Scielo RSS <![CDATA[SA Orthopaedic Journal]]> http://www.scielo.org.za/rss.php?pid=1681-150X20140003&lang=pt vol. 13 num. 3 lang. pt <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>Orthopaedic competence in South African junior doctors</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2014000300001&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Letter received from Dr JP Driver-Jowett</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2014000300002&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>The rise and fall of large bore metal-on-metal hip prostheses</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2014000300003&lng=pt&nrm=iso&tlng=pt ABSTRACT Metal-on-metal was the first articular couple to be successfully used in total hip replacement. Large heads and high frictional torque resulted in a high incidence of implant loosening. This led Charnley to introduce the low friction arthroplasty where the torque was reduced by using small heads and low friction hard-on-soft bearings. Osteoarthritis is a disease of cartilage, and resurfacing arthroplasty is therefore intuitively the logical conservative surgical solution. The early resurfacing devices with metal-on-plastic bearings were associated with catastrophic wear of the plastic. In the 1990s resurfacing was revisited, and metal-on-metal was selected to resolve the challenge of the bearing surface. Various factors were not initially recognised as being critical for the successful outcome of these implants. These include the importance of component orientation, the significance of an adequate 'arc of cover', the prevalence of edge loading, and the impact of microseparation. In addition the biological response - pseudotumour/ALVAL etc. - was unpredicted and unexpected. Femoral neck fractures in patients with a resurfacing arthroplasty were treated by revision to a stemmed implant with a large head. However this option was seen to have a wider application than resurfacing, was perceived as a 'high performance bearing' and addressed the problem of dislocation - one of the commonest causes of revision. These large bearings provided a dislocation 'safety net' to surgeons, many of whom consequently became less meticulous about component orientation. Liberation of metallic debris by fretting and corrosion at the taper junction between the large head and the taper of the stem - totally unforeseen by the bioengineers - emerged as a real problem in these hips. This paper attempts to scientifically place some of these issues in perspective against the backdrop of hysteria created by legal colleagues and the media. <![CDATA[<b>Venous thromboembolic disease in hallux surgery</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2014000300004&lng=pt&nrm=iso&tlng=pt INTRODUCTION: Hallux surgery is the most commonly performed elective surgery in the foot and ankle. As with all surgery, there are many potential complications quoted in the literature. Venous thromboembolism (deep vein thrombosis and pulmonary embolism) prophylaxis, however, is not adequately addressed and remains controversial. MATERIALS AND METHOD: This prospective study includes 100 patients who underwent hallux surgery. Risk factors implicated to increase the risk of developing venous thromboembolic disease as well as anaesthetic time, thigh tourniquet time and regional anaesthetic blocks were documented. Compressive ultrasonography was performed in all the patients post-operatively. RESULTS: There was one incident of calf deep vein thrombosis (DVT). No patient developed a pulmonary embolus. The one patient who developed a DVT was not at any higher risk than the average patient in the study. CONCLUSION: As a result of the low incidence of venous thromboembolic disease in this study, the authors do not recommend the routine use of chemical venous thrombo-prophylaxis in patients undergoing hallux surgery. The decision to give post-operative anticoagulation remains the surgeon's responsibility. The duration of prophylaxis will depend on when the patient is fully mobile. LEVEL: 2 <![CDATA[<b>The management of chronic osteomyelitis: Part II - Principles of post-infective reconstruction and antibiotic therapy</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2014000300005&lng=pt&nrm=iso&tlng=pt Over the past few decades considerable progress has been made in terms of our ability to reconstruct post-infective soft tissue and bone defects. Soft tissue reconstruction is not always required and it is frequently possible to achieve a tension-free closure of well-perfused tissue following debridement. It is now generally accepted that primary closure of the wound, be it by direct suturing or tissue transfer, may be performed at the same sitting as the debridement. In cases were debridement has resulted in tissue loss, muscle or musculocutaneous flaps appear to be superior to random-pattern flaps in achieving resolution of infection. The management of bone defects is dependent on several factors including the host's physiological status, the size of the defect, duration of the defect, quality of the surrounding soft tissue, the presence of deformity, joint contracture / instability or limb length discrepancy, as well as the experience of the surgeon. Surgery remains the mainstay of treatment when a curative treatment strategy is selected. As is the case with chemotherapy for bone tumours, antibiotic therapy fulfils an adjuvant role in curative management strategies. The choice of antibiotic, in this setting, remains a very difficult one and there are many problems with the interpretation of 'cure rate' data. The controversy surrounding the optimal duration and route of antibiotic therapy has not been resolved. The second role of antibiotics in the management of chronic osteomyelitis is disease suppression as part of a palliative treatment strategy. Further studies are required to clarify which patients may successfully be treated with antibiotics alone. <![CDATA[<b>Intraneural lipoma of the common peroneal nerve: A case report and review of the literature</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2014000300006&lng=pt&nrm=iso&tlng=pt Intraneural lipomas are rare hamartomas, encompassed within the spectrum of fatty lesions associated with peripheral nerves. More commonly associated with nerves of the upper limb, there are few reports of intraneural lipomas associated with nerves of the lower limb. In these cases they are usually found around the foot and ankle, or more proximally in the upper thigh or hip. We report a case of an intraneural lipoma associated with the common peroneal nerve: the presenting features, diagnosis and subsequent management. We give a concise review of fatty lesions associated with peripheral nerves, and in particular, intraneural lipomas. <![CDATA[<b>Alveolar soft part sarcoma in pregnancy: A case report and review of the literature</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2014000300007&lng=pt&nrm=iso&tlng=pt Alveolar soft part sarcoma is a rare tumour that mostly affects young female patients. Most published literature involves isolated cases or small case series. We report the case of a 23-year-old woman who presented with a fast-growing, isolated alveolar soft part sarcoma of the left calf. She had no co-morbidities and was 22 weeks pregnant at the time of presentation. Immunohistochemical analysis of the tumour revealed it to be positive for progesterone receptors. Wide excision was performed, with no local recurrence or systemic spread at six-month follow-up. The fact that the tumour expressed progesterone receptors, combined with previous reports of disease progression during pregnancy, raises the possibility of a hormonal contribution to the pathogenesis. This raises the possibility for novel treatment strategies and warrants further investigation. <![CDATA[<b>Early and medium-term complications of the modified Latarjet procedure</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2014000300008&lng=pt&nrm=iso&tlng=pt PURPOSE: We aimed to assess the short- and medium-term complications of patients who had undergone a modified Latarjet procedure. METHOD: We retrospectively reviewed the notes and X-rays of all patients identified by surgical log books and/or operation codes for instability. A telephonic follow-up was used to obtain an Oxford Shoulder Score (OSS) and information regarding complications. Patients who had a soft tissue stabilisation procedure were excluded. RESULTS: The data for 96 shoulders in 93 patients were available for follow-up. Thirty-four complications were noted in 30 patients. These included seven nerve injuries, all of which had resolved at final clinical follow-up; five screw-related complications; five early recurrent dislocations and three early recurrent subluxations, and 14 other minor complications. There was a total re-operation rate of 8%. Patients who developed complications had a median post-op OSS at last follow-up of 21, while those without complications had a median score of 13. A high-risk group of patients was identified. Epileptics, substance abusers and chronic dislocations were statistically more likely to have a poor outcome when they developed complications when compared with patients without these risk factors who developed complications (OSS 35 vs 14, P<0.002). Patients who did not develop a complication had a median OSS of 13. CONCLUSION: Epileptic patients, substance abusers and chronic dislocations were more likely to develop severe complications following a modified Latarjet. Once a complication occurred their outcomes were significantly worse. <![CDATA[<b>Assessing musculoskeletal training in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2014000300009&lng=pt&nrm=iso&tlng=pt A familiarity with musculoskeletal disorders is vital for medical school graduates. The purpose of this study was to investigate perceived deficiencies in undergraduate education to provide motivation for a restructuring of the curriculum. A basic competency examination in musculoskeletal medicine was used. Group 1 comprised 79 interns in their first postgraduate year. The recommended passing score for the examination was 73.1%. The score for the interns in Group 1 was 45.3%. Seventy-two (91%) of the 79 interns failed to demonstrate basic competency. The examination was reapplied to 53 interns (Group 2), to establish whether a two-month orthopaedic rotation during internship improved performance. The score for the group was 56.8%. 85.7% (18/21) of those who had completed an orthopaedic rotation and 93.8% (30/32) of those who had not completed an orthopaedic rotation failed the assessment. The additional exposure to musculoskeletal medicine during internship did not show statistical benefit (95% CI 58.0-79.5). In summary, 91% of medical-school graduates failed a basic competency examination, and no benefit was found from completing an internship rotation. We believe that undergraduate musculoskeletal education in South Africa is inadequate and that programmes throughout the country should be reassessed. <![CDATA[<b>Effect of additional ultrasound therapy to analgesics in treatment of acute low back pain: A randomised control trial conducted at the Aga Khan University Hospital, Nairobi (AKUH, N)</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2014000300010&lng=pt&nrm=iso&tlng=pt BACKGROUND: Acute low back pain (LBP) is a common condition that is encountered by many physicians with varied treatments instituted in its management. Ultrasound physiotherapy is a common modality used in its management, although its effectiveness and its role in management of acute LBP is not well known. METHODS: A randomised controlled trial was conducted to compare the effect of the addition of ultrasound therapy to a defined analgesia protocol in patients presenting with acute LBP at the Aga Khan University Hospital, Nairobi. The main outcomes were reduction in disability and pain which were evaluated using the mean change in Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) score for pain, respectively. Patients were followed up for a minimum of four weeks with assessment using the ODI and VAS at weekly clinic visits. RESULTS: Seventy-four patients were included in the study. Thirty-six patients were allocated to the analgesia with additional ultrasound group and 38 to the analgesia alone group. The Minimal Clinically Important Difference (MCID) of 10% points at four weeks after initiation of treatment was achieved in the ultrasound group but not in the analgesia only group. This difference was not statistically significant though, 10.35% vs 8.44%; p=0.36. There was no difference in the mean change in the ODI score between the two groups at any of the four follow-up visits after initiation of treatment. Mean difference in change of ODI (95% confidence interval) was -3.2(-7.0 to 0.6) after the first week, 2.96(-1.3 to 7.2) after the second and 1.90(-2.3 to 6.1) after the third week, p=0.36, 0.17 and 0.096 respectively. There was also no difference detected in the mean change of VAS score between the two groups at the first and fourth visit. Mean difference in VAS between the first and fourth weeks was 0.2 with a 95% confidence of -0.85 to 1.2 (p=0.72). CONCLUSION: The addition of ultrasound therapy to the treatment of acute LBP improved patient outcomes as assessed by an MCID of a disability index, but which was not statistically significant. No outcome difference was noted in the two groups using the VAS pain score. <![CDATA[<b>Expert Opinion on Published Articles</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2014000300011&lng=pt&nrm=iso&tlng=pt BACKGROUND: Acute low back pain (LBP) is a common condition that is encountered by many physicians with varied treatments instituted in its management. Ultrasound physiotherapy is a common modality used in its management, although its effectiveness and its role in management of acute LBP is not well known. METHODS: A randomised controlled trial was conducted to compare the effect of the addition of ultrasound therapy to a defined analgesia protocol in patients presenting with acute LBP at the Aga Khan University Hospital, Nairobi. The main outcomes were reduction in disability and pain which were evaluated using the mean change in Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) score for pain, respectively. Patients were followed up for a minimum of four weeks with assessment using the ODI and VAS at weekly clinic visits. RESULTS: Seventy-four patients were included in the study. Thirty-six patients were allocated to the analgesia with additional ultrasound group and 38 to the analgesia alone group. The Minimal Clinically Important Difference (MCID) of 10% points at four weeks after initiation of treatment was achieved in the ultrasound group but not in the analgesia only group. This difference was not statistically significant though, 10.35% vs 8.44%; p=0.36. There was no difference in the mean change in the ODI score between the two groups at any of the four follow-up visits after initiation of treatment. Mean difference in change of ODI (95% confidence interval) was -3.2(-7.0 to 0.6) after the first week, 2.96(-1.3 to 7.2) after the second and 1.90(-2.3 to 6.1) after the third week, p=0.36, 0.17 and 0.096 respectively. There was also no difference detected in the mean change of VAS score between the two groups at the first and fourth visit. Mean difference in VAS between the first and fourth weeks was 0.2 with a 95% confidence of -0.85 to 1.2 (p=0.72). CONCLUSION: The addition of ultrasound therapy to the treatment of acute LBP improved patient outcomes as assessed by an MCID of a disability index, but which was not statistically significant. No outcome difference was noted in the two groups using the VAS pain score.