SA Orthopaedic Journal

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Medicine American-style: On the sharp edge of the knife

Hip arthroplasty in HIV-infected patients

We conducted a prospective study evaluating the clinical outcome of the arthroplasty in HIV-infected patients. Between July 2000 to August 2001, 14 patients (mean age 42 years) underwent uncemented total hip replacement for osteonecrosis (10 patients) and neglected neck of femur fractures (four patients). Patients were classified according to the WHO and CDC classification and were operated by a single surgeon using the Hardinge approach. At a mean follow-up of 72 months, all patients were fully ambulant. The mean total lymphocyte count (TLC) was 2.24 cells/mm³, CD4-425 cells/mm³, CD8-873 cells/mm³ and CD4 /CD8-0.52. In three patients the CD4 counts declined to <200 and they are presently receiving antiretroviral therapy. There was no loosening, infection or dislocation. One patient sustained a periprosthetic fracture which was treated successfully non-operatively. We conclude that total hip replacement in HIV-infected patients who have not progressed to WHO stage IV can be rewarding and the procedure does not carry an increased risk of postoperative infection.

An evaluation of firework injuries to the hand - New Year 2007

A growing tradition among the residents of Johannesburg, South Africa, is to light firecrackers to welcome the New Year. Despite legal limitations on the sale of these explosives, firecrackers as well as larger fireworks are freely available in stores and on the streets of Johannesburg. Over the first few weeks of January 2007, our hand unit treated 34 patients who sustained blast injuries due to firecrackers. The injuries were sustained by patients of all ages. Five children were under 8 years of age, with the peak age group being 20 to 35 years. Only 50% of the injured were employed and 18% were scholars. The majority of injuries were to the right hand, the dominant hand in most patients. Twenty-four patients injured three or more fingers with some fingers having more than one separate injury. Twenty-one patients ended up with tissue loss of one or more digits. Thirty patients were debrided and/or repaired within five days of the injury. Three patients did not return for follow-up, two developed localised wound sepsis and required re-debridement, and a further three patients required extended follow-up for dressings. The remainder of the wounds healed uneventfully. Despite adequate wound healing, the functional loss and side-effects of these injuries are long-lasting or permanent. Social, legal and enforcement solutions are essential for the adequate resolution of this problem.

Incidence of syndesmotic injuries in all different types of ankle fractures

AIM: To determine the incidence of syndesmotic injuries in ankle fractures within the division of Orthopaedic Surgery, University of Pretoria. METHODS: A total of 94 serial patients with ankle fractures were assessed for syndesmotic injury by means of ankle mortise stress views and manual traction with a bone hook. Each fracture was classified according to both the Weber and Lauge Hansen classification and the incidence of syndesmosis injury in each group was determined. RESULTS: In total, 94 patients were evaluated over a 6-month period. There were 54 males and 40 females. The mean age was 39.3 years with a range of 13 to 85 years. An overall incidence of syndesmotic injuries of 32.97% (31 injuries) was found in our series. Of these 31 syndesmotic injuries 3% were Weber A, 29% Weber B, 65% Weber C, and 3% were isolated medial-malleolus fractures. According to the Lauge-Hansen classification, 3% were abduction injuries, 61% pronation-external rotation, 29% supination-external rotation and 7% vertical-compression dorsiflexion injuries. CONCLUSION: The overall incidence of 33% of syndesmotic injuries was much higher than expected. Due to the fact that an incidence of 3% in Weber A fractures and 29% in Weber B fractures was found, we suggest that all types of ankle fractures should be stressed in theatre.

The treatment of tibial defects following chronic pyogenic haematogenous osteomyelitis in children

The aim of this paper was to review the results of treatment of 31 children, aged 3 to 12 years, with tibial defects resulting from haematogenous osteomyelitis seen between 1989 and 2006. Common features were skin defects, discharging sinuses, pathological fractures, sequestra and pseudarthroses, with a duration of 4 to 12 months prior to reconstruction. The defects ranged from 2 to 20 cm, 18 were in the proximal third of the tibia, 10 in the middle third, and three in the distal third. Surgical treatment consisted of repeated debridement, sequestrectomy, gentamycin beads and soft tissue cover for skin defects, followed by reconstruction at a later stage. Bone grafting was done by using cancellous chips in cavitating defects (Papineau technique) (n = 2), onlay grafting in defects < 2 cm (n = 5), corticocancellous square segments threaded and fixed over a Kirschner wire in the defect (n = 15), and fibular transference to the proximal tibia in large defects with poor skin and fibrosis (n = 9). All grafts healed well at 1 to 17 years follow-up. Complications of shortening (1 to 20 cm), equinus (1), ankle varus (3) and recurvatum (1) were related to the infective process. All patients are ambulant.

Do patients prefer a unicompartmental to a total knee replacement?

BACKGROUND: Very few direct comparative studies evaluating the results after unicompartmental knee replacement (UKA) and total knee replacement (TKA) are available. Only three previous studies have reported the results of UKA and TKA performed in the same patient. We report our results of simultaneous UKA and TKA in the same patient, performed under the same anaesthetic, at same the time, by the same surgeon. This is the first study to assess the results of UKA and TKA in the same patient, where all the patients had the procedures performed under the same anaesthetic at the same time MATERIALS AND METHODS: Twenty-one patients who had simultaneous primary UKA in one knee and primary TKA in the other knee were evaluated prospectively by means of the SANE (Single Assessment Numerical Evaluation) rating. In addition each patient was asked the simple question: "Which is your preferred knee?" RESULTS: The follow-up period was a mean of 26 months (range 12-58 months). We found a statistically significant improvement in the SANE in both the UKAs and TKAs. Eleven patients had no preference between the UKA and the TKA (52.4%), seven patients preferred the TKA (33.3%) while three patients stated that the UKA was their preferred knee (14.3%). The trend for patients to prefer the TKA was not statistically significant (p= 0.27). CONCLUSIONS: UKAs have been shown to be kinematically superior and the preservation of the cruciate ligaments affords better proprioception than a TKA. However, the findings of this study suggest that this does not translate to a better patient preference. In view of this finding, and considering the documented inferior survival rates of UKAs, we propose that the role of UKA in the treatment of gonarthrosis be reassessed.

Management of intracapsular fractures of the hip in elderly patients

Intracapsular fractures of the neck of femur in the elderly patient population results in an enormous economic and social burden. The aim of this paper is to present a review of the literature providing guidelines for the management of this common fracture with emphasis on patient selection, optimisation and preventative strategies.

Radioulnar fusion for forearm defects in children - a salvage procedure

Eight children aged 1-14 yrs with defects in the forearm were treated with the one-bone forearm procedure and followed up for 1-11 yrs. The defects were due to pyogenic osteomyelitis (n=3), osteochondroma (n=3), neurofibromatosis (n=1) and ulnar dysmelia (n=1). The radius was fixed to the ulna shaft with an intramedullary pin in six cases, and two children had centralisation of the radial metaphysis onto the ulna for "radial club hand" type deformity with Kirschner wires. All forearms united in 3-6 months. Shortening ranged from 1-10 cm. Fixed flexion deformity of the elbow (20°) resulted in one child and cubitus valgus (20°) occurred in another. One child had a radial articular tilt of 45°. The procedure achieved stability at the wrist and elbow. There was cosmetic and functional improvement in all patients.

Pathological sacral fracture in type 1 neurofibromatosis

Complicated shoulder dislocation in the elderly patient

Anterior shoulder dislocation in the elderly patient is an injury that is often neglected. Because people are retiring early and living longer than previous generations, the demands for good function remain high despite an increased age. We report on the case of a 66 year-old male patient who had sustained a right anterior shoulder dislocation, greater tuberosity fracture and brachial plexus traction injury. An aggressive approach was followed which led to a satisfactory outcome. We also review opinions expressed in literature on the management of injuries associated with shoulder dislocation in the elderly.