Scielo RSS http://www.scielo.org.za/rss.php?pid=1681-150X20110002&lang=en vol. 10 num. 2 lang. en 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=S1681-150X2011000200001&lng=en&nrm=iso&tlng=en http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000200002&lng=en&nrm=iso&tlng=en http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000200003&lng=en&nrm=iso&tlng=en Costs of medicine and fees in private practice are topical as ever with pressure from all sides to make care affordable to all. Many see specialists as cost drivers and excessively remunerated, yet many specialists are unhappy with their earnings. Unless surgeons earn adequately, their service will reduce. The conflicts of financial reimbursement and professionalism are discussed along with the history of billing in medicine. Using the state salaries as a basis, equivalent private practice turnovers are calculated demonstrating the vast difference between perceived earnings based on turnover and the real earnings of the surgeon. An individualised tariff calculation is recommended along with appropriate billing practice. This paper is based on an ethics lectured delivered at the 2010 South African Spine Society meeting in Cape Town. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000200004&lng=en&nrm=iso&tlng=en The prevalence of HIV-positive patient is high in the sub-Saharan region. This is a report of two unknown asymptomatic HIV carriers presenting with major thoracolumbar fractures for emergency management. The patients' results were complicated by delayed infection. The cases demonstrate the need to know the HIV status in a major orthopaedic trauma setting to enable additional treatment to be implemented that may improve the treatment outcome. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000200005&lng=en&nrm=iso&tlng=en AIM: The aim of the study was to establish the human immunodeficiency virus (HIV) seroprevalence in an acute orthopaedic trauma setting in an urban teaching hospital. METHODS: All patients admitted at the Orthopaedic Trauma Unit of the academic hospital during a six-month period from 1 July 2008 to 31 December 2008 were counselled and an informed consent for HIV testing was obtained. Only acute orthopaedic trauma patients aged 18 years and above, with a Glasgow Coma Scale of 15/15 and competent to give consent were recruited for the study. Where the consent was given blood samples were analysed by way of a rapid HIV test followed by a confirmatory ELISA when the rapid HIV tested positive. Those patients who tested positive for the virus were then counselled and offered referral to an HIV centre for follow-up. RESULTS: A total of 797 patients were admitted during the study period. One-hundred-and-fifty-nine patients (20%) did not meet the inclusion criteria. A total of 638 patients were therefore eligible for recruitment. Two-hundred-and-forty-six patients (38%) consented and signed the informed consent form. Of those that were tested, 57 (23%) tested positive and were followed up accordingly. CONCLUSION: Seroprevalence in an acute orthopaedic trauma setting in an urban teaching hospital was found to be high in this study. The power of this study was weakened by the low percentage of eligible patients who consented to be tested. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000200006&lng=en&nrm=iso&tlng=en BACKGROUND: We have studied a South African family in which four persons in three generations had bilateral coxa vara. The proband, a boy aged 4 years, presented with a disturbance of gait. His affected father and uncle had been assessed and operated on by the first named consultant (DT), and his grandmother by DT's father. METHOD: We performed a general and orthopaedic examination as well as a radiologic skeletal survey of the above four family members. RESULTS: The proband's clinical and radiological assessment showed facial features and clavicular changes in keeping with cleidocranial dysplasia, an autonomous autosomal dominant genetic disorder. Radiographs of his hips revealed bilateral coxa vara deformities. The proband's father, uncle and grandmother also had similar facial and clavicular features of cleidocranial dysplasia. Their hip radiographs showed evidence of previous internal fixation subsequent to proximal femoral osteotomies. CONCLUSION: Cleidocranial dysplasia is relatively common in South Africa and this condition warrants consideration as a diagnosis in any person with familial coxa vara. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000200007&lng=en&nrm=iso&tlng=en Awareness of the importance of skin exposure to UV rays for normal bone growth and systemic health increased with landmark scientific discoveries over the past century. Several Nobel-prize laureates unravelled the steps involved in the activation of 7-dehydrocholesterol to 1,25 (OH)2 vitamin D (or vit D3) which is rapidly becoming the most important medical discovery in the past decade. Recent developments in our understanding of the impact of vit D on the immune system, carbohydrate metabolism, and cardiovascular and neoplastic diseases are briefly highlighted. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000200008&lng=en&nrm=iso&tlng=en Tuberculosis is a common diagnosis in the developing world. Its incidence is increasing in the developed world due to immigrants from endemic regions, increased cases of immune-compromised patients, multi-drug resistance and low socio-economic status. Tuberculous spondylitis is the commonest extra-pulmonary manifestation of tuberculosis. The rib is only very rarely involved. We present a case of multifocal tuberculous spondylitis in the T6-9 and L3 regions with involvement of the ninth rib. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000200009&lng=en&nrm=iso&tlng=en BACKGROUND: Treatment of aggressive benign bone lesions with curettage, burring, cementation and plate augmentation is a widely accepted treatment. We have used the above method utilising a locked plate, rather than conventional plating methods, facilitating immediate stability and early mobilisation. We hypothesised that this joint-preserving method would provide an economic alternative to megaprosthetic joint replacement without compromising good functional outcomes. METHODS: Patients with peri-articular aggressive benign bone lesions were treated with marginal excision, curettage, burring and cementation. This was augmented with a locked plate. Liquid nitrogen was used as an adjunct where feasible. Functional assessment and radiological recurrence was assessed at follow-up using the Musculoskeletal Tumour Society Score (MSTS) and routine X-rays. RESULT: The average MSTS score was 88%. Average follow-up time was 21 months. To date, no revisions have been performed for recurrence or pain and no significant complications have occurred. CONCLUSIONS: Our early results in a small series make us optimistic that this may be an alternative to immediate megaprosthetic reconstruction; furthermore, this may provide a useful intermediate step in the treatment of aggressive benign peri-articular bone tumours with some degree of associated joint deformation without significantly compromising later prosthetic reconstruction. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000200010&lng=en&nrm=iso&tlng=en Bilateral clavicle fractures are rare and are seldom reported on. Based on the literature review the incidence of bilateral clavicle fractures is 0.43% of clavicle fractures with an overall incidence of between 0.011 and 0.017%. The common mechanism of injury is one of a compressive force across both shoulder girdles and is different from that causing unilateral clavicle fractures. Bilateral clavicle fractures are usually associated with high-energy impact injuries and are commonly associated with other severe injuries. These injuries are not always evident and should be actively sought for and excluded. Bilateral clavicle fractures are not commonly mentioned as an indication for operative intervention. It is suggested that bilateral clavicle fractures should be surgically managed to limit the duration of functional disability. Furthermore the use of low profile locking plates provides the ideal fixation method allowing for an earlier functional outcome. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000200011&lng=en&nrm=iso&tlng=en It is widely recommended that children with Legg-Calvé-Perthes (LCP) disease aged 5 years or younger be treated non-surgically. Studies have nevertheless shown that this group does not have a universally good outcome. A prospective clinical trial was started in 1978, using lateral subluxation (extrusion) of the femoral head in the fragmentation stage of the disease as an indication for surgery. A review of 71 patients with 73 involved hips treated at age 5 years or younger shows that children who present with a Catterall 4/Herring C classification, as well as the presence of lateral subluxation, do better following a Salter innominate osteotomy than a comparable group that was treated with intermittent analgesics, rest and physiotherapy. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000200012&lng=en&nrm=iso&tlng=en Cryptococcosis is a systemic disease caused by the fungus Cryptococcus neoformans which predominantly affects immuno-compromised individuals. Cryptococcal osteomyelitis is rare, having an incidence of 5-10% in patients with systemic cryptococcosis. Isolated cryptococcoma of bone is even less common, especially in immuno-competent individuals. We report a case of a 10-year-old girl who presented with a mass over her left iliac crest. Radiographs showed a lytic lesion of the ilium. Open biopsy and surgical curettage of the lesion was done. Histology showed a cryptococcoma. The patient was treated with fluconazole. After three months of treatment she required a repeat curettage of the lesion due to wound drainage and persistent soft tissue swelling. She continued with oral fluconazole treatment and after 7 months the wound had healed, the soft tissue swelling had resolved and radiographs showed resolution of the lesion. Fungal infections should be included in the differential diagnosis of lytic bone lesions. Tissue diagnosis should be obtained to confirm diagnosis. Fluconazole is an effective treatment for cryptococcal osteomyelitis, with surgical curettage a useful adjunct. Good results can be expected in the majority of cases. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000200013&lng=en&nrm=iso&tlng=en The incidence of venous thromboembolism complicating shoulder surgery is low. We present a case of a patient who developed a thrombus in the lower leg and subsequently a pulmonary embolus following an arthroscopic rotator cuff repair. Further investigation revealed a genetic predisposition to venous thromboembolism. A review of the current literature on this topic has revealed very little research related to possible causes or risk factors. It is clear though that prevention by means of a proper patient-screening protocol is essential. Adequate preventative measures need to be taken in high risk cases. Failure to apply an adequate screening protocol can lead to adverse outcomes in patients who undergo arthroscopic shoulder surgery.