Scielo RSS <![CDATA[SA Orthopaedic Journal]]> http://www.scielo.org.za/rss.php?pid=1681-150X20100004&lang=en vol. 9 num. 4 lang. en <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>Orthopaedic training in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000400001&lng=en&nrm=iso&tlng=en http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000400002&lng=en&nrm=iso&tlng=en <![CDATA[<b>Online presence</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000400003&lng=en&nrm=iso&tlng=en <![CDATA[<b>Risser sign</b>: <b>trends in a South African population</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000400004&lng=en&nrm=iso&tlng=en INTRODUCTION: In scoliosis management the five stages of the Risser sign on the iliac crest have been widely used as a tool to assess skeletal age and remaining spinal growth. However, as with other markers of skeletal age, it is under the influence of genetic and environmental factors. Proof of this was given by Risser, who observed that children in warmer climates developed earlier. Numerous other authors have also shown differences for other measures of maturity between different race groups. OBJECTIVE: This study was aimed at determining the trends of Iliac crest apophyseal ossification as represented by the Risser sign in the South African population and how it compares with that published by Scoles et al in their population group. METHOD: Radiographs of patients between the ages of 8 to 20 years undergoing abdominal X-rays for abdominal pains at our teaching hospitals were collected and assessed by two independent observers for the Risser sign. X-rays of patients with Risser stage 0, skeletal abnormalities and conditions which can affect skeletal growth and maturity were excluded from the study. The Risser stage, the ages and the race of the patients were observed and documented. RESULTS: A total of 743 abdominal X-rays were collected; of those 280 X-rays were excluded as per exclusion criteria leaving 463 X-rays to analyse. Of the 463 X-rays available, 292 were for black patients, 117 whites, 42 coloureds, 11 Indians and 1 Chinese. The average age of Risser stage 1, 2, 3, 4 and 5 were 12.75, 15.38, 15.83, 16.38, and 17.06 years respectively. The girls tended to be of a younger age group in all Risser stages. There were no statistically significant differences in average age of the Risser stages among the black and white population groups except for the white male in Risser stage 1 who had a younger age than the black population in the same Risser stage. The South African boys at Risser stage 1 were of a younger age when compared those published by Scoles et al in their population group. CONCLUSION: The Risser sign can be applied equally among the South African population as no significant statistical differences between the major population groups were found in this study. <![CDATA[<b>Occipito-cervical fusion</b>: <b>review of surgical indications, techniques and clinical outcomes</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000400005&lng=en&nrm=iso&tlng=en STUDY DESIGN: A retrospective review of patients undergoing single-surgeon occipito-cervical fusion. OBJECTIVE: The aim of this study is to evaluate the surgical indications, techniques and clinical outcomes of occipito-cervical fusion, including C2 fixation methods and complications. MATERIALS AND METHOD: Thirty-four consecutive patients (16 males, 18 females) who underwent occipito-cervical fusion were reviewed. The indications for fusion were instability due to inflammatory diseases (13), trauma (9), congenital abnormalities (9), infections (2) and tumours (1). Nine patients (all but 1 paediatric) underwent fusion with bone grafting and halo immobilisation. Twenty-five patients underwent posterior instrumented fusion. Halo removal was performed after 6 weeks and soft collars were worn for 6 weeks in the instrumented group. Surgical techniques and clinical outcomes (stability, fusion, complications) were reviewed. RESULTS: Clinical and radiological fusion was attained in all patients available for follow-up, with an average of 2.7 months in the uninstrumented group and 5.2 months in the instrumented group. All fusions resulted in resolution of preoperative pain and an improvement in pre-operative neurology. Two patients demised in the acute postoperative period as a result of the underlying pathology. Eighteen patients required simultaneous decompressions. No instrumentation failures occurred. Superficial wound sepsis occurred in 4 patients, one subsequently requiring instrumentation removal. CONCLUSION: Occipito-cervical fusion is a safe and reliable procedure, predictably providing stability and improvement in preoperative pain and neurology. Multiple cervical fixation options are available according to surgeon preference and anatomical variants. <![CDATA[<b>Assessment of undergraduate orthopaedic training at medical schools in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000400006&lng=en&nrm=iso&tlng=en BACKGROUND: A familiarity with basic musculoskeletal disorders is of vital importance for medical school graduates. The purpose of this study was to assess a group of newly qualified South African medical school graduates commencing internship at Groote Schuur and Tygerberg Hospitals for competency in musculoskeletal injury and disease. METHODS: An internationally validated competency examination in musculoskeletal medicine was used as the assessment tool. The examination consisted of 25 short-answer questions and was marked using a validated answer key and scoring system. Topics included fractures and dislocations, back pain, arthritis, basic anatomical knowledge and emergencies that require urgent referral to an orthopaedic surgeon. The study group comprised 79 interns who were in their first postgraduate year at Groote Schuur or Tygerberg Hospitals. The examination was administered during the orientation programme on their first day at work. The examination was also administered to all registrars in orthopaedic surgery at the University of Cape Town. Data was analysed using Stata 11 to estimate percentages and their binomial exact 95% confidence intervals. RESULTS: The recommended mean passing score for the examination was 73.1 ± 6.8 per cent. The mean score for the 17 orthopaedic registrars was 96.0 per cent, and that for the 79 interns in their first postgraduate year was 45.3 per cent (95% CI 42.3-48.4). Seventy-two (91 per cent) of the 79 interns failed to demonstrate basic competency in the examination. CONCLUSION: In summary, 91 per cent of medical school graduates in our study failed a valid musculoskeletal competency examination. We therefore believe that medical school preparation in musculoskeletal injury and disease in South Africa is inadequate and that undergraduate training programmes should be reassessed throughout the country. <![CDATA[<b>Anatomic study of the atlas for surgical planning of lateral mass screw fixation</b>: <b>is it safe in our population?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000400007&lng=en&nrm=iso&tlng=en INTRODUCTION: Atlantoaxial instability is not uncommon and its management can be a challenge. Several stabilisation techniques have been described. All have their challenges because of the paucity of some osseous elements, the neural and vascular structures found in that region. Lateral mass screw fixation is one of the techniques which has been described for selected cases. Like all the other techniques it is a challenging technique to use and calls for full familiarisation with the anatomy at that region. OBJECTIVES: The objective of the study was to assess if the atlas lateral mass screw can be safely accommodated in our population. The secondary aim was to establish if there were any differences in the size between the male and female or among the white and black population groups. METHODS AND MATERIALS: Samples of dry adult atlas vertebra from the Raymond Dart Collection of human skeletons at the Wits University Department of Anatomy were measured for several parameters including the height, width and length of the lateral mass using an electronic digital caliper. Atlas of persons below 18 years of age at the time of death and those who had anomalies or deformities were excluded from the study. Data was recorded in Microsoft Excel and was imported in SAS V9.1 (SAS Institute Inc., Cary, NC, USA) for analysis. RESULTS: One-hundred-and-fifty-nine atlas specimens were studied with almost equal numbers in both sexes and between black and white populations. The mean width of the lateral mass was 13.77 ± 1.23 mm, the height of lateral mass below the overhang was 4.51 ± 0.634 mm and the height of the lowest point of lateral mass was 11.94 ± 1.21 mm. The anteroposterior distance of the lateral mass was 17.64 ± 1.36 mm. The angle of inclination of posterior arch to lateral mass was 76.83 ± 5.12º. Of the 159 vertebrae, two vertebrae had lateral mass height below the overhang of 3.5 mm, and 37 vertebrae had height below overhang of 4 mm. There were no statistical significant differences between male and female and between the race groups. The reason for us to assess if there was any difference in the male and female and also in blacks and whites is that in our previous study on the size of the odontoid process we had found a significant difference between the groups. In that study we found that South African blacks had a much smaller odontoid process than South African whites. Interestingly we also found that South African blacks had a smaller odontoid process than African Americans. This indicated to us that there is more than genetic factors playing a role; environmental factors and nutritional factors could have influence. It was for that reason that we felt we could not take it for granted that these groups will have similar findings. This was the secondary aim of the study, not the main aim. CONCLUSION: The atlas mass morphology was found to be adequate to accommodate the lateral mass screw safely in our population. Only two of the 159 dry atlas bones examined had the potential of not accommodating a 3.5 mm screw risking violating the occiputo-atlas joints. In 37 of the specimens the height of the lateral mass was below 4 mm. For that reason it is advisable not to use 4 mm size screws in our population as there is a significant risk that the occiputo-atlas joint may be violated by it. <![CDATA[<b>Efficacy of sexual counselling during the rehabilitation of spinal cord injured patients</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000400008&lng=en&nrm=iso&tlng=en Spinal cord injury is a life-changing experience. During rehabilitation the emphasis is to help the patient to become as independent as possible in performing the activities of daily living. This study was conducted to determine the importance and efficacy of sexual counselling in the rehabilitation of spinal cord injured patients. The study population comprised a randomly selected group of 102 spinal cord injured patients treated at a tertiary institution. A research questionnaire was used to perform personal as well as telephonic interviews. The study showed that some spinal cord injured patients were inadequately counselled on sexual function during rehabilitation. There were statistically significant differences between male and female patients, and white and black patients. Patient counselling needs to be more thorough, specialised and individualised. Patients' partners should also be counselled to ensure that they work as a team to create mutual sexual satisfaction. Counselling should always be available at follow-up visits. <![CDATA[<b>Subcapital femoral neck fracture in patients with HIV and osteonecrosis of the femoral head</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000400009&lng=en&nrm=iso&tlng=en BACKGROUND: Osteonecrosis of the femoral head generally presents with collapse of the femoral head. A small subset of patients with osteonecrosis of the femoral head, however, have been described in various case reports as presenting with subcapital femoral neck fracture instead. METHODS: The three cases presented were gathered retrospectively from the National Joint Registry in Malawi. RESULTS: We present three case reports of patients with HIV who suffered atraumatic subcapital femoral neck fractures in the setting of osteonecrosis of the femoral head. DISCUSSION: Patients with subcapital femoral neck fractures and osteonecrosis of the femoral head in the setting of HIV represent a unique population with diagnostic and management dilemmas that require careful consideration. <![CDATA[<b>Misdiagnosis of hip pain could lead to unnecessary spinal surgery</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000400010&lng=en&nrm=iso&tlng=en Osteoarthritis of the hip occurs in 10-30% of adults and is especially common in the elderly. Twenty-one per cent of people over the age of 65% are also shown to have degenerative spinal stenosis. It thus follows that patients with osteoarthritis of the hip could have a concomitant degree of spinal stenosis. <![CDATA[<b>A deadly bed partner</b>: <b><i>m'Fesi</i></b><b> (Mozambique spitting cobra)</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000400011&lng=en&nrm=iso&tlng=en Venomous snake bites are estimated to occur in 2.5 million people annually worldwide, with 125 000 resulting in death. The incidence of snake bites in Africa has been estimated at 100-400 bites per 100 000 people. Currently literature is largely restricted to case reports. In this case series, we describe three patients who sustained Mozambique spitting cobra bites on their hands, with their subsequent management. As was reported in the previous publications, all of the patients sustained snake bites while at home sleeping and two of the patients sustained multiple bites. All patients were bitten on their hands and developed significant soft tissue necrosis requiring surgical intervention. As reported in international publications, an initial delay in debridement led to improved outcome. Initial soft tissue necrosis has been shown to correlate poorly with ultimate wound demarcation. In accordance with publications, compartment syndrome did not occur in any of the patients, and swelling could be easily managed with simple elevation. In conclusion, m'Fesi bites are medical emergencies, but they warrant delayed wound debridement. Orthopaedic surgeons are often consulted for management of limb injuries; therefore, a thorough knowledge regarding management of cytotoxic snake bites should be a part of the general orthopaedic surgeon's training. <![CDATA[<b>Predictive values of serum nutritional indices for early postoperative wound infections in surgically treated closed femoral fractures</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000400012&lng=en&nrm=iso&tlng=en BACKGROUND: Laboratory assessments of nutritional status consisting of evaluation of serum albumin and total lymphocytes count (TLC) are valid tests of a patient's nutritional status. This study evaluated these indices and the findings were correlated with the occurrence of early surgical site infection (SSI). METHODS: This was a prospective study conducted on 100 patients with closed femoral fractures for a period of ten months. Blood samples were taken to determine levels of serum albumin, total lymphocytes count and for human immunodeficiency virus (HIV). Postoperatively, body mass index (BMI) was calculated and wounds were examined regularly for signs of SSI. RESULTS: On the basis of the albumin index, 25% of the patients had malnutrition and the infection rate in this group was 28%. Malnutrition as per TLC was 3% with an infection rate of 33.3%. Only one patient was malnourished when both albumin and TLC indices were considered and this patient developed SSI. Risk of developing SSI was about 10 times in those with albumin depletion, four times in those with reduced TLC and 12 times when both indices were low. Significant association was seen in low albumin levels (P = 0.000). CONCLUSIONS: Patients at risk of SSI can be identified pre-operatively using relatively inexpensive laboratory tests of nutritional parameters such as serum albumin. Preventive measures like nutritional support and prophylactic antibiotics can then be initiated. <![CDATA[<b>Bilateral anterior shoulder dislocation</b>: <b>a case report of this rare entity</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000400013&lng=en&nrm=iso&tlng=en Unilateral shoulder dislocation is a common condition and often seen at trauma facilities worldwide. In general anterior shoulder dislocations are more common than posterior dislocations. Bilateral shoulder dislocations are rare and of these, bilateral posterior shoulder dislocations are more prevalent than bilateral anterior shoulder dislocations. Bilateral posterior shoulder dislocations are caused by seizures, electrical shock and hypoglycaemia. Bilateral anterior shoulder dislocation is mostly associated with trauma and most have accompanying fractures. We present a case of bilateral anterior shoulder dislocation following minor trauma, with no associated fractures. <![CDATA[<b>Postoperative ophthalmic complication</b>: <b>what's the diagnosis?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000400014&lng=en&nrm=iso&tlng=en Unilateral shoulder dislocation is a common condition and often seen at trauma facilities worldwide. In general anterior shoulder dislocations are more common than posterior dislocations. Bilateral shoulder dislocations are rare and of these, bilateral posterior shoulder dislocations are more prevalent than bilateral anterior shoulder dislocations. Bilateral posterior shoulder dislocations are caused by seizures, electrical shock and hypoglycaemia. Bilateral anterior shoulder dislocation is mostly associated with trauma and most have accompanying fractures. We present a case of bilateral anterior shoulder dislocation following minor trauma, with no associated fractures. <![CDATA[<b>Overlapping pubic symphysis dislocation</b>: <b>a case report and proposal of a classification system</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000400015&lng=en&nrm=iso&tlng=en We report on a rare case of pelvic ring injury with an overlapping pubic symphysis dislocation in a patient who was a pedestrian involved in a motor vehicle accident. She sustained a lateral compression pelvic ring injury with an overlapping pubic symphysis dislocation and a mildly displaced zone 2 sacral fracture. She was treated with open reduction and internal fixation of the pubic symphysis and a percutaneously inserted ilio-sacral screw for the sacral fracture. She recovered well and is asymptomatic at 9 months' follow-up. Only one case has been reported previously that was treated in a similar way. We review the literature, offer recommendations on management and propose a classification system for this injury. <![CDATA[<b>Traumatic hip dislocation in children</b>: <b>the role of MRI</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000400016&lng=en&nrm=iso&tlng=en We report a case of traumatic left hip dislocation in a nine-year-old child following the article: Firth GB, Mazibuko AD, Munir M. Traumatic dislocation of the hip joint in children. SAOJ Autumn 2010; 9(1):68-71. This article, as do others, refers to the use of MRI and CT scan in investigating young patients with hip dislocations. These authors conclude that a CT scan or MRI is probably always indicated.¹ In this case report and literature review, we focus on the role of special investigations and the indication to perform either a CT scan or MRI in this young age group. The routine use of MRI and CT scan following hip dislocations in children is probably unnecessary and should only be done when indicated. This includes incongruent joint reduction noted on postreduction plain films and instability after reduction. There is not enough evidence to perform further investigations routinely without indication as they are costly, CT scans expose the child to radiation and MRI may involve anaesthesia or sedation of the child. If indicated, especially in the young child, an MRI scan provides more information and is the investigation of choice. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000400017&lng=en&nrm=iso&tlng=en <![CDATA[<b>Prof Cas Motala</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2010000400018&lng=en&nrm=iso&tlng=en We report a case of traumatic left hip dislocation in a nine-year-old child following the article: Firth GB, Mazibuko AD, Munir M. Traumatic dislocation of the hip joint in children. SAOJ Autumn 2010; 9(1):68-71. This article, as do others, refers to the use of MRI and CT scan in investigating young patients with hip dislocations. These authors conclude that a CT scan or MRI is probably always indicated.¹ In this case report and literature review, we focus on the role of special investigations and the indication to perform either a CT scan or MRI in this young age group. The routine use of MRI and CT scan following hip dislocations in children is probably unnecessary and should only be done when indicated. This includes incongruent joint reduction noted on postreduction plain films and instability after reduction. There is not enough evidence to perform further investigations routinely without indication as they are costly, CT scans expose the child to radiation and MRI may involve anaesthesia or sedation of the child. If indicated, especially in the young child, an MRI scan provides more information and is the investigation of choice.