Scielo RSS <![CDATA[SA Orthopaedic Journal]]> http://www.scielo.org.za/rss.php?pid=1681-150X20110003&lang=en vol. 10 num. 3 lang. en <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>Obesity and total joint replacement</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000300001&lng=en&nrm=iso&tlng=en <![CDATA[<b>Musculoskeletal trauma</b>: <b>are we winning?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000300002&lng=en&nrm=iso&tlng=en <![CDATA[<b>Anatomical classification and surgical considerations</b>: <b>primary spinal tumours an overview</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000300003&lng=en&nrm=iso&tlng=en Primary spinal tumours make up 11% of primary musculoskeletal tumours, and 4.2% of spinal tumours.¹ Six per cent of these spinal tumours are to be considered malignant.² The intrinsic rarity of these tumours therefore make it very difficult for a single spinal surgeon to amass a large enough number of surgical cases to string together a valid and well-constructed series in a single career. The sparse body of available literature stems mostly from multi-centre research. Inappropriate treatment and incomplete resection not only increase the rate of recurrence, but have in fact been shown to be detrimental to the patient's survival.3-5 Thorough understanding of the principles involved as well as experience therefore limits the treatment of such cases to bigger centres with high enough numbers to be considered practised. <![CDATA[<b>Periprosthetic fractures of the femur associated with hip arthroplasty</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000300004&lng=en&nrm=iso&tlng=en Periprosthetic fractures following total hip or knee arthroplasty have become more common as the indications and age distribution for these procedures have increased in the last few years. Revision surgery in these patients holds a very high complication rate and therefore measures should be taken to prevent these fractures. Osteolysis with subsequent component loosening has been shown to pose a risk for periprosthetic fractures. Regular follow-up visits could reveal early signs and symptoms of component loosening. Patients who develop loosening should be revised as soon as possible to prevent periprosthetic fractures. The Vancouver classification (intra- and post-operative) for periprosthetic fractures associated with total hip replacement has been shown to be reproducible and an excellent guideline for management. Revision surgery for periprosthetic fractures carries a significant risk for complications. This review and instructional article will focus mainly on periprosthetic fractures in hip arthroplasty, although some risk factors and biomechanical considerations are also applicable for periprosthetic fractures of the femur in knee arthroplasty. Greater trochanteric fractures can present intra-operatively or post-operatively. Non-unions of the greater trochanter commonly presents many years down the line in patients where the surgical approach was done through greater trochanteric osteotomy, and are generally difficult to treat. This review will cover some aspects on the fixation methods of these fractures. Finally the hardware and surgical adjuncts to treat periprosthetic fractures will be discussed briefly. The more common fracture patterns (type B2) and the problematic (type B3) will be discussed in more detail. <![CDATA[<b>How to create a PowerPoint presentation that will play video clips on any computer</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000300005&lng=en&nrm=iso&tlng=en The following is applicable to PCs or laptops using Microsoft systems. The difference between a professional presentation and one that is merely adequate is sometimes the proper use of multimedia. A picture tells a thousand words and video clips tell even more. Nothing is more frustrating or breaks the flow of a presentation more than a video clip that does not play. Therefore most presenters use their own laptops. This presents its own set of problems, i.e. it is time-consuming, laptops don't recognise projectors, and so on. <![CDATA[<b>Anterior-only transthoracic surgery for adult spinal tuberculosis</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000300006&lng=en&nrm=iso&tlng=en Historically, anterior decompression followed by posterior fusion has been the surgical management of choice in spinal tuberculosis. Due to theatre time being at a premium, we have evolved to anterior only debridement, allograft strut reconstruction and instrumentation for tuberculosis in the adult thoracic spine. The aim of this study was to review the safety and efficacy of this treatment. METHODS: Twentynine adult thoracic tuberculosis patients were identified where anterior-only surgery had been performed. These were all midthoracic TB as circumferential surgery is still favoured in thoraco-lumbar disease. The surgery was performed by a single surgeon at a tertiary hospital. A retrospective review of clinical notes and radiological studies was performed. RESULTS: The average surgical time was 2 hours 15 minutes with a median blood loss of 700 ml. The majority of patients had two vertebral bodies involved and required an average of a four-body fusion. Twenty-eight of the patients presented with altered neurology; three only had sensory changes while 25 presented with paraparesis and an inability to ambulate. Twentythree patients recovered to independent mobility at their latest follow-up appointment. There was an average preoperative kyphosis angle of 33º, which improved immediately post-operatively to 22º, (p = 0.03). The average deformity at latest follow-up was 32º (p = 0.003). Sixteen of 28 patients had documented bony fusion with no evidence of instrumentation failure or loosening in any patients. There were two deaths related to the patients' general poor state of health and co-morbidities. CONCLUSION: Transthoracic anterior-only debridement, allograft strut graft and simple body fixation provides an effective option for the management of adult thoracic tuberculosis. There is a high success rate in achieving return to ambulatory status with few complications. Although loss of early sagittal correction is seen with time, this does not affect neurological outcome. Intra-operative attention to maintaining end-plate integrity is encouraged in an effort to reduce graft subsidence. <![CDATA[<b>The orthopaedic management of myelomeningocoele</b>: <b>GT du Toit founders lecture, SAOA Congress, September 2010</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000300007&lng=en&nrm=iso&tlng=en Myelomeningocoele is the commonest congenital birth defect.¹ The Cape Town prevalence has been reported as 2.5 per 1 000 births in the white population and 1 per 1 000 births in the black and coloured population.² The incidence at Red Cross Children's Hospital has remained static at a mean of 12 new patients a year since 1987. Although this is a relative decrease, it remains significantly high. Part of the reason is that the foetal anomaly ultrasound (and elective termination) available to all antenatal patients in the Western Cape is not utilised by unbooked patients. The incidence of elective termination in the USA is 23%.³ Myelomeningocoele requires a multi-disciplinary approach. At Red Cross Children's Hospital the weekly spinal defects clinic involves neurosurgeons, urologists and stomatherapists (who teach the patients bladder and bowel care), orthopaedic surgeons and orthoptists. Neurosurgeons do the primary closure and insert and maintain a ventriculo-peritoneal shunt in 95% of the patients who have hydrocephalus due to an Arnold-Chiari malformation. Urologists treat the ninety per cent of patients who are incontinent. Orthopaedics has protean applications in myelomeningocoele. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000300008&lng=en&nrm=iso&tlng=en <![CDATA[<b>Overtreatment of cruciate ligament injuries</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000300009&lng=en&nrm=iso&tlng=en Myelomeningocoele is the commonest congenital birth defect.¹ The Cape Town prevalence has been reported as 2.5 per 1 000 births in the white population and 1 per 1 000 births in the black and coloured population.² The incidence at Red Cross Children's Hospital has remained static at a mean of 12 new patients a year since 1987. Although this is a relative decrease, it remains significantly high. Part of the reason is that the foetal anomaly ultrasound (and elective termination) available to all antenatal patients in the Western Cape is not utilised by unbooked patients. The incidence of elective termination in the USA is 23%.³ Myelomeningocoele requires a multi-disciplinary approach. At Red Cross Children's Hospital the weekly spinal defects clinic involves neurosurgeons, urologists and stomatherapists (who teach the patients bladder and bowel care), orthopaedic surgeons and orthoptists. Neurosurgeons do the primary closure and insert and maintain a ventriculo-peritoneal shunt in 95% of the patients who have hydrocephalus due to an Arnold-Chiari malformation. Urologists treat the ninety per cent of patients who are incontinent. Orthopaedics has protean applications in myelomeningocoele. <![CDATA[<b>Low grade chondrosarcoma</b>: <b>is long-term follow-up necessary?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000300010&lng=en&nrm=iso&tlng=en INTRODUCTION: Currently, the follow-up regimen for patients treated for low-grade chondrosarcoma is similar to that of all chondrosarcomas. It is possible that low-grade chondrosarcoma may have a far more benign course than other chondrosarcomas and, if treated adequately, may require a far less vigorous follow-up regimen. PATIENTS AND METHODS: A retrospective study was performed on all patients treated for chondrosarcoma at the Pretoria Musculoskeletal Tumour Unit,, University of Pretoria, over a 22-year period, between 1987 and 2009. In total 56 patients were treated for chondrosarcoma over this period, but two patients were lost to follow-up. The study totalled 54 patients. The grade of chondrosarcoma, outcome and tumour recurrence was evaluated in these patients. The lesions were divided into four histological grades: atypical enchondroma (grade 0), low-grade chondrosarcoma (grade I), intermediate grade chondrosarcoma (grade II), and high-grade chondrosarcoma (grade III). RESULTS: Histologically 46 tumours were low-grade (grade 0 or I) chondrosarcoma (82%), there were nine cases of intermediate (grade II) chondrosarcoma (16%), and one patient had a metastatic mesenchymal chondrosarcoma. The femur and humerus were the commonest sites involved. The axial skeleton was affected in only three cases, all of which had more aggressive lesions. Two patients died, one with metastatic mesenchymal chondrosarcoma involving the scapula, and the other with an intermediate (grade 2) lesion of the pelvis. There was no tumour recurrence in 49 patients after a mean period of 57.5 months, of which 42 patients had low-grade (grade 1) lesions, and seven patients had intermediate (grade 2) lesions. Two patients with low-grade lesions were lost to follow-up. Three patients presented with recurrence, all of which had a local recurrence. No metastatic disease was detected radiographically. Of these three patients one had a grade 2 lesion, and the other two patients were initially not treated with surgical adjuvant therapy. Not one patient with low-grade chondrosarcoma treated adequately with local curettage and surgical adjuvant therapy presented with local recurrence or distal metastasis. CONCLUSION: We believe that adequately treated low-grade chondrosarcomas have a very low local recurrence rate. Treatment consists of local curettage with surgical adjuvant therapy. When faced with recurrence, it rarely presents with distant metastases. A revised follow-up schedule is advised consisting of visits at 3 and 6 months and followed by yearly visits for 5 years. This appears to be adequate for timely detection and treatment of any local recurrence of low-grade chondrosarcoma. <![CDATA[<b>Primary bone lymphoma</b>: <b>imaging findings of a rare primary bone tumour</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000300011&lng=en&nrm=iso&tlng=en Primary bone lymphoma (PBL) is a rare cause of primary bone malignancy and it is unusual for extranodal lymphoma to arise in the skeletal system. The imaging appearance is variable and the diagnosis is usually made on histology. We present the radiographic and CT features of primary bone lymphoma of the humerus in a young patient and discuss the variable imaging appearances of this condition. <![CDATA[<b>Orthopaedic litigation in South Africa</b>: <b>a review of the Medical Protection Society data base involving orthopaedic members over the last 10 years</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000300012&lng=en&nrm=iso&tlng=en BACKGROUND: Medical litigation, especially against orthopaedic surgeons, is a worldwide phenomenon with a marked upward trend in the developed nations. There has been a 20% increase over the last five years in South Africa alone. The purpose of the study was to review the cases involving Medical Protection Society (MPS). members in RSA, identify trends and review the literature to see what can be done to prevent litigation. METHODS: A retrospective review was conducted (1 January 2000 to 31 December 2009) of all anonymised orthopaedic cases reported to the MPS. The total number of cases reviewed was 1 186. Furthermore, a review of the literature was conducted to identify possible strategies to reduce litigation cases. RESULTS: The results revealed that spinal surgery was the group most commonly litigated against, accounting for 11.6% of all cases. Second most common were the cases in which the patient deemed to have had an unsatisfactory result (10.5%). Following these were cases of: communication problems (6.9%), billing problems (6.6%), missed diagnosis (5%), gross negligence/unavailability (4.7%), medical report problems (3.9%), wrong site surgery (3.5%), failed surgery (3.4%), nerve injury (3.4%), death (2.7%), infection (1.9%), arthroscopy (1.8%), retained instruments (1.6%), POP complications (1.5%), diathermy and other burns (1.3%), consent (1%), vascular (0.9%) and compartment syndrome (0.67%). The current international literature reveals that most of the cases leading to litigation are caused by poor communication between the surgeon and patient. This can be prevented by attending a communication skills workshop (as presented by the MPS). Wrong site surgery still occurs worldwide and is indefensible in a court of law but is easily prevented by following the universal protocol for preventing wrong site, wrong procedure and wrong person surgery (explained later in the article). Consent remains vital before any surgical case and a record of the discussion pertaining to the consent should be documented in your clinical notes. Missed vascular injury has a high morbidity and by having a high index of suspicion and using the ankle brachial pulse index the incidence can be brought down. Product liability cases are surfacing as the law changes and orthopaedic surgeons start to help designing products. <![CDATA[<b>Functional outcome of bicondylar tibial plateau fractures treated with the Ilizarov circular external fixator</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000300013&lng=en&nrm=iso&tlng=en BACKGROUND: Bicondylar tibial plateau fractures are often associated with severe soft tissue injuries that can frequently result in compartment syndrome and are frequently open fractures. Operative management of these injuries is invariably complicated by the condition of the soft tissue envelope of the proximal tibia. METHODS: Between July 2008 and March 2009, 13 consecutive patients who sustained bicondylar tibial plateau fractures were treated with Ilizarov fine wire circular external fixators. These 13 patients were reviewed with regard to their functional outcome and any complications incurred during the management period. RESULTS: Eleven patients met the inclusion and exclusion criteria. All patients achieved bony union and had good functional results without serious complications. No osteomyelitis, septic arthritis, loss of reduction or wound dehiscence occurred. Superficial pin tract infection was the most common complication encountered, but in all cases pin site care and oral antibiotics were sufficient to eradicate the problem and no pins or wires needed to be removed or resited. CONCLUSION: The treatment of bicondylar tibial plateau fractures with the Ilizarov circular external fixator is safe and effective, and produces good functional results without serious complications. <![CDATA[<b>Spondylolytic spondylolisthesis</b>: <b>surgical management of adult presentation</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000300014&lng=en&nrm=iso&tlng=en Retrospective review of 27 patients presenting as adults with spondylolytic spondylolisthesis. The average age at surgery was 42.9 years. Most patients (21/27) had long standing tolerable axial back pain with symptoms present for up to 156 months. It was however the radicular pain that brought them to surgery. Posterior transforaminal lumbar inter-body fusion (TLIF) was performed in all patients with a median surgical time of 183 minutes and 650 ml blood loss. There were two complications, one a large blood loss of 4 000 ml due to uncontrollable epidural bleeding and another transient cauda equina syndrome after a delayed secondary bleed. Following haematoma evacuation, the latter patient returned to normal neurological status. There was maintenance of a normal segmental lordosis with increased disc height. The fusion rate was 90% by 2 years with a significant improvement in all pain and functional scores (EQ 5D, ODI, Roland-Morris, Health Slider and VAS). CONCLUSION: Although lumbar lysis is largely a benign condition, a subgroup of patients will develop disc degeneration and present with debilitating radicular pain from foraminal stenosis despite minimal listhesis. These patients are well managed with a posterior-based decompression and fusion with the TLIF technique as it provides high radiographic fusion rates with excellent patient outcome. <![CDATA[<b>Tuberculosis of the skull with associated cranio-cervical subluxation</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000300015&lng=en&nrm=iso&tlng=en Skeletal tuberculosis (TB) is commonly seen in South Africa, especially in the immune-compromised patient group. The thoracic and lumbar spine are commonly affected and the decision-making around pathology in that area has become easier based on experience gained in, especially, government institutions. The danger occurs when atypical sites of infection occur and the associated structures and pathology thereof are not thoroughly considered and investigated. A case is reported which highlights the potential pitfalls of tuberculosis of the skull. The associated cranio-cervical pathology appears very similar to meningitis and subtle changes on imaging in that area is often difficult to assess and easily missed. There are several management options based on individual presentation. Medical management remains the same as for all other skeletal TB. <![CDATA[<b>Lumbar disc herniation in a 9-year-old child</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2011000300016&lng=en&nrm=iso&tlng=en Lumbar disc herniation is very uncommon in children under the age of 10 years. We report on a lumbar disc herniation in a 9 year old. The patient presented with spontaneous onset of back pain and right leg pain which had failed to respond to 6 months of conservative treatment at a primary health care facility. Examination revealed severe lumbar back muscle spasm, listing of the spine to the left and a positive straight leg raising test on the right. The child had weakness of the right big toe extension. Magnetic resonance imaging (MRI) confirmed a disc prolapsed at L4L5 compressing the traversing right nerve root of L5. A standard discectomy followed by rehabilitation was performed after a further 2 weeks of observation. The muscle spasm and listing together with the right big toe motor weakness disappeared post operation. At 3 months follow-up he was back into his school activities.