Scielo RSS <![CDATA[SA Orthopaedic Journal]]> http://www.scielo.org.za/rss.php?pid=1681-150X20090004&lang=en vol. 8 num. 4 lang. en <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>Why do we become orthopaedic surgeons?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2009000400001&lng=en&nrm=iso&tlng=en <![CDATA[<b>Editorial</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2009000400002&lng=en&nrm=iso&tlng=en <![CDATA[<b>Letter to the Editor</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2009000400003&lng=en&nrm=iso&tlng=en <![CDATA[<b>Comparison of pre-operative correction X-rays with post-operative correction achieved in adolescent idiopathic scoliosis</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2009000400004&lng=en&nrm=iso&tlng=en AIM: To determine how accurately pre-operative stress radiographs predict the final outcome in adolescent idiopathic scoliosis surgery. METHODS: Records of 20 patients were reviewed retrospectively. Pre-operative correction was measured by comparing the initial Cobb angle of the main structural curves on plain standing radiographs to values measured at corresponding levels after correction on traction and fulcrum bending radiographs. Post-operative correction was obtained by measurements at corresponding levels of the instrumented and uninstrumented curves. RESULTS: Mean correction of the main instrumented curve by traction was 24.2° (40.9%), and by fulcrum bending 32.3° (56.0%). Post-operative correction yielded a mean value of 41.1° (68.2%). Expressing pre-operative values as a percentage of final correction, traction views predicted 60%, and fulcrum bending radiographs 82% of the final correction. If agreement within 10° of pre- and post-operative values is regarded as clinically significant, only 18% of traction and 45% of fulcrum bending views came within that range. DISCUSSION: We concluded that fulcrum bending views are of superior predictive value in terms of surgical correction to be expected, but still correlate poorly with final surgical correction achieved. <![CDATA[<b>Avascular necrosis and chondrolysis in slipped upper femoral epiphysis</b>: <b>A comparative study between multiple pin fixation with or without osteotomy and single screw fixation</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2009000400005&lng=en&nrm=iso&tlng=en Single screw in situ fixation for the management of slipped upper femoral epiphysis was introduced in 1990 and has been reported to result in a decreased incidence of avascular necrosis and chondrolysis compared to previous methods using multiple pin fixation with or without osteotomy. To investigate this we retrospectively reviewed two groups of patients. Group A (44 patients, 55 hips) was treated over a 27-year period (1963-1989). Forty-four hips were treated with multiple pins and 11 hips had primary intra- or extracapsular osteotomy with multiple pin fixation. Group B (83 patients, 106 hips) was treated over a 7-year period (1999-2005) with single screw fixation without osteotomy. All patients were followed up for at least 2 years. In group A avascular necrosis occurred in eight hips (14.5%); five occurred after osteotomy; two after forceful manipulation; and one was due to pinning in the posterosuperior quadrant of the femoral head. Chondrolysis occurred in 14 hips (25%), of which six (11%) were due to persistent pin penetration, and in eight (14%) chondrolysis was present at presentation (before treatment). In group B avascular necrosis occurred in only two hips (2%); both were severe, unstable slips. Chondrolysis occurred in ten hips (10%) of which two (2%) were due to persistent pin penetration, and eight (8%) had chondrolysis at presentation We conclude that single screw fixation is a safer technique than multiple pin fixation or osteotomy. Without osteotomy avascular necrosis only occurs in severe, unstable slips. Chondrolysis due to pin penetration is almost eradicated. Chondrolysis at presentation, however, is still prevalent and occurs in female patients with severe, chronic slips. <![CDATA[<b>Retrospective review of multiple myeloma and immunosecretory disorder cases diagnosed in a tertiary setting</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2009000400006&lng=en&nrm=iso&tlng=en PURPOSE OF THE STUDY: Despite the relatively high incidence of multiple myeloma reported worldwide, South African statistics seem to be significantly lower. Our purpose in doing this study was to determine whether patients with suspected immunosecretory disorders are being appropriately evaluated and followed up. Secondary purposes include an impression of the most common clinical features prompting investigation as well as the stage of disease at time of diagnosis. DESCRIPTION OF METHODS: All patients investigated for immunosecretory disorders by serum or urine electrophoresis over a 4-year period were included in this study. Each patient's laboratory and radiological data were evaluated to determine the true diagnosis, and assess the comprehensiveness of the investigation. SUMMARY OF RESULTS: In total, 582 patients were included - 39 patients had multiple myeloma (6.7%). A single case of plasmacytoma and plasma cell leukaemia was identified. Waldenström's macroglobulinaemia was identified in seven patients (1.2%) and monoclonal gammopathy of undetermined significance (MGUS) in 83 patients (14.3%). Due to the risk of progression from MGUS to multiple myeloma, patients need to be re-evaluated biannually, shown to be the case in only 11% of cases. Of all the malignant disorders (48 cases) the majority of patients were diagnosed in an orthopaedic setting (45%), followed by internal medicine (39%). Radiological abnormalities were the most common clinical finding prompting investigation, with lytic lesions or osteoporosis seen in 50%, pathological fractures in 17% and neurological manifestations noted in 18% of cases. The majority of patients who could be staged were diagnosed at a relatively late stage of disease, rendering the prognosis worse than in early disease. This suggests a relatively low index of suspicion in our clinical setting. CONCLUSION: Multiple myeloma and related disorders are commonly encountered in the orthopaedic setting. Although the sample size is small, this data suggests that patients are diagnosed late in disease progression and often not evaluated appropriately. A clear protocol should be established to actively exclude this diagnosis if it is suspected. <![CDATA[<b>Shoulder dislocations: Management by doctors in emergency units</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2009000400007&lng=en&nrm=iso&tlng=en The risk of recurrent instability after shoulder dislocation reduces with increasing age at time of first dislocation with recurrence in young patients of up to 100%. While traditional immobilisation has been shown to be ineffective, recent research suggests immobilisation in external rotation for three weeks reduces recurrence rates. We developed a questionnaire to determine how doctors working in emergency departments manage acute shoulder dislocations, to assess their knowledge and determine the source of their knowledge. Doctors staffing the emergency departments of private and provincial hospitals, and registrars in emergency medicine, were surveyed regarding: • details of the doctor's rank, experience and training • number and details of dislocations managed and type and length of immobilisation • knowledge of prognosis for future dislocation • current and preferred sources of information. Responses were subjected to multivariate analysis, allowing evaluation of the prevalence of misconceptions and identification of subsets of doctors who were better informed or who held similar beliefs. Seventy questionnaires were completed (66.6%), with an average of 7.5 years post-graduate experience. All immobilised their patients for a period of between 1 and 6 weeks; however none did so in external rotation. Only 27% would refer patients for assessment by an orthopaedic surgeon. The redislocation rate for young patients was correctly chosen by 32.8%. Two-thirds of doctors incorrectly believed that redislocation is more common with increasing age. No group of doctors had statistically better knowledge than another. Books and colleagues were the most common, but were not the most preferred, sources of information. We concluded that doctors working in emergency departments appear to have a poor understanding of existing and newer treatment options for shoulder instability and are not referring patients appropriately for orthopaedic specialist assessment. A variety of sources of knowledge are utilised, suggesting that multiple sources are required to better inform doctors of current and new treatment options. <![CDATA[<b>Sonographic evaluation of the arthroscopically repaired rotator cuff</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2009000400008&lng=en&nrm=iso&tlng=en Ultrasound is gradually achieving more acceptance by orthopaedic surgeons as a diagnostic imaging tool for rotator cuff and biceps tendon pathology. Two hundred and ten patients with arthroscopic rotator cuff repairs were examined clinically and with ultrasound at early (3 weeks) and late follow-up (average 22 months; range: 12 to 49). A high correlation between clinically intact cuffs and sonographically intact rotator cuffs after repair is shown. This article gives an overview of relevant sonographic signs of rotator cuff tears, and it gives a detailed description of the sonographic signs of an intact rotator cuff after repair. Ultrasound appears to be a valuable examination for the orthopaedic surgeon to evaluate the postoperative integrity of (arthroscopically) repaired rotator cuff tendons. <![CDATA[<b>The surgical management of</b> <b>spinal tuberculosis in children and adolescents</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2009000400009&lng=en&nrm=iso&tlng=en BACKGROUND: Antituberculous chemotherapy remains the cornerstone of treatment of tuberculosis (TB) of the spine and the paediatric and adolescent populations respond particularly well to medical management. These patients are however more prone to kyphotic deformity of the spine both during the active phase, and after the disease has been cured. The British Medical Research Council Working Party on tuberculosis of the spine has found only slight advantages to surgical management over medical management and advocated ambulant chemotherapy alone where adequate facilities are lacking.¹ However patients with neurological compromise were excluded from the initial trials. Patients managed surgically had either anterior debridement and strut grafting (Hong Kong procedure) or anterior debridement alone. No posterior fusion was performed and no instrumentation was used. METHODS: We reviewed all patients under the age of 18 years who had undergone surgery for TB spine at Groote Schuur and the Red Cross War Memorial Children's Hospital from 2001-2008. Forty patients were identified on interrogation of the senior author's (RND) prospectively maintained database. The anatomical distribution was: Sixty-six per cent thoracic, 15% lumbar, 14% cervical or cervicothoracic and 5% thoracolumbar. Indications for surgery included: deformity (50%), neurological compromise (44%), instability (13%), pain (10%), revision (10%), diagnosis (4%) and failure of medical management (4%) Surgical procedures included: primary fusion (35), graft revision (5), drainage of psoas abscess (4), costotransversectomy (3) and biopsy (2). The majority of the fusions were anterior and posterior (25) the others were posterior only (9) or anterior only (1). RESULTS: Where acute correction of deformity was attempted, an average kyphosis of 53° was improved to an average of 38°. At last follow-up correction was better maintained in cases where instrumentation was used, compared to un-instrumented fusions. No neurological deterioration occurred after surgery but two patients failed to improve despite decompression. The rest became ambulant. Complications included graft failure that required revision in five cases and recollection of psoas abscesses in a patient with multi-drug-resistant (MDR) TB. CONCLUSIONS: Surgery for spinal TB in the paediatric and adolescent groups can be safe in terms of a low complication rate, and effective with good correction of deformity that is well maintained with instrumentation. <![CDATA[<b>Acromioclavicular joint: Direct arthroscopy, the Mumford procedure</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2009000400010&lng=en&nrm=iso&tlng=en BACKGROUND: Isolated degeneration of the acromioclavicular joint (ACJ) is a common cause of ACJ pain in active young to middle-aged athletes and workers performing overhead activities. Once conservative treatment has failed, various surgical options are available. These are an open ACJ excision or an arthroscopic resection, either via a subacromial approach or via direct superior approach. METHODS: The diagnosis of isolated ACJ pathology was confirmed on history, examination, and special investigation including X-rays and ACJ injection. Patients then underwent an arthroscopic ACJ resection via a superior approach as described by Flatow, a brief description of which is presented in this article. RESULTS: A total of 168 patients who had undergone a superior ACJ resection were interviewed telephonically to assess their current level of function and satisfaction. In total 81% reported excellent results, with 7% good results and 12% poor results. CONCLUSION: Although various surgical techniques are available, when considering surgical treatment options for isolated ACJ pathology, resection of the ACJ via a direct superior approach is a safe and effective method. <![CDATA[<b>Early results of the Ponseti technique for a clubfoot clinic in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2009000400011&lng=en&nrm=iso&tlng=en An audit was performed at a South African clinic in an attempt to compare results with those already published internationally. The aim was to determine the outcome and need for further surgery using this technique. A retrospective review was performed of a single surgeon practice using the Ponseti technique on all patients presenting with a clubfoot deformity. Patients with less than one year of final follow-up were excluded. A total of 70 patients were reviewed (106 feet). Patients were seen at a mean age of 3 months and 20 days. A mean of 6.5 casts were applied. The Achilles tenotomy rate was 74% (78 feet). A good outcome with complete correction was achieved in 63 feet (59%). Overall recurrence requiring re-plastering occurred in 24 feet (23%) and further surgery (other than Achilles tenotomy) was required in seven feet (7%). The Ponseti technique is a successful and rewarding method of treating all children with clubfeet. The technique must be done according to Ponseti's principles with attention to detail, rigorous parent education and close follow-up. Prior treatment was not associated with a worse outcome. Greater awareness and education regarding the Ponseti technique is mandatory to ensure early successful treatment. <![CDATA[<b>Ischaemia of the foot in infants</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2009000400012&lng=en&nrm=iso&tlng=en Ischaemia of the foot in infants is a cause for concern leading to gangrene, amputation and medicolegal inquiry. The causes of gangrene are usually complicated and multifactorial.¹ The gangrene usually develops following a severe bacterial or viral infection. Septicaemia is usually accompanied by dehydration, shock and severe metabolic derangements. Mechanical causes include invasive vascular procedures and venipuncture especially in newborns. The gangrenous change may imply surgical error especially when the infections occur following surgery or plaster cast immobilisation. Children who survive these infections are at a higher risk for complex orthopaedic problems later with growth. Involvement of the physeal circulation due especially to bacterial septicaemia may take several years to manifest resulting in longitudinal and transverse growth problems.² Ischaemic insults to the developing skeleton result in gangrene, skin necrosis and irregularities of epiphysis, metaphysis and physis with premature physeal closure. This may require skin grafting (and later release of contractures), amputation (and later revision of stump) and orthopaedic procedures to address deformity and leg length discrepancy. It is important for the orthopaedic surgeon to become involved early in the treatment team to decide on fasciotomy, amputation level, prosthetic fitting and anticipated long-term growth problems. <![CDATA[<b>Anatomy of the posterior cruciate ligament</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2009000400013&lng=en&nrm=iso&tlng=en The indication for surgery in isolated posterior cruciate ligament (PCL) rupture remains unclear. Although conservative treatment seems to be compatible with good functional outcome in the short and medium term, surgery seems to improve the subjective outcome in symptomatic patients.¹ Because as a principle 'form follows function' understanding the anatomy is both important in clinical examination and the subsequent decision to treat the PCL rupture conservatively or surgically. For the purpose of this paper I did a literature review as well as a fresh cadaveric dissection in order to search for the relevant biomechanical and anatomical factors of importance when embarking on surgical reconstruction. I hope that it will help surgeons to simplify the surgical anatomy. Better knowledge of the anatomy will improve the quality of reconstruction as in the case of anterior cruciate ligament repairs. <![CDATA[<b>Low-secretory multiple myeloma</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2009000400014&lng=en&nrm=iso&tlng=en The indication for surgery in isolated posterior cruciate ligament (PCL) rupture remains unclear. Although conservative treatment seems to be compatible with good functional outcome in the short and medium term, surgery seems to improve the subjective outcome in symptomatic patients.¹ Because as a principle 'form follows function' understanding the anatomy is both important in clinical examination and the subsequent decision to treat the PCL rupture conservatively or surgically. For the purpose of this paper I did a literature review as well as a fresh cadaveric dissection in order to search for the relevant biomechanical and anatomical factors of importance when embarking on surgical reconstruction. I hope that it will help surgeons to simplify the surgical anatomy. Better knowledge of the anatomy will improve the quality of reconstruction as in the case of anterior cruciate ligament repairs. <![CDATA[<b>Simultaneous ipsilateral femur and tibia lengthening after an iatrogenic nerve injury: Shortening external fixator time</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2009000400015&lng=en&nrm=iso&tlng=en Limb lengthening using distraction osteogenesis is an established technique; however it is often limited by prolonged external fixation times, with their associated difficulties and complications. A case is presented where a leg lengthening was performed with a relatively short external fixation time. This was made possible by the equal distribution of the patient's leg length discrepancy between the femur and tibia, secondary to an iatrogenic nerve injury while the patient was still growing. The technique of simultaneous ipsilateral femoral and tibial lengthening was shown to be an effective method of shortening external fixator time in this case and opens the door for further application of this technique in other clinical scenarios. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2009000400016&lng=en&nrm=iso&tlng=en Limb lengthening using distraction osteogenesis is an established technique; however it is often limited by prolonged external fixation times, with their associated difficulties and complications. A case is presented where a leg lengthening was performed with a relatively short external fixation time. This was made possible by the equal distribution of the patient's leg length discrepancy between the femur and tibia, secondary to an iatrogenic nerve injury while the patient was still growing. The technique of simultaneous ipsilateral femoral and tibial lengthening was shown to be an effective method of shortening external fixator time in this case and opens the door for further application of this technique in other clinical scenarios.