Scielo RSS <![CDATA[SA Orthopaedic Journal]]> vol. 16 num. 2 lang. pt <![CDATA[SciELO Logo]]> <![CDATA[<b>Growing local research in the era of Global Surgery</b>]]> Equity of access to quality musculoskeletal health care is a massive challenge for orthopaedic surgeons in South Africa. Over generations we have developed an inherent capability of frugal innovations and creative ways to improve our patient care. To establish a lean research culture and seek productive collaborations in the current research environment is key to generate indigenous evidence, independent of resources and funding. This bottom-up approach can co-exist and find synergies with an external strategy which evolved from the concept of 'Global Surgery'. <![CDATA[<b>Management of osteogenesis imperfecta at the Chris Hani Baragwanath Hospital</b>]]> BACKGROUND: Osteogenesis imperfecta (OI) is a genetically inherited metabolic bone disorder that results in multiple fractures and deformities in children. The treatment of OI has undergone tremendous improvement in the last two decades worldwide. AIMS: To review the clinical presentation and management of fractures in children with OI. METHODS: A retrospective audit of patients treated for OI at Chris Hani Baragwanath Academic Hospital. (CHBAH), from January 2000 to December 2011 was performed. RESULTS: Seventy-eight patients with OI were reviewed. The male to female ratio was 1:1.1. The median age at presentation was 20 months. The patients were classified according to the Sillence classification. Thirty-four patients were type III and 22 were type IV. Twenty patients (26%) had a first degree relative with OI The majority of patients received bisphosphonate (88%) and of these patients, 69 (93%) received intravenous bisphosphonate therapy; the remaining 7% received oral bisphosphonates. The most common long bone fractures were of the femur (93 fractures) and tibia (60 fractures). Sixty-six long bones (49 patients) received intramedullary rodding (IM). The mean age at time of surgery was 7 years. The indication for osteotomy and IM rodding was fracture of the long bones. Fifty-one long bones out of the 66 long bones rodded (77%) underwent revision surgery for complications - 49% (25/51) had rod migration, 39% (20/51) had peri-implant fractures and 12% (6/51) had rod breakage. Of 27 patients with type III OI, 14 (52%) were walking at final follow-up - eight were walking with assistive devices and six (22%) were walking independently. Of 19 patients with type IV OI, 16 (84%) were walking at final follow-up - four were walking with an assistive device and 12 (63%) were walking independently. CONCLUSION: An ongoing multidisciplinary approach to the management of children with OI is of paramount importance. There is an urgent need to improve the level of awareness of this rare condition among health professionals in order to facilitate prompt diagnosis and early referral. <![CDATA[<b>Assessment of emotional distress and parenting stress among parents of children with clubfoot in south-western Nigeria</b>]]> BACKGROUND: Clubfoot, the commonest orthopaedic congenital deformity in the tropics, is usually recognised from birth and affects one or both feet. The discovery of the child's deformity may diminish the joy of childbirth with attendant emotional reactions. Hence, this study assessed the levels of emotional distress and parenting stress among parents of children with clubfoot in Nigeria. METHODOLOGY: This was a cross-sectional study conducted among 58 parents of children with clubfoot attending the clubfoot clinic of a tertiary health institution in Nigeria. They completed a socio-demographic questionnaire, the Hospital Anxiety and Depression Scale (HADS) and Parenting Stress Index Short Form. RESULTS: The prevalence of emotional distress and parenting stress were 15.5% and 12.0% respectively. The mean score of parenting stress and its subscales were 67.44 (SD=18.07); parental distress 26.71 (SD=8.82); parents-child dysfunctional interaction 19.13 (SD=5.91) and difficult child 21.60 (SD=7.19). The patient age group was significantly associated with emotional distress level (x²=13.566, p=0.004). Pearson's correlation showed significant positive correlation between parental stress and the patient's age (r=0.277, p<0.05) and HADS depression score (r= 0.290, p<0.05). CONCLUSION: This study has provided relevant information on the experiences of Nigerian parents caring for children with clubfoot. Health care professionals involved with the care of children with clubfoot should also pay attention to the emotional wellbeing of the parents. <![CDATA[<b>Ligamentous integrity in Spinal Cord Injury without Radiographic Abnormality (SCIWORA): a case series</b>]]> PURPOSE OF STUDY: Prolonged bracing following injury in patients with Spinal Cord Injury without Radiographic Abnormality (SCIWORA) remains controversial. Some authors claim that there is occult instability and a risk of recurrent injury whereas others propose that the spinal column will deform elastically, but will return to its baseline stability by elastic recoil. We aim to assess the presence of ligamentous injury on MRI and the incidence of recurrent instability following SCIWORA in order to determine the need for prolonged bracing. METHODS: A retrospective chart review was performed for a series of 12 patients with documented SCIWORA that presented to Red Cross Children's Hospital over the past 8 years. Details regarding mode of injury, age at presentation, neurological deficit at presentation, MRI findings and long-term prognosis were documented. RESULTS: There were nine males and three females. The median age was 4.35 years. All patients were victims of high energy motor vehicle accidents. In two patients there was disruption of the ligamentum flavum at the level of the injury. There were no episodes of recurrent instability or neurological compromise in those patients that had recovered. None of our patients had rigid bracing following the diagnosis of SCIWORA. CONCLUSION: Infrequently observed disruption of isolated stabilising structures in SCIWORA did not lead to early or delayed instability in our patients. We did not find evidence to support the practice of prolonged rigid bracing to prevent recurrence following SCIWORA. LEVEL OF EVIDENCE: Prognostic case study, level IV. <![CDATA[<b>The microbiology of chronic osteomyelitis in a developing world setting</b>]]> OBJECTIVES: The primary aim of this study was to identify the microorganisms that cause chronic osteomyelitis in a developing world clinical setting and to characterise the antibiotic sensitivity profile of these pathogens. Furthermore, we aimed to determine whether the causative organisms vary in relation to physiological status of the host, the HIV status of the patient or the cause of the infection (post-traumatic, post-operative and haematogenous. METHODS: We performed a retrospective review of consecutive adult patients treated curatively for chronic osteomyelitis of long bones, over a two-year period. Patient charts were reviewed and data extracted in respect of patient demographics, the cause of infection, physiological status of the host in accordance with the Cierny and Mader classification, HIV status, surgical treatment strategy and causative organism. RESULTS: A total of 108 organisms were identified in the 60 patients included in the study. Multiple organism were cultures in 45% of patients, a single Gram-positive organism in 22% and a single Gram-negative organism in 26% of patients. In four cases (7%) no causative organism was cultured. The most prevalent organisms were Enterobacteriaceae (34%), Staphylococcus spp. (29%), Pseudomonas aeruginosa (11%), and Enterococcus spp. (9%). Many isolates were found to be resistant to commonly used empirical anti-microbial agents. Seventy per cent of Enterobacteriaceae spp. were resistant to either cefuroxime and/or ampicillin-clavulanic acid. Seventy-seven per cent of Staphylococcus aureus isolates were susceptible to cloxacillin. More than 50% of Pseudomonas aeruginosa strains were resistant to meropenem, imipenem, piperacillin-tazobactam or cefepime. There was a significant association between the aetiology of the infection and the microorganisms involved (p-value < 0.01). The bacterial pathogen profile was, however, not associated with the physiological status of the host (p=0.22) or the HIV status of the patient. CONCLUSION: While the majority of haematogenous chronic osteomyelitis still involved a solitary Gram-positive organism, the incidence of Gram-negative infections was found to be higher than previously reported. Contiguous chronic osteomyelitis was mostly polymicrobial in nature and solitary infections involving a Gram-negative organism was most common in the post-traumatic group. The bacterial pathogen did not vary in relation to the HIV status of the patient or the physiological status of the host. <![CDATA[<b>Subungual amelanotic melanoma of the hallux: Review of the literature with a case report</b>]]> Subungual melanoma of the hallux is a rare malignancy occurring mainly in elderly black Africans and Asians. It is often misdiagnosed as a benign lesion. We present a review of the English literature and report on a case of an 80-year-old Caucasian female patient who presented with a rare subungual amelanotic malignant melanoma of the hallux that was initially misdiagnosed as an ingrown toenail. Due to lack of pigmentation, amelanotic melanoma poses a huge dilemma in diagnosis. Upon comparing this case with the current literature, we propose that unlike most acral subungual melanomas, subungual amelanotic melanoma occurs mainly in elderly Caucasian females. Level of study: IV case series <![CDATA[<b>Incidence of Dupuytren's disease in Africans: A report of 48 new cases and a literature review</b>]]> BACKGROUND: Dupuytren's disease is rare in the black population. It was initially believed it occurred only in males of north European origin and since the initial confirmed report of a male of African descent with the disease only a few other Africans have been reported with the condition in the literature. We wanted to conduct a literature search for all reports of patients of African descent with the disease and to report on our own numbers in our institution. METHODS: We searched our theatre records for all surgeries for Dupuytren's disease from 1997 to 2015 and identified all those that are of pure African descent. A comprehensive literature search in Pub Med, Google Scholar and Clinical Key was then done to identify all reported cases to date. RESULTS: From our records a total of 48 patients were identified. Of them, 43 were male and five were female with an average age of 58.7 years (29 to 75). From the literature, only 462 patients were ever reported with the condition to date. One paper which constituted the majority of these cases was treated with caution as there were questions of reliability about the true ethnicity of the patients, leaving only 50 cases ever reported to date prior to our 48. CONCLUSION: The true incidence of Dupuytren's disease in Africans cannot be accurately determined but it is an extremely rare condition. Population studies should be encouraged so as to come up with an accurate incidence and disease burden. <![CDATA[<b>The radial nerve danger zone: A cadaver study</b>]]> Certain distal humerus fractures and elbow fracture dislocations warrant early fixation with an external fixator. The distal humerus is close to the radial nerve and a hazardous area for the placement of an external fixator. No known safe zone for the placement of an external fixator has been identified on the lateral border of the humerus. We record the incidence of radial nerve damage following external pin fixation and note the relation of the radial nerve to each pin. A total of 39 cadavers were dissected for this study. Two 4 mm pins were placed with a multi-pin clamp into the lateral border of the right and left humerus at 100 mm and 70 mm proximal to the lateral epicondyle. We dissected the upper limbs and recorded the incidence of radial nerve damage and the position of the nerve in relation to the two pins. Data for right and left sides were combined. The radial nerve was damaged by the proximal and distal pin in 56.4% and 20.5% respectively. The radial nerve was located anterior to the proximal pin (41%) and distal pin (79.5%). The radial nerve was located posterior to the proximal pin (2.6%) and distal pin (0.0%). We were unable to identify a safe zone from this study. We propose that pins should be placed less than 100 mm proximally from the lateral epicondyle and as posterior as possible to minimise the risk of radial nerve damage. <![CDATA[<b>Rapid mobilisation following total hip and knee arthroplasty</b>]]> INTRODUCTION: A rapid recovery protocol for hip and knee replacement surgery is a multidisciplinary, standardised pathway to meet the increasing demands for surgery and enhancement of recovery. This is the idea behind the recent global push by funders for cost effective, elective primary hip and knee arthroplasty. We report on a pilot study to assess the implementation and feasibility of a standardised care pathway in a South African private hospital setting. MATERIALS AND METHODS: Eligible patients presenting for primary hip or knee arthroplasty were enrolled in a rapid recovery programme. The protocol that was implemented was based on current literature and international best practices. It involved members of a multidisciplinary team and the standardisation of the treatment of patients undergoing elective hip and knee arthroplasty. RESULTS: Forty-six patients were enrolled in the pilot study and 43 patients were successfully discharged by the third post-operative day. There were no major complications and high patient satisfaction was recorded. CONCLUSION: This pilot study successfully implemented a multidisciplinary and standardised treatment protocol for hip and knee arthroplasty in a South African setting. The rapid recovery protocol proved to be safe and effective for the management of hip and knee replacements. <![CDATA[<b>Additive manufacturing in orthopaedics: Clinical implications</b>]]> BACKGROUND: The reconstruction of complex pelvic trauma or developmental bone abnormalities is challenging as it involves in-depth understanding of a complex three-dimensional structure. Advances in medical imaging and rapid prototyping allow for detailed pre-operative planning and manufacture of planning models, custom jigs and prostheses to make this type of surgery manageable with good results. METHODS: We report the reconstruction of a hip and proximal femur using planning models, jigs and custom prostheses produced by rapid prototyping methods. These tools helped to solve a complex problem and produced a good functional result for the patient RESULTS: In this case report the patient underwent the reconstruction of her right hip joint. She was unable to mobilise well independently prior to the surgery. The surgery provided her with a stable and functional hip joint. This allows her to mobilise independently with an external prosthesis. One year down the line she has a Fair MSTS score (14 of 30) CONCLUSION: Advances in medical imagining and rapid prototyping have produced planning and operative tools with which surgeons are able to solve complex problems safely and with good result. This technology has widespread use not only in orthopaedics but other surgical disciplines, and with increasing availability and improved cost effectiveness will be used more frequently in the future. Level of evidence: Level V (case report)