Scielo RSS <![CDATA[SA Orthopaedic Journal]]> http://www.scielo.org.za/rss.php?pid=1681-150X20100002&lang=en vol. 9 num. 2 lang. en <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>Orthopaedic research in South Africa </b>: <b>the unstable pot</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000200001&lng=en&nrm=iso&tlng=en <![CDATA[<b>Challenges for future research</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000200002&lng=en&nrm=iso&tlng=en <![CDATA[<b>The Internet</b>: <b>selecting relevant orthopaedic knowledge and managing it on your personal computer</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000200003&lng=en&nrm=iso&tlng=en <![CDATA[<b>Rheumatoid arthritis</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000200004&lng=en&nrm=iso&tlng=en Rheumatoid arthritis (RA) is a chronic symmetrical inflammatory arthropathy with potentially debilitating consequences in the early phases of the disease functional limitation is reversible; however, persistent inflammation results in irreversible structural changes and systemic effects accounting for considerable morbidity and premature mortality. This review, second of a two-part series, explores a paradigm shift in management of emphasising the pitfalls and benefit of early aggressive pharmacological therapies including the timely use of highly efficacious pharmacological innovations. Side effects, including peri-operative implications of pharmacological therapy, are discussed. These therapies are cost effective if used early and judiciously, giving hope to many patients with RA. <![CDATA[<b>Efficacy of an exercise programme on the functional capacity and disease activity in females with rheumatoid arthritis</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000200005&lng=en&nrm=iso&tlng=en BACKGROUND: Rheumatoid arthritis (RA) is a chronic, immune-inflammatory disease of unknown aetiology affecting the synovial membrane of joints and surrounding tissues. Typically RA affects both large and small joints in a bilateral, symmetrical, poly-articular fashion. Degradation of bone, cartilage and muscle eventually lead to a reduction in physical function. The purpose of this study was to determine the efficacy of an endurance exercise programme on the fitness parameters (flexibility, strength and aerobic measurements), quality of life (visual analogue scale and health assessment questionnaire) and disease activity (DAS28[4] version with CRP) of female RA patients. METHODS: Female RA patients were randomly allocated to the experimental group (EG) (n=19) and the control group (CG) (n=8). All participants went through a battery of tests before the intervention, and again after completion of the study. The 12 week training programme consisted of three 45-minute training sessions per week and included walking or aquatics, as well as stretches and isotonic strengthening exercises. The Mann-Whitney U test was used to compare measurements between groups. The Wilcoxon signed-rank test was used to compare baseline and post-intervention measurements within each group. RESULTS: At the initiation of the study the CG and the EG were comparable for fitness, quality of life and disease activity. On completion of the training programme, statistically significant improvements at the 5% level of significance were seen between the EG and CG, in favour of the EG, for left lateral flexion (p=0.015) and the 1 mile walk test (p=0.011). Within the EG there were improvement of knee flexion left (p=0.026), knee extension (right p=0.011; left p=0.009), scratch test (right p=0.007; left p=0.01), chair sit and reach (right p=0.011; left p<0.001), strength parameters (p<0.05), 1 mile walk test (p<0.001), VO2 max (p=0.01) and DAS scores (p<0.001). Within the CG, improvements were shown for knee extension (right p=0.05; left p=0.013). Although their strength parameters improved significantly it was not in the same order as for the EG. The CG had a decline in their aerobic measurements but their HAQ score improved (p=0.03). CONCLUSION: An endurance exercise programme, combined with isotonic strengthening exercise and stretching, improves the functional capacity, quality of life and disease activity of female patients with RA. Attention received during the study may have led to some placebo-induced improvements in control subjects, but not to the same extent as those involved in exercise programmes. <![CDATA[<b>Lumbar osteochondroma causing spinal compression</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000200006&lng=en&nrm=iso&tlng=en BACKGROUND: Rheumatoid arthritis (RA) is a chronic, immune-inflammatory disease of unknown aetiology affecting the synovial membrane of joints and surrounding tissues. Typically RA affects both large and small joints in a bilateral, symmetrical, poly-articular fashion. Degradation of bone, cartilage and muscle eventually lead to a reduction in physical function. The purpose of this study was to determine the efficacy of an endurance exercise programme on the fitness parameters (flexibility, strength and aerobic measurements), quality of life (visual analogue scale and health assessment questionnaire) and disease activity (DAS28[4] version with CRP) of female RA patients. METHODS: Female RA patients were randomly allocated to the experimental group (EG) (n=19) and the control group (CG) (n=8). All participants went through a battery of tests before the intervention, and again after completion of the study. The 12 week training programme consisted of three 45-minute training sessions per week and included walking or aquatics, as well as stretches and isotonic strengthening exercises. The Mann-Whitney U test was used to compare measurements between groups. The Wilcoxon signed-rank test was used to compare baseline and post-intervention measurements within each group. RESULTS: At the initiation of the study the CG and the EG were comparable for fitness, quality of life and disease activity. On completion of the training programme, statistically significant improvements at the 5% level of significance were seen between the EG and CG, in favour of the EG, for left lateral flexion (p=0.015) and the 1 mile walk test (p=0.011). Within the EG there were improvement of knee flexion left (p=0.026), knee extension (right p=0.011; left p=0.009), scratch test (right p=0.007; left p=0.01), chair sit and reach (right p=0.011; left p<0.001), strength parameters (p<0.05), 1 mile walk test (p<0.001), VO2 max (p=0.01) and DAS scores (p<0.001). Within the CG, improvements were shown for knee extension (right p=0.05; left p=0.013). Although their strength parameters improved significantly it was not in the same order as for the EG. The CG had a decline in their aerobic measurements but their HAQ score improved (p=0.03). CONCLUSION: An endurance exercise programme, combined with isotonic strengthening exercise and stretching, improves the functional capacity, quality of life and disease activity of female patients with RA. Attention received during the study may have led to some placebo-induced improvements in control subjects, but not to the same extent as those involved in exercise programmes. <![CDATA[<b>Management of sports overuse injuries of the lower limb</b>: <b>an evidence-based review of the literature</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000200007&lng=en&nrm=iso&tlng=en This article reviews common lower limb sports overuse injuries relevant to the orthopaedic surgeon. The following conditions are covered: • Snapping hip syndrome • Iliotibial band syndrome • Patellar tendinopathy • Achilles tendinopathy • Medial tibial stress syndrome • Tibial stress fractures • Chronic compartment syndrome These conditions can be managed conservatively inmost cases. Adequate rest followed by a graded rehabilitation is extremely important. Intrinsic and extrinsic contributing factors must be sought for and corrected. It is only in the uncommon case of failed conservative treatment that surgical intervention is necessary. For each of the above conditions, the indications for surgery, surgical principles, various surgical procedures and results and complications thereof are analysed and discussed. A meta-analysis of surgical treatment studies with similar methodologies was performed. The majority of studies found were of Level IV evidence with small patient numbers. The recommended outcome measures to assess results of surgical intervention are relief of pain and return to pre-injury level of sporting activity. Surgical treatment often does not result in a cure but an improvement of symptoms. Prospective randomised control trials with adequate patient numbers comparing different surgical treatments are needed. <![CDATA[<b>Knee pain, swelling and stiffness after total knee replacement</b>: <b>a survey of South African knee surgeons</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000200008&lng=en&nrm=iso&tlng=en Knee pain, swelling and stiffness after total knee replacement (TKR) surgery are well-recognised complications. However, in some cases, despite investigation, the cause may be unexplained. This study, using a questionnaire sent to South African orthopaedic surgeons, examined the perceived incidence of unexpected knee pain and swelling after a straightforward TKR, aiming to identify possible associated or contributory factors. Of the 61 respondents, two-thirds had more than 10 years' experience and close to three-quarters performed 20 or more TKRs per annum. Less-experienced surgeons report a greater frequency of unexpected pain than more-experienced surgeons (90% vs 53%) (p<0.05). Similarly, surgeons using the visual analogue scale (VAS) to assess a patient's pain also have a greater awareness of unexpected pain. Two-thirds of surgeons reported finding more pain than had been anticipated in between 6% and 20% of their cases. Unexpected swelling is also an issue. Approximately one-half of surgeons could identify the cause for pain in less than 5% of their cases. Surgeons who use drains and have shorter surgical times reported a reduced incidence of unexpected pain and swelling, although this did not reach statistical significance. No suggestive relationships were found for other peri-operative parameters such as analgesic regimens, thrombo-embolic prophylaxis or mobilisation protocols. <![CDATA[<b>Orthopaedic implications of physeal arrest following meningococcal septicaemia</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000200009&lng=en&nrm=iso&tlng=en BACKGROUND: Physeal arrest following meningococcal septicaemia is the result of ischaemia secondary to vasculitis. Only two cases have been reported with a long-term follow-up to maturity. METHODS: We did a retrospective study of 13 patients treated over 17 years (1991-2007) to assess the orthopaedic manifestations, treatment and long-term outcome of the physeal arrest. All patients were followed up clinically and radiologically; eight to skeletal maturity. RESULTS: The average age of the meningococcal septicaemia was 12 months, and the patients presented with physeal arrest at an average of 5.6 years. Thirty-nine physes were involved: 29 focal, six complete and four had a premature arrest. Sixty two surgical procedures (average 4.6, range 1-11 per patient) were required to prevent or correct angular deformity and/or leg length discrepancy. Seven physeal bars were resected (four successfully), 26 epiphyseodeses, 20 angular corrections (all at the knee or ankle) and nine limb lengthenings were done. CONCLUSIONS: We concluded that these patients may require several orthopaedic procedures, and should be followed up until skeletal maturity. Once growth is balanced with bar resection or epiphyseodesis, angular correction and limb lengthening have a good outcome. <![CDATA[<b>Isolated loss of flexor pollicis longus function after plating of the radius</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000200010&lng=en&nrm=iso&tlng=en A patient presented with an open midshaft radius and ulna fracture which was treated with debridement and open reduction and internal fixation using the LC-DCP technique. Postoperatively the patient had isolated loss of flexor pollicis longus function which recovered fully after 10 weeks with a 'wait-and-see' policy. An isolated traction neuropraxia of the branch of the anterior interosseous nerve to the flexor pollicis longus muscle is the presumed cause. <![CDATA[<b>Dupuytren's contracture</b>: <b>'The Z-factor'</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000200011&lng=en&nrm=iso&tlng=en Dupuytren's contracture (DC) or palmar fasciitis is notorious for its high recurrence rate after surgical fasciectomy. In a personal series of 426 operated hands over a 15-year period with a follow-up period of 2 to 17 years, the recurrence rate was only 3.7% (in the literature: 26-63%). The demographics, surgical technique and results are discussed. It is suggested that the possible reason for the low recurrence rate lies in multiple Z-plasties. <![CDATA[<b>Prosthesis sepsis in a tertiary setting</b>: <b>a retrospective analysis</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000200012&lng=en&nrm=iso&tlng=en PURPOSE OF THE STUDY: Annually, more than a million joint replacements are performed worldwide. The most feared complication is infection. The purpose of this study is to establish the spectrum of organisms and their respective sensitivities, cultured during primary and secondary debridements of staged revision surgery. These findings were then utilised to suggest alternative empiric antimicrobial therapy. DESCRIPTION OF METHODS: A retrospective analysis was performed on patients undergoing revision hip or knee arthroplasty at a tertiary hospital in South Africa from June 2005 to March 2009. Only patients in whom intra-operative deep microbiological cultures had been performed were included. SUMMARY OF RESULTS: Deep microbiological cultures were performed in all cases on either joint synovium, fluid or pus swabs taken from the site intra-operatively. Following primary debridement of staged revision surgery, 38% of samples submitted were culture positive from 61 patients, rendering 29 isolates (six double infections). The spectrum was highly variable. Although no methicillin-resistant Staphylococcus aureus (MRSA) was isolated in the initial cultures, the majority of organisms were Gram positive (62%). Fourteen of these patients (23%) required a second debridement; 12 patients had positive cultures (86%), rendering 20 isolates (four double and two triple infections). Gram-negative organisms played a significant role in these patients with the majority of cases culturing multi-resistant organisms. CONCLUSION: Although no MRSA was cultured, vancomycin is widely used as an empiric postoperative antimicrobial. In this setting, 72% of isolates were sensitive to vancomycin; however, co-amoxyclav also covered 72% of isolates, with the benefit of superior efficiency and fewer side effects. We suggest the possible use of co-amoxyclav with rifampicin as a potential first-line antimicrobial in this clinical setting. Multi-drug resistance is increasingly important in patients requiring secondary debridements. In this setting a combination of carbapenems with vancomycin should be considered as empiric postoperative antibiotics, as it covered 75% of organisms in our clinical setting. <![CDATA[<b>Metastatic mesenchymal chondrosarcoma</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000200013&lng=en&nrm=iso&tlng=en Mesenchymal chondrosarcoma is an entity first described in 1959 by Lichtenstein and Bernstein.¹ It is rare and comprises approximately 1% of all chondrosarcomas, with a peak incidence in the second and third decade of life.³ There is a comparable male-to-female sex ratio with two-thirds of cases arising from bone and a third from the soft tissues mainly in central areas such as the head and neck or the axial skeleton. We present a case of this highly malignant lesion arising from skeletal muscles of the thigh having already metastasised to multiple unusual areas. <![CDATA[<b>Paediatric septic arthritis in a tertiary setting</b>: <b>a retrospective analysis</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000200014&lng=en&nrm=iso&tlng=en PURPOSE OF THE STUDY: Acute haematogenous septic arthritis is a relatively common condition in the paediatric population. Although Staphylococcus aureus is implicated as the most common causative agent, changes in resistance and the increasing importance of other pathogens have been reported. The purpose of this study is to establish the spectrum of aetiological organisms with their respective sensitivities, and to use this data to evaluate choices in empiric antimicrobial therapy. DESCRIPTION OF METHODS: A retrospective analysis was performed on patients aged 12 years and younger, admitted for suspected septic arthritis, at a tertiary hospital in South Africa from June 2005 to March 2009. All patients with a clinical diagnosis of septic arthritis were included in this study. SUMMARY OF RESULTS: A total of 44 patients from the age of 2 weeks to 12 years were included. Thirty-nine samples were submitted for microbiological investigation. Thirty of these samples yielded bacterial growth; five of these had two microorganisms. Gram-positive organisms were cultured in 79% of isolates. Staphylococcus aureus was cultured in 66% of all isolates. Only three samples were multi-drug resistant. Gram-negative organisms constituted 17% of isolates. Of note is the isolation of a single isolate of Haemophilus influenzae type B, signifying possible vaccine or vaccination failure. CONCLUSION: Gram-positive organisms, in particular Staphylococcus aureus, are still the most prevalent aetiological agent. The current use of cloxacillin as empiric antibiotic therapy will cover 69% of all isolates in this setting; use of coamoxyclav as empiric therapy will increase cover to 80%. Although this 11% difference is seemingly small, opting for co-amoxyclav may significantly reduce morbidity. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000200015&lng=en&nrm=iso&tlng=en