Scielo RSS <![CDATA[SA Orthopaedic Journal]]> vol. 7 num. 4 lang. pt <![CDATA[SciELO Logo]]> <![CDATA[<b>Message from the President</b>]]> <![CDATA[<b>Doctor, patient and the law: A delicate triangle</b>]]> <![CDATA[<b>Medical ethics - will it continue to exist?</b>]]> <![CDATA[<b>The importance of good communication in the physician-patient relationship</b>]]> <![CDATA[<b>Managing risks in surgical practice: A necessity</b>]]> The bi-annual seminar of the South African Medico-legal Society was held recently on the topic of "Management of medico-legal risks and costs in surgical practice in South Africa". The invited speakers were Dr Liz Meyer of the Medical Protection Society (MPS) and Adv Graham van der Spuy of the Cape Bar. Some of their excellent contributions follow in this report. Everyone who attended left the conference left more aware of the many risks of surgical practice and the possible legal consequences. <![CDATA[<b>Part I: Metabolic bone disease: Histomorphometry as a diagnostic aid</b>]]> Metabolic diseases affecting bone are generally diagnosed late when patients present clinically with end stage skeletal debilitation. This is the result of their subclinical progression and the lack of unequivocal biochemical-or radiological techniques to identify bone changes at an early stage. This manuscript presents histomorphometry as a quantifiable method for the accurate assessment of metabolic bone disease at cellular level. <![CDATA[<b>Accessory features of frozen shoulder</b>]]> We have described nine clinical features to aid the clinical diagnosis of frozen shoulder. These include symptoms of pain and pins-and-needles radiating down the arm to the hand, feeling of lameness in the arm, tenderness over the medial border of scapula, rotator interval and supraclavicular fossa, reduction of pain with passive abduction and forward flexion of the shoulder, asymmetry of the arm position at rest with an increase in elbow-to-waist distance and apparent winging of the scapula. In this prospective study, we report the sensitivity, specificity, predictive values and diagnostic accuracy of each clinical test and discuss their probable causes and clinical relevance. The single most accurate diagnostic test was relief of symptoms with abduction and flexion. In the diagnosis of a patient with a painful stiff shoulder, if six of the accessory features with the highest correlation are present, the probability of having frozen shoulder is 80%. <![CDATA[<b>Bifacet dislocations of cervical spine: Acute management and outcome</b>]]> INTRODUCTION: Although the goal in treating bilateral facet dislocations remains the early realignment of the spine, there is controversy regarding the timing and method of reduction, as well as the optimal approach for stabilisation. A retrospective analysis of prospective collected data from 36 consecutive patients treated for bilateral cervical facet dislocations (BCFD) at the Groote Schuur Hospital Acute Spinal Cord Injury Unit (ASCI) is presented. METHODS: Case notes and radiographs of 36 BCFD patients managed from April 2003 to January 2007 were reviewed with reference to reduction, stabilisation, radiographic measurements, union, neurology and complications. RESULTS: There were 27 males and 9 females. MVAs were the cause in 26 cases. C6/7 was the commonest level of dislocation, followed by C5/6. Seventy-five per cent of the patients had a complete neurological deficit, with only three limited to radiculopathy. Thirteen out of 21 had successful closed reductions, while 14/17 underwent successful open reduction via an anterior approach. Anterior cervical discectomy and fusion (ACDF) was utilised in 25 cases, posterior fixation in five, anterior and posterior in four, and conservative management in two cases. There were three cases of fixation failure, with two requiring revision. There were two transient recurrent nerve palsies but no sepsis. There was a 100% confirmed union rate. There were three deaths related to respiratory compromise. There was no difference in outcome between the posterior and anterior approaches. Although only a few patients improved neurologically, there were no patients with deteriorating motor function at last follow-up. CONCLUSION: Early aggressive surgical management for cervical bifacet dislocations yields good results. Open reduction followed by immediate stabilisation by ACDF is highly successful in the acute case and obviates the need for traction and possible associated neurological complications. In highly unstable cases or cases with poor screw purchase, supplemental posterior fixation may be required. Posterior alone surgery is occasionally indicated, such as delayed presentation and cervico-thoracic junction. Closed reduction with delayed stabilisation remains an acceptable option in the resource-restricted environment. <![CDATA[<b>The position of the 'bare spot' - not central in the glenoid</b>]]> Dislocation of the glenohumeral joint is often associated with a bony lesion of the antero-inferior glenoid rim. This can be assessed at arthroscopy using the 'bare spot' - an area in the central glenoid where articular cartilage is comparatively thin. The aim of this study was to assess the bare spot in a large number of cadavers. Fifty cadavers with no known history of bone or joint disease were examined. The bare spot was present in nearly 90% of shoulders and is centrally placed in the antero-posterior plane. However, the bare spot is significantly further away from the antero-inferior rim of the glenoid by 1.4 mm. The median distance from bare spot to the anterior rim is 13.2 mm, while the median distance to the antero-inferior rim is 14.6 mm. Bone loss of the antero-inferior glenoid is associated with failure of soft tissue repairs after shoulder dislocation. These data will help in the arthroscopic assessment of the glenoid and in decision-making for surgery for gleno-humeral instability. <![CDATA[<b>Evaluating donor tissue for bacterial contamination at the South African National Tissue Bank</b>]]> The internationally accepted method of acquiring allograft bone is to retrieve it in a sterile environment. In South Africa, we are limited by resources and funds, making it impossible to adhere to these standards of retrieval. The purpose of the study is to evaluate the safety of the surgically clean retrieval of allograft bone outside of a theatre set-up. The study population consisted of all the accepted donors from the beginning of 2003 to September 2008. The donors included in the study (n=749) were tested for microbial growths at various stages of retrieval and processing. An internal audit was done on the results and the safety of the processes was evaluated. The amount of bacterial contamination of the various samples was used to evaluate the safety of the process. We concluded that by following a strict protocol for processing and by using mandatory gamma irradiation our allograft is bacteria-free and extremely safe, making our method comparable with international standards. <![CDATA[<b>The use of allograft in knee surgery</b>]]> Musculoskeletal allograft has a wide application in orthopaedic surgery. The most common applications are bone and ligament allografts, but other tissues are also available for grafting. Knee surgery has evolved in the last few years, and there has been renewed interest in the use allografts around the knee. There is a wide variety of grafts available, and these have given us alternative management options for some of the most difficult problems in knee surgery. This review will cover osteochondral, meniscal and ligament allografts. <![CDATA[<b>Is a positive nerve conduction study a predictor of a satisfactory result after tarsal tunnel release?</b>]]> We reviewed 28 patients who had had tarsal tunnel syndrome diagnosed clinically and with the aid of nerve conduction studies over the last five years. The aim was to establish if a positive nerve conduction study was an indicator of a good postoperative result. We found that in general less than 50% of all patients were satisfied with the procedure and a positive nerve conduction study did not predict a good post-surgical outcome. We advise that surgery for tarsal tunnel syndrome even with positive nerve conduction studies be undertaken as a last resort, and patients be informed of the potential of a poor outcome after surgery.