SA Orthopaedic Journal

MESSAGE FROM THE PRESIDENT

Post-graduate training in orthopaedics

Hippocrates revisited: opening address at the European Hip Society Meeting, Athens, 2010

Pyogenic osteomyelitis of the forearm bones in children

Twelve children, aged 1-10 years at presentation, diagnosed with pyogenic osteomyelitis of the forearm bones, were reviewed retrospectively. The radius was involved in six patients, the ulna in five and both bones in one child. Three children had acute osteomyelitis; the remaining nine had features of chronic osteomyelitis. The acute infections had incision and drainage and healed well. In six patients with chronic osteomyelitis treatment involved curettage, debridement and sequestrectomy, with resulting bone defects. Three children with chronic infection were referred with established defects from outlying hospitals. Corticocancellous iliac bone chips were used in defects <2 cm in two children; and in two children with larger defects (6-8 cm), segmented bicortical iliac bone graft was used over a K wire. Two children with distal ulna resorption had radioulnar synostosis. Two children had radial club hand deformity with loss of the radial shaft. One had transposition of the residual metaphysis of the radius to the distal ulna, and the other had transposition of the carpus to the ulna. The remaining child had shortening of the radius following multifocal osteomyelitis in infancy. All reconstructive procedures healed by 3 months. All children had improved function. Shortening of the forearm ranged from 2-20 cm.

Blood product utilisation during massive transfusions: audit and review of the literature

Acute exsanguination is the leading cause of mortality in trauma patients.1-3 Massive blood loss potentially results in the development of the 'lethal triad', comprising hypothermia, acidosis and coagulopathy.4 Without prompt intervention, including the appropriate administration of blood and blood products, the majority of these patients will demise within 6 hours.2,4,5 Utilisation of blood and blood products in this setting is considered a lifesaving intervention. A massive transfusion can be defined as the 1) the infusion of five units or more of packed red cell concentrate (RCC) within 4 hours;6 2) infusion of more than ten units RCC within the first 24 hours;7-15 or 3) infusion of six or more units RCC within 12 hours.16-18 Irrespective of the formal definition, it has become evident that patients requiring six to nine units of RCC within a 24-hour period have a 2.5 times higher mortality. This mortality risk was significantly higher in patients requiring massive transfusion, than compared to patient groups requiring transfusion of less than six units of RCC.19 Despite controversy with regard to the definition, the aim of these definitions remains the same: early identification of patients with life-threatening bleeds, to ensure proper resuscitation and prevention of complications associated with resuscitation.6 The use of fixed ratios of infused blood products in massive transfusion remains controversial as authors fail to reach consensus on appropriate ratios. These ratios vary from a 1:1:1 ratio for RCC:fresh frozen plasma (FFP):platelets7,12,20-24 to a 6:4:1 ratio.25,2 6 Despite this lack in consensus, it is evident that the practice of fixed ratio transfusions27,28 in the form of a consistent protocol25,2 9 has led to a significant reduction in mortality10,30 from in excess of 90%31 to between 30 and 70%,32 although some authors refute these findings.13,17 The aim of this study was to determine local practices with regard to transfusion of blood and blood products in patients undergoing massive transfusion.

Proximal thoracic spine fractures: a dangerous blind spot

INTRODUCTION: The proximal thoracic spine is difficult to visualise on X-ray investigation with up to 22% of proximal fractures being missed. This is a major concern, especially in environments such as South Africa where trauma is endemic. AIM: To review the challenges of diagnosis and management in patients with proximal thoracic fractures. METHODS: Thirty-three patients with proximal thoracic fractures in the T1-T4 area managed in a spinal unit were identified. There were 21 males and 12 females with a median age of 31.8 years. A retrospective review of medical records and radiology was undertaken. Demographic data, mechanism of injury, diagnostic modalities, diagnostic delay, fracture characteristics, neurological status, associated injuries, hospital stay, management, complications and outcomes were recorded. RESULTS: The aetiology was 21 MVA passengers, eight drivers, one pedestrian, one assault, one bicycle and one hangglider accident. Eight had a one-day diagnostic delay, two between 2 to 5 days and five greater than 2 weeks. The fractures were A1 in seven, A3 in 14, B1 in seven, C1 in two and C2 in two. Twenty-three patients had neurological compromise, 13 being complete. Twentythree had associated chest and head injuries. Hospital stay was a mean of 27 days (max of 246). ICU median was 14 (max of 115) days. Twenty-six patients underwent surgery, posterior instrumented fusion being the commonest procedure. Although the surgery did not change the median kyphosis (25º pre-op to 20º at 1 year and 21º at 2 years), most kyphotic patients were improved (55º to 45º). CONCLUSION: Proximal thoracic fractures are most commonly encountered following motor vehicle accidents. There is a risk of delayed diagnosis due to poor visualisation with X-ray investigation. There is a high risk of associated spinal cord injury, chest, limb and abdomino-pelvic injuries that result in prolonged hospital stay. These fractures can be managed successfully by posterior pedicle screw fixation and fusion, only if unstable. A high index of suspicion for proximal thoracic fractures should be maintained in all patients involved in high impact accidents and with chest injuries, and CT should be employed if X-rays are unclear.

Spinal schistosomiasis in the era of tuberculosis

Spinal schistosomiasis although rare is a welldescribed entity. We report an unusual manifestation of ectopic spinal schistosomiasis involving T6/T7 with spinal cord compression in a patient on treatment for a suspected TB of the spine. The patient had T6/T7 vertebral destruction with complete paraplegia. This patient was treated at a rural hospital for spinal tuberculosis without neurological improvement and was diagnosed with spinal schistosomiasis by both histopathological means as well as serology. In areas endemic for schistosomiasis and tuberculosis, in patients with paraparesis irrespective of the level of the spinal lesion, schistosomiasis should be looked for as a differential diagnosis, especially in patients with poor response to an antiTB treatment regimen.

Canterbury index: an accurate predictor of fracture redisplacement?

PURPOSE: Paediatric forearm fractures are commonly seen and treated by closed reduction and plaster cast application in theatre. Historically cast application has been subjectively evaluated for its adequacy in maintaining fracture reduction. More recently emphasis has been placed on objectively evaluating the adequacy of cast application using indicators such as the Canterbury index (CI). The CI has been used in predicting post-reduction, re-displacement risk of patients by expressing the cast and padding indexes as a ratio. The CI has been criticised for not including cast three-point pressure, fracture personality, lack of standardisation of X-ray views as well as practical requirement of physical measurement using rulers. The aim of this study was to determine whether subjective evaluation of these indices, before and after a tutorial on the CI, was accurate in predicting a patients ultimate risk of re-displacement, following reduction and casting. In addition, we aimed to determine whether objective evaluation of these indices by measurement on the hospitals digital X-ray system correlated with the final fracture outcome post-reduction. MATERIALS AND METHODS: A retrospective study was done on a sample of 11 patients during the period May 2010 to July 2011 at Steve Biko Academic Hospital. In total, 44 X-rays/fluoroscopy views were subjectively evaluated by 20 registrars and eight consultants for possible fracture re-displacement, before and after a tutorial on the CI. Five consultants and 10 registrars each measured 22 cast, padding and CIs on the digital X-ray system. RESULTS:A formal tutorial did not produce an increase in subjective predictive accuracy. Pre- and post-tutorial observed agreement was seldom better than agreement by chance alone. Poor strength of agreement (κ <0.20) was found in all groups, irrespective of level of displacement, imaging modality, level of orthopaedic training and tutorial attendance. Objective measurement of the indexes all had insignificant p-values for comparing groups, indicating that there was no correlation between the measured indexes and the final outcome irrespective of the level of fracture, imaging modality and level of orthopaedic training. Shortcomings were variable co-operation from participants and non-standardisation of X-rays. CONCLUSION: In our hospital setting, no clinical value for the subjective and/or objective use of the CI could be found. Subjective agreement was almost the same as expected agreement and objective measurement indicated no correlation with the fracture outcome. It is suggested that patients following closed reduction of forearm fractures be followed up within the first three days, and regularly thereafter, as there is currently no ideal system to predict re-displacement. Further studies are needed to validate the CI by standardisation of X-rays.

Bilateral pneumothoraces and thyroid storm in undiagnosed Graves' disease following posterior fusion scoliosis surgery: a case report

The coexistence of idiopathic scoliosis and Graves' disease is not an established phenomenon. Bilateral pneumothoraces as a complication of posterior pedicle screw correction of scoliosis is an uncommon finding. Thyroid storm as initial presentation in Graves' disease is also uncommon. Surgery and stress are known precipitants of thyroid storm in untreated Graves' disease. We report on a 14-year-old female with idiopathic scoliosis who underwent posterior only pedicle screw correction of the deformity and developed bilateral pneumothoraces and thyroid storm in the first postoperative day. This was her first presentation with Graves' disease. Preoperatively she had reported no symptoms of hyperthyroidism. She was treated successfully and discharged from the hospital.

Autologous intramedullary bone graft harvesting as an alternative to conventional harvesting methods

Conventional bone graft harvesting using the iliac crest is often cited as having significant donor site morbidity and complications. A technique has become available in the form of intramedullary harvesting, using a reamerirrigationaspiration (RIA) system. It is hailed as a safe alternative, with minimal donor site morbidity and pain. This study presents a retrospective case series of 16 patients where the RIA system was used as a harvesting technique from June 2008 to January 2010. This technique involves harvesting autograft from the femoral canal (anterograde or retrograde) by reaming the intramedullary cavity only once. A single surgeon performed the operations over a 24month period. Fluoroscopy was used to size and measure the width of the canal and to confirm guide wire placement. Outcomes evaluated were postoperative pain perception and patient satisfaction. Bone harvest volumes, intraand postoperative complications and bony union were noted. Telephonic interviews were conducted in all 16 cases. The average age of the patients was 31 years (15-55 years). The femoral canal was used as the donor site in all the patients. The mean postoperative followup period was 18.8 months (8-27 months). The average amount of bone harvested was 39.6 cc (20-70 cc). Two technical complications were encountered intraoperatively and there were no systemic complications due to reaming. Although The RIA system was found to be a safe technique, with reliable volumes of autograft obtained. Patients recovered quickly without wound complications and minimal donorsite morbidity. This technique seems to be a viable option as an alternative to conventional bone graft harvesting. Ethical clearance was obtained from The Research Ethics Committee, Faculty of Health Sciences, University of Pretoria.

Role of ultrasound as a non-invasive method of diagnosis of chronic exertional compartment syndrome

Chronic exertional compartment syndrome (CECS) is a well-recognised condition, which can result in significant morbidity and limitation of activity in athletes and non-athletes alike. At present invasive intramuscular pressure (IMP) measurements are still considered the gold standard for diagnosing CECS. The non-invasive nature of ultrasound makes it an attractive alternative to direct IMP measurement. This retrospective study is a literature and case review of 34 subjects with exerciseinduced leg pain who underwent ultrasound compartment measurement for CECS. Eighteen (group P) of 34 were found to be positive. Fifteen of group P demonstrated calf increases of >15 mm and an additional three with increases of <15 mm failed to return to the resting state at 10 mins after exercise. Sixteen subjects demonstrated a normal ultrasound after exercise. At follow-up (1-2 years) a telephonic interview of 25 participants showed that 15 of the 18 with a positive confirmation of CECS had responded well to surgical decompression and 10 of the 16 negative cases had responded well to conservative treatment. This study suggests that ultrasound may be a useful tool for the assessment of CECS.

Industry driven research: have we reached a crisis point?

Intramedullary locked fixation of clavicle shaft fractures: review of early results

Background To assess the effectiveness of a novel locked intramedullary device in the treatment of acute clavicle shaft fractures. Description of methods Patients admitted with midshaft clavicle fractures were assessed to determine whether operative fixation of the fracture was required. Indications for surgery were: midshaft clavicle fractures with 100% displacement; more than 1.5 cm of shortening; presence of a displaced butterfly segment; bilateral clavicle fractures; ipsilateral displaced glenoid neck fractures; skin and neurovascular compromise. Patients who matched the criteria for surgery were treated operatively with an intramedullary locked device by the author. Postoperatively, patients were kept in a shoulder immobiliser for a period of 6 weeks. Patients were invited to attend a scheduled followup visit where the data was collected that comprised the review. All patients were assessed on the same day by the surgeon, a radiologist, a physiotherapist and an occupational therapist. Scar size and quality, Dash score, Constant Shoulder score, complications and the radiological picture were assessed. Summary of results Twentynine patients (31 clavicle fractures - two patients sustained bilateral fractures), 18 males and 11 females with a mean age of 28 years attended the schedule data collection visit and were included in the study. Twentynine clavicles achieved complete union with the remaining two fractures progressing normally to union at 10 and 13 weeks post surgery. Three patients developed postoperative complications - two nail failures and one hardware sepsis. All three fractures achieved union despite the respective complications and achieved union in an acceptable position. Two of the patients were noncompliant with the postoperative regimen and one sustained secondary trauma to the affected shoulder. These factors are believed to have caused the nail breakages in the two cases but implant failure could not be excluded. Conclusion Locked intramedullary fixation of clavicle shaft fractures that matches the criteria for operative fixation was found to be a reliable method of achieving fracture reduction and fracture union. This operation is moderately demanding with a short learning curve. Level of evidence Case series; level IV evidence

Prevalence of agenesis of flexor digitorum superficialis of the fifth digit in East Africa through clinical examination

Introduction The flexor digitorum superficialis (FDS) is a flexor of the digits of the hand and has been reported to have varying rates of agenesis. We conducted a study to determine the prevalence of agenesis of the FDS in an East African population by clinical examination. Materials and methods A prospective study was conducted using three clinical tests among patients and students in a large teaching hospital in East Africa to determine the presence of the FDS in the fifth digit. Results The overall rate of absence was 2.5% with unilateral absence at 1.5% and bilateral absence at 1.0%. The over-all difference between males and females was not statistically significant (p=0.654). Discussion Our findings are in contrast to many studies worldwide. There is a paucity of studies on the subject in Africa which hinders adequate comparison. Conclusion The prevalence of the absence of the FDS to the fifth digit in East Africa has been determined. Surgeons should acquaint themselves with prevalence in their areas of practice.

Dupuytren's contracture

Intra-articular rice bodies: imaging for persistent joint pain

Rice bodies are fibrous bodies that macroscopically resemble grains of rice. They may uncommonly occur as a complication of inflammatory arthritides but may create diagnostic confusion when the patient has no underlying inflammatory disease. The combined use of ultrasound, magnetic resonance imaging (MRI) and plain film makes it possible to reach a correct diagnosis. We describe a patient with a chronic monoarthritis of unknown aetiology who presented with rice bodies in the right elbow joint demonstrated on MRI.

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