Scielo RSS <![CDATA[SA Orthopaedic Journal]]> vol. 20 num. 3 lang. pt <![CDATA[SciELO Logo]]> <![CDATA[<b>Antibiotic resistance - Netflix, HAL 9000 and the $100 billion question</b>]]> <![CDATA[<b>Proposal for a South African sarcoma registry</b>]]> <![CDATA[<b>Positive patient experience of wide awake local anaesthesia no tourniquet (WALANT) hand surgery in the government setting: a prospective descriptive study</b>]]> BACKGROUND: The purpose of this study was to establish a subjective patient experience with wide awake local anaesthesia no tourniquet (WALANT) procedures performed in the institution from May 2019 to March 2020. WALANT surgery was initiated to improve standard operating procedure and to decrease theatre burdenMETHODS: This prospective, descriptive study included 100 patients with a mean age of 59 years who required either a carpal tunnel or trigger finger release. The patients' pain experience was documented on the visual analogue scale (VAS) for the local anaesthetic injection and the surgical procedure. Overall experience was assessed on the patient's preference to have the procedure performed by the WALANT method or the conventional methodRESULTS: One hundred patients were included, of which 67 had medical comorbidities. The mean VAS score was 1.5 (SD±1.6) with pain on injection. The mean VAS pain score during the surgical procedure was 0.2 (SD±0.7). One hundred per cent of patients (100/100) felt they would do the WALANT outpatient procedure again instead of admission to hospital and surgery in the theatre. Two complications occurred related to wound care problems, and were successfully managed. None of the patients required reoperations for incomplete release of the carpal tunnel or trigger finger surgeryCONCLUSION: The results of this study suggest that minor hand surgery using the WALANT protocol can be performed effectively and with high patient satisfaction rates in the orthopaedic outpatient clinic, and is a useful tool in the skillset of a hand surgeonLevel of evidence: Level 4 <![CDATA[<b>The prevalence of vascular injury utilising the lateral parapatellar approach for malignant distal femoral tumour resections: a case series</b>]]> BACKGROUND: Distal femoral tumour resections are mostly performed through a medial or anteromedial approach. The lateral parapatellar approach is an alternative method. This case series assessed vascular complications during the resection of malignant distal femoral tumours via the lateral parapatellar approachMETHODS: A retrospective case series at a private practice in Pretoria was performed. All patients who underwent malignant distal femoral tumour resections through a lateral parapatellar approach between 2001 and 2019 were included in the study. All cases were performed by a single surgeon. An analysis of the patients' files was performed, to determine if there were any intraoperative or immediately postoperative vascular complicationsRESULTS: Thirty-six patients were identified who underwent resection of their malignant distal femoral tumours via the lateral parapatellar approach. Osteosarcoma was the most prevalent bone tumour (81%). All resection margins were clear on histology reports. The vascular complication rate was 3% (95% CI 0-8%). Twelve patients demised over the 18-year period (33%CONCLUSION: The findings suggest that a low risk of vascular complications can be expected when resecting malignant distal femoral tumours through a lateral parapatellar approach. This rate of vascular injury is comparable to other studies that also performed distal femoral tumour resections through other approachesLevel of evidence: Level 4 <![CDATA[<b>The surgical management of metastatic lesions of the femur</b>]]> BACKGROUND: Malignant tumours commonly metastasise to bone. When this occurs in the femur, surgical intervention is required to reduce pain and restore mobility post fracture, or as a prophylactic measure when fracture is anticipated. This is typically in the form of replacement with hemi- or total arthroplasty or stabilisation with an intramedullary device. The indications for one modality over the other are debatable and the reported outcomes and complications are varied. The purpose of this study is to assess the management algorithm for bony metastasis of the femur at a tertiary bone tumour unit, and the outcomes of the surgical strategies employedMETHODS: A retrospective cohort study was performed of all patients presenting to our institution with femoral metastasis, both with and without pathological fracture, who were managed surgically from April 2016 to February 2020. Fractures of the femoral neck were managed with cemented arthroplasty. All other fractures were managed with intramedullary nailing, as were all lesions requiring prophylactic stabilisation. Data was recorded regarding demographics, primary pathology, location of lesion, type of surgery, and implant used. The incidence of complications including radiological failure of fixation, infection, thromboembolic phenomena, re-operation and mortality were recordedRESULTS: Eighty-five femurs in 77 patients were included (mean age 61 years, range 20-90). Lesions were located in the femoral neck (19/85, 22%), intertrochanteric (20/85, 24%), subtrochanteric (40/85, 47%), diaphyseal (2/85, 2%) and metaphyseal/per-condylar (4/85, 5%) regions of the femur. A total of 64/85 (753%) procedures were performed for fractures and 21/85 (25%) prophylactically. Eighteen of the 85 (21%) underwent long-stemmed cemented bipolar hemiarthroplasty, 1/85 (1%) long-stemmed cemented total hip replacement (THR), 62/85 (73%) cephalomedullary nailing, and 4/85 (5%) retrograde femoral intramedullary nailing. Mean follow-up was eight months (range 1-36). There were no dislocations or periprosthetic fractures in the arthroplasty group. One failure (1/66, 2%) of fixation occurred in the intramedullary nailing group. Six deaths occurred in the arthroplasty group (6/64, 9%) and 24 in the nailing group (24/66, 36%) during the study period. Four patients suffered from thromboembolic phenomena (4/77, 5%). Of the 13 patients who sustained a pathological fracture and were managed with intramedullary nailing and followed up for at least one year, all had achieved clinical and radiological unionCONCLUSION: Femoral metastasis can be appropriately managed with intramedullary nailing, both prophylac-tically and in the event of fracture, with a low rate of implant failure and an expectation that healing will occur once stabilised. Intracapsular fractures can be managed with long-stemmed cemented arthroplasty with a low risk of subsequent fracture or dislocationLevel of evidence: Level 4 <![CDATA[<b>Phosphaturie mesenchymal tumour, 'non-phosphaturic' variant: a case report and review of the literature</b>]]> BACKGROUND: Phosphaturic mesenchymal tumours are uncommon neoplasms, usually associated with tumour-induced osteomalacia, that occur in middle-aged adults but have been reported at the extremes of age. The 'non-phosphaturic' variant is even rarerMETHODS: Herein, we describe the non-phosphaturic variant in a 12-year-old male who presented to the Department of Orthopaedic Surgery with a six-month history of painful progressive swelling of his right forearm in the absence of trauma. He had no other significant symptomsRESULTS: The patient had normal serum calcium and phosphate levels on biochemical analysis. An inci-sional biopsy was performed and a histopathological diagnosis of a phosphaturic mesenchymal tumour, non-phosphaturic variant, was rendered. Six weeks later, he underwent surgical excision of a 15x15 cm soft tissue mass from his right forearm. He had an uneventful postoperative period and was discharged. He has been followed up at the outpatient department and has been free of tumour recurrence for over 18 months since his surgery with no evidence of osteomalacia and no other tumoursCONCLUSION: Phosphaturic mesenchymal tumours are rare mesenchymal neoplasms and their microscopically identical counterpart without phosphaturia, known as the 'non-phosphaturic' variant, is even more uncommon and may prove a greater diagnostic challenge. While the diagnosis may be confirmed by hypophosphataemia and phosphaturia secondary to the paraneoplastic phenomenon of tumour-induced osteomalacia, there may be instances, such as with our patient, where tumour-induced osteomalacia is absent. This case underscores the importance of clinicopathological correlation together with a wide differential diagnosis required to arrive at a correct diagnosis to facilitate appropriate patient managementLevel of evidence: Level 5 <![CDATA[<b>Malignant transformation in an 11-year-old child with multiple hereditary exostosis</b>]]> BACKGROUND: Multiple hereditary exostosis (MHE) is a rare autosomal dominant disorder predisposing to the development of multiple osteochondromas. Malignant transformation is an uncommon complication of osteochondromas and is especially rare in the paediatric population. Making a diagnosis of malignant transformation is recognised as a challenge globallyMETHODS: We obtained informed consent and ethics approval prior to reviewing the hospital file, radiology and pathology of our index patient, as well as conducting a directed literature searchRESULTS: An 11-year-old male with MHE presented with new onset pain in the right leg with an associated inability to weight bear. Plain radiographs and magnetic resonance imaging (MRI) showed features consistent with malignant transformation. The child underwent a Malawer 1 resection of the proximal fibula with no complications. The pathology confirmed a grade 1 secondary peripheral chondrosarcoma (CS) arising in an osteochondroma The rate of malignant transformation in MHE is as high as 36.3% in select specialist tertiary centres. Ninety per cent of the resultant malignancies are chondrosarcomas. Malignant transformation before the age of 20 years is exceptional. Plain radiology is routinely used for monitoring of patients with MHE. Other modalities exist to assess for cartilage cap thickness, a much-debated criterion of malignant change. Pathology is essential for confirmation of malignant transformation as well as to exclude high grade lesions. Treatment is wide local excision (WLE) with limb-sparing surgery and long-term follow-up to detect for local recurrences.CONCLUSION: The malignant transformation of osteochondromas occurs more frequently in individuals with MHE and may even arise in the paediatric population. In the presence of suspicious clinical or radiological features, en-bloc surgical resection and histopathological correlation is mandatory to make the diagnosis. We encourage a multidisciplinary team approach with collaboration between the orthopaedic surgeon, radiologist and pathologistLevel of evidence: Level 5 <![CDATA[<b>Correlation of the squat-and-smile test against other patient-reported outcome scores in knee pathology</b>]]> BACKGROUND: The use of patient-reported outcome measures (PROMs) for knee pathology may be affected by socioeconomic factors, language barriers and time constraints in busy outpatient clinics. The squat-and-smile test (SST) is an example of such a test that has previously been validated for femur fractures. The aim of this study was to validate the SST against other PROMs in patients with knee pathologyMETHODS: Patients presenting to a subspecialist knee clinic in a large hospital in sub-Saharan Africa were approached to participate. They were asked to squat and the depth of the squat as well as the need to support themselves were classified into four categories. To describe their pain, participants also selected one of three smiley faces (unhappy, neutral, smiling). These test scores were correlated to the patient's Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner Lysholm score and EQ-5D scoresRESULTS: Seventy patients (median age 53.4 years) were included. The squat depth correlated moderately with the KOOS score (r=0.56) and poorly with the EQ-5D and Lysholm scores (r=0.46; r=0.43). The need for squat support had poor correlations with the KOOS, EQ-5D and Lysholm scores (r=0.29; r=0.31; r=0.31), as did the smiley face component (r=0.40; r=0.32; r=0.30CONCLUSION: For patients with knee pathology, the squat depth correlates moderately with other PROMs. It could therefore be used in settings for which conventional PROMs have limited application. Support needed to squat, and a visual analogue scale of smiley faces, had poor correlation when compared to other knee PROMs and should not be used for the assessment of knee pathologyLevel of evidence: Level 4 <![CDATA[<b>A computer tomography-based anthropomorphic study of forearm osteology: implications for prosthetic design</b>]]> BACKGROUND: The aim of this study was to accurately establish the variability in the anatomy of the radius and ulna in the context of the design of an intramedullary nail for both bonesMETHODS: Forearm computed tomography scans were used to measure the specific internal and external anatomy of the radius and ulna in adult patients. Patients with fractures or dislocations involving either the radius and/or ulna were excludedRESULTS: A total of 97 scans, comprising 84% male and 16% female patients, were included. The mean radius length was 238.43±18.38 mm (95% CI 234.60-241.74 mm). The mean curvature was an arc with a radius of 561.43±93.49 mm (95% CI 543.09-580.78 mm). The smallest measurement of the canal width was 5.17 mm (95% CI 4.87-5.47 mm). The ulna showed a mean length of 259.90±19.88 mm (95% CI 255.89-263.91 mm). The smallest measurement of the canal width was 4.80±1.30 mm (95% CI 4.53-5.87 mm). The mean proximal shaft angle was 11.39±3.30° (95% CI 10.76-12.82°CONCLUSION: This computed tomography scan-based anthropomorphic study has identified novel anatomical features and associations of human forearm bones. This information will be used in the design and manufacture of anatomic intramedullary devices to better manage radius and ulna fractures or pathologyLevel of evidence: Level 4 <![CDATA[<b>Patella dislocations and patellofemoral instability: a current concepts review</b>]]> Lateral patellar dislocation affects young, active patients with an incidence rate of 5.8 per 100 000. The management of first episode dislocations is non-surgical in the majority of cases, unless associated pathology dictates surgical intervention. Approximately 40% of cases that are treated non-surgically will develop recurrent patellofemoral instability. Evidence supports surgical intervention in these cases; however, the best approach is debatable. Most research and consensus statements agree that medial patellofemoral ligament reconstruction (MPFLR) should be performed in most cases. Additional procedures can be used 'a la carte' according to certain conditions or pathology. A tibial tubercle osteotomy (TTO) is usually indicated in patients with maltracking and/or patella alta, but the direction and degree of correction must be carefully considered. Trochleoplasty is technically demanding and should be reserved for a select few patients with severe trochlear dysplasia. It should be performed by an experienced knee surgeon due to the high risk of inadvertent complications.Level of evidence: Level 5