2%). The bifurcation level of the nerve was variable in more than half the sample. No significant differences occurred in any of the variant patterns or bifurcation regions between side or sex; however, variations were more common in females than in males. The mean length of the sciatic nerve was 133.30±19.33 mm, with no differences in length between sex or sideCONCLUSION: Variations in the anatomy of the sciatic nerve occurred in up to half of the sample, which may have implications for increased risk of iatrogenic injury in total hip arthroplasty and arthroscopy, piriformis syndrome or sciatic block failureLevel of evidence: Level 4 <![CDATA[<b>Intramedullary nailing of tibial non-unions using the suprapatellar approach: a case series</b>]]> BACKGROUND: A number of treatment options are available for diaphyseal non-unions of the tibia, including intramedullary (IM) nailing. An infrapatellar entry point with the knee in deep flexion can make this procedure challenging, especially with associated deformity or an obliterated canal. The suprapatellar approach allows nail insertion with the knee extended, which facilitates correction of malalignment in the sagittal and coronal planes. The aim of our study was to review the outcome of diaphyseal tibial non-unions, treated with an intramedullary nail, using the suprapatellar approachMETHOD: We retrospectively reviewed consecutive cases with non-union of the tibial shaft, treated with a suprapatellar entry nail between May 2016 and January 2018. Patients who were previously managed with a nail or who had active sepsis were excluded. The rate and time to union, as well as complications were assessedRESULTS: Thirteen cases were included and followed up until union at a mean of 5.8 months. All were performed percutaneously, without opening of the non-union site. Two patients developed complications, although bony union was still achievedCONCLUSION: A suprapatellar entry tibial nail is an acceptable treatment option for tibial non-unions not previously treated with a nailLevel of evidence: Level 4 <![CDATA[<b>Bursal synovial chondromatosis overlying a solitary osteochondroma of the distal femur: a case report</b>]]> Synovial chondromatosis and osteochondromas are frequently encountered benign cartilaginous lesions. The concomitant occurrence of these lesions is rare. We report one such case in an 11-year-old female patient and speculate on the common underlying pathogenetic mechanisms which might be involved.Level of evidence: Level 5