Scielo RSS <![CDATA[SA Orthopaedic Journal]]> http://www.scielo.org.za/rss.php?pid=1681-150X20100001&lang=en vol. 9 num. 1 lang. en <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000100001&lng=en&nrm=iso&tlng=en http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000100002&lng=en&nrm=iso&tlng=en <![CDATA[<b>Rheumatoid arthritis</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000100003&lng=en&nrm=iso&tlng=en RA is a chronic inflammatory disease resulting in severe morbidity and premature mortality. This review explores in a series of two articles, the current developments in the pathogenesis, diagnosis, monitoring and management of patients with RA. The diagnosis of early as well as established disease is discussed, including the diagnostic criteria. Particular emphasis is placed on the pitfalls and benefits of early diagnosis and early intervention. Prevention and limitation of comorbidity from the disease is highly important. This can be achieved following a paradigm shift in RA management. The emphasis is now on early introduction of disease-modifying anti-rheumatic drugs, including timely use of highly efficacious pharmacological innovations. Side effects, including peri-operative implications of pharmacological therapy, are discussed. Current therapeutic strategy to manage this disease should also be applied in resource-poor settings and developing countries. These therapies are cost effective if used early and judiciously, giving hope to many patients with RA. <![CDATA[<b>C-reactive protein response in open fractures of the tibia</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000100004&lng=en&nrm=iso&tlng=en BACKGROUND: C-reactive protein (CRP) is an acute-phase protein secreted by hepatocytes during various types of tissue injury. We tried to determine whether the severity of an open fracture of the tibial diaphysis as classified according to the Gustilo-Anderson system corresponds to the degree and pattern of CRP response after trauma and infection. METHODS: This was a prospective study done over a six-month period on 48 patients with open tibial-diaphyseal fracture. Serial blood samples for CRP testing were taken seven times over a two-week period. The fractures were graded according to the Gustilo-Anderson classification and after surgery wounds were examined regularly for signs of surgical-site infection (SSI). RESULTS: Twenty-nine patients (60.4%) did not develop postoperative SSI and mean CRP levels peaked on different days for the different fracture grades with grade II, IIIa, and IIIb fractures all having mean peak levels of 52.2 mg/l. There was no association between the mean peak CRP levels and the fracture grades (p = 0.5). Those patients who developed postoperative SSI (19; 39.6%) still showed no clear association between mean peak levels and fracture grades (p = 0.48) and CRP levels also peaked on different days with grade IIIc fractures having the highest level at 67.7 mg/l. When fracture grading was excluded from data analysis, mean CRP levels for both groups of patients peaked on the third postoperative day with a higher value of 52.2 mg/l for patients with postoperative SSI compared with 47.7 mg/l for those without postoperative SSI, and the difference was significant (p = 0.015). CRP remained elevated up to the fourteenth postoperative day in patients with postoperative SSI while it showed a decline until it approached the pre-operative level in patients without postoperative SSI. CONCLUSIONS: This study has shown that the severity of an open fracture of the tibial diaphysis as classified according to the Gustilo-Anderson system does not correspond to the degree and pattern of CRP response after trauma and SSI. This is demonstrated by the erratic CRP response in both infected and uninfected open fractures of the tibia when fracture grade was compared with the kinetics of CRP response. The elevated CRP level on the third postoperative day and continued persistence thereafter in patients with SSI is, however, a potential early screening tool for infection before clinical signs of infection appear on the fifth postoperative day. <![CDATA[<b>Single event multilevel surgery in cerebral palsy</b>: <b>a review of the literature</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000100005&lng=en&nrm=iso&tlng=en Single event multilevel surgery (SEMLS) ha s become an increasing trend in the orthopaedic management of cerebral palsy due to the advantages of one hospital admission and one period of rehabilitation. This article reviews the studies relating to the outcome of SEMLS published over the last 10 years. Improvements in gait parameters are reported in the literature but the articles provide a low level of evidence and there are limitations in the conduct of the research. Further studies, employing good scientific rigour are indicated to provide higher levels of evidence regarding the efficacy of this intervention for persons with cerebral palsy. <![CDATA[<b>Arthroscopic treatment of calcifying tendonitis of the shoulder</b>: <b>deposit removal and intra-articular lavage</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000100006&lng=en&nrm=iso&tlng=en The optimal treatment of calcifying tendonitis is still controversial and several techniques exist. In this article we describe the arthroscopic operative technique for removal of calcific deposits as well intra-articular lavage. We hypothesised that the removal of these calcium particles from the intra-articular space, usually seen arthroscopically as a 'snowstorm' appearance, would result in a reduction in the incidence of post-procedure frozen shoulder. A retrospective analysis of 93 patients confirmed this. <![CDATA[<b>The medical management of spinal tuberculosis</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000100007&lng=en&nrm=iso&tlng=en The overall prevalence of spinal tuberculosis (TB) in South Africa is currently 948 per 100 000. All trends are upward, including incidence of sputa positive cases, relapses and retreatment rates, as well as new extra-pulmonary cases. This is driven by the co-existent HIV endemic and the effect of HIV on TB re-activation.¹ Autopsy studies confirm that 30-40% of HIV-positive patients die of TB and 44% of TB patients have HIV.² Musculoskeletal manifestations of TB are more frequent in the HIV host, reported as high as 60% compared to the normal 3-5% incidence.³ TB is largely a public health issue and will only be controlled when the problems of abject poverty such as malnutrition, overcrowding and early access to medical care is improved. To this end it is notifiable by law in an effort to allow preventative measures to be effected. TB spine represents about 1% of overall cases but places a large demand on resources due to the costs of paraplegia and tertiary level care. Although surgery is indicated in selected cases, medical care remains the key component. Medical care involves both the diagnostic process and the medical intervention by means of supportive care and anti-tuberculous chemotherapy. <![CDATA[<b>Immediate postoperative prosthesis (IPOP) utilisation in septic and tumour amputees in a government hospital</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000100008&lng=en&nrm=iso&tlng=en Rapid rehabilitation of lower limb amputees has far-reaching psychological and economic implications. Postamputation regimens commonly involve the application of a dressing and light compression bandage while awaiting wound healing. This is followed by the application of a coning bandage to facilitate stump reduction, and thereafter fitment of a primary prosthesis. This process commonly takes 17 weeks in transfemoral amputees and 11 weeks in transtibial amputees. A prospective study of 25 amputees (15 males and 10 females) who underwent the application of an immediate postoperative prosthesis (IPOP) was conducted. Utilising this technique, rehabilitation and prosthetic application commence immediately postoperatively within the operating theatre, and run in tandem with stump healing. Mobilisation with crutches or a walker on a temporary prosthesis was achieved within five days for both transtibial and transfemoral amputees, and crutch-assisted mobilisation on a primary prosthesis was attained within four and five weeks respectively. This was attributable to a relative preservation of stump size, muscle strength and cardiovascular fitness, minimisation of contracture development, as well as apparent psychological benefits to the amputees, many of whom were children. The IPOP technique was found to reliably accelerate the rehabilitation of tumour and septic amputees at the Johannesburg Hospital tumour and sepsis unit. <![CDATA[<b>Cervical corpectomy and anterior standalone plate stabilisation in sub-axial cervical spine trauma</b>: <b>a retrospective review of the radiological outcomes</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000100009&lng=en&nrm=iso&tlng=en INTRODUCTION: Compression-flexion injuries of the cervical spine often result in instability of both the anterior and posterior columns. Debate exists in the literature regarding the surgical approach to stabilisation of these fractures, the options being anterior, posterior or combined surgical approaches. The combined approach offers superior stability, but results in increased cost, patient morbidity and theatre time. This study reviews the results of the anterior approach with standalone cervical corpectomy and plate stabilisation combined with postoperative Philadelphia collar immobilisation. METHODS: We retrospectively reviewed 30 patients with compression-flexion injuries of the cervical spine. Surgical management consisted of anterior corpectomy, iliac tricortical strut autograft, and anterior cervical static locked plating. Postoperatively patients were immobilised in a Philadelphia collar for six weeks. This radiological review assessed the postoperative constructs, and the final follow-up radiographs. RESULTS: Overall radiological union was achieved in 90% of cases at an average of 3.8 months. Patients with good constructs had a union rate of 100%. Those with poor constructs had a 25% union rate. Poor results included delayed union, cervical kyphosis, graft migration and loss of screw fixation. CONCLUSION: Poor results in this study were related to operative technique. With good operative technique, excellent results can be expected. Therefore, anterior cervical corpectomy and locked plating alone, with Philadelphia collar immobilisation, appears to be a safe and cost-effective alternative in the management of these fractures. <![CDATA[<b>Mortality in elderly patients with intertrochanteric fractures</b>: <b>three years' experience</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000100010&lng=en&nrm=iso&tlng=en AIM: To review the mortality rate of patients admitted with intertrochanteric fractures within a period of three years. Intertrochanteric fractures are common in elderly patients and result in a high morbidity and mortality rate. This article retrospectively reviewed 57 patients (65 years of age and older) admitted with intertrochanteric fractures. Descriptive statistics using the frequency / proportion method was used to interpret the results. The mortality rate in hospital was 14%, in the first year 32%, in the second year 39% and insignificant in the third year. <![CDATA[<b>Chondromyxoid fibroma</b>: <b>a case series and radiological review</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000100011&lng=en&nrm=iso&tlng=en Chondromyxoid fibromas are rare, benign tumours that resemble cartilage, initially arising in the cortex of affected bones (most commonly the lower limbs).1,2 Their documented incidence is less than 1% of all primary bone tumours (approximately 2% of all benign bone tumours) with males and females being equally affected.1,2 This case series and radiological review demonstrates some of the typical findings associated with this tumour. <![CDATA[<b>Achilles tendonitis</b>: <b>latent foreign body</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000100012&lng=en&nrm=iso&tlng=en Although foreign-body injuries are quite common, 15 to 55 per cent of these are misdiagnosed at the initial emergency room visit.¹ The normal clinical course of a foreign-body injury is that of sudden pain at the time of injury followed by a dormant asymptomatic phase that can last from one month to a couple of years.¹ The patient can, however, develop an acute flare-up at any stage. The length of this dormant phase may obscure the inciting incident, thus separating it from the onset of these 'late' symptoms. Another problem leading to the occasional incorrect diagnosis is caused by the composition of the foreign body. If the foreign body is radiopaque it is easily detected on a standard radiograph or fluoroscopy. The problem arises when the foreign body is not radiopaque, as is the case with a wooden splinter or thorn. These can remain undetected even with surgical exploration and will only become evident when a toxic reaction to the foreign body causes inflammation with synovitis due to local irritation. We present a case report of Achilles tendonitis secondary to a retained thorn of the date palm (Phoenix caneriensis). <![CDATA[<b>Traumatic dislocation of the hip joint in children</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000100013&lng=en&nrm=iso&tlng=en Two cases of acute traumatic dislocation of the hip joint are reported. This is a rare injury and the literature on this subject is limited to either case reports or combined multicentre studies. The aim is to report on two cases of acute dislocation of the hip joint treated by us and to review the literature on this injury. <![CDATA[<b>Bilateral sternoclavicular synovial cysts in juvenile idiopathic arthritis</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000100014&lng=en&nrm=iso&tlng=en Juvenile idiopathic arthritis (JIA) is an inflammatory disorder of connective tissue. Joint pain or tenderness, and swelling affecting one or more joints for at least six weeks, in patients under the age of 16 years, are diagnostic of JIA. Involvement of the juxta-articular structures is less common in JIA compared to adult rheumatoid arthritis. We present a case of JIA with bilateral sternoclavicular synovial cysts. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000100015&lng=en&nrm=iso&tlng=en