Scielo RSS <![CDATA[SA Orthopaedic Journal]]> vol. 11 num. 1 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>Will the real expert witness please take the stand</b>]]> <![CDATA[<b>Our time and our mistakes</b>]]> <![CDATA[<b>Outcomes of osteosarcoma in a tertiary hospital</b>]]> Thirty consecutive cases of osteosarcoma treated over a five-year period were reviewed retrospectively. The cases were notable for the advanced stage of disease at presentation with half the patients presenting with metastases, and unusually large mean tumour sizes. The majority of patients needed amputation for local control of the tumour. Although follow-up is short, a third of the patients are disease-free at a mean of 30 months and a sixth alive with metastases at a mean of 16 months. Half the patients are presumed or known to be dead. Presence of metastases at diagnosis and size greater than 10 cm were associated with a poor prognosis. <![CDATA[<b>Clinical utility of tissue polymerase chain reaction in the diagnosis of spinal tuberculosis</b>]]> BACKGROUND: An estimated 14 million people worldwide have active tuberculosis (TB). About 3% of these patients will have osteoarticular involvement and approximately 25% to 60% will have an infectious focus in the spine. Early diagnosis is essential as prompt treatment is associated with improved outcome and reduced mortality. This is particularly true within a high HIV-1 seroprevalence setting. MATERIALS AND METHODS: All patients admitted to Kalafong District Hospital from January 2008 to December 2010 with a clinico-radiological diagnosis of spinal TB were included in this study. In all cases Ziehl-Nielsson (ZN) microscopy, TB culture, TB polymerase chain reaction (PCR), and histology with ZN stains were collected, and the turnaround times for these assays recorded. HIV testing was performed on patients who gave consent for the procedure. RESULTS: In total, 29 patients were included in this study. Seventeen patients consented to HIV testing of which 11 were confirmed to be positive. It was determined that sensitivity for culture and PCR were comparable at 77% and 72% respectively. Furthermore, when looking at the subgroup of HIV-1 positive patients specifically, both assays performed better, with sensitivities of 88% and 82% respectively. The TAT for assays was highly variable, with PCR and histology having comparable times. CONCLUSIONS: PCR testing for spinal TB shows promising results especially within the HIV-1-positive population. Although this type of testing theoretically offers a shorter turnaround time, results were available in similar time frames as for histology. Therefore, on-site testing should be offered in hospitals with high case loads of TB, and combination testing should be used rather than opting for a single testing modality. <![CDATA[<b>Greater trochanteric pain syndrome</b>]]> Greater trochanteric pain syndrome is a common, but often misdiagnosed cause of lateral hip pain. Recent advances in the imaging of the hip has improved the understanding of the causative mechanisms of greater trochanteric pain syndrome (GTPS). The syndrome encompasses a wide spectrum of causes including tendinosis, muscle tears, iliotibial band (ITB) disorders and surrounding soft tissue pathology. Clinically GTPS presents with lateral hip tenderness and pain with resisted abduction. A positive Trendelenburg test is the most sensitive predictor of a gluteal tear. Altered lower limb biomechanics is proposed as an important predisposing factor for gluteal muscle pathology. Many conditions are associated with GTPS: some of them may predispose to GTPS, while others may mimic the symptoms. Although plain radiographs are still important for ruling out other causes of hip pain, MRI has become the imaging modality of choice in GTPS. Most cases of GTPS can be regarded as self-limiting. Conservative modalities (rest, NSAIDs, physiotherapy) are still the mainstay of treatment. Corticosteroid injections are still widely used and reported to be successful. Proven gluteal muscle tears are treated with surgical repair and bursectomy. Endoscopic techniques have become increasingly popular. <![CDATA[<b>Arthrogryposis multiplex congenita of the upper limb</b>]]> The name arthrogryposis is derived from the Greek and means stiff joints (arthron = joint and grypos = stiff). Arthrogryposis represents a large group of disorders that present with joint contractures at birth. These congenital contracture syndromes total over 65 conditions with different clinical courses and pathological processes. Contracture syndrome groups can be divided into the following: • Group involving all four extremities - includes arthrogryposis multiplex congenita (AMC) and Larsen syndrome, usually with total body involvement. • Distal arthrogryposis - group predominantly or exclusively involving the hands and feet. Freeman-Sheldon whistling face is an example in this group. • Pterygia syndromes - identifiable skin webs cross the flexion aspects of knees, elbows and other joints. Multiple pterygias and popliteal pterygia belong to this group. <![CDATA[<b>Pin tract sepsis</b>: <b>Incidence with the use of circular fixators in a limb reconstruction unit</b>]]> BACKGROUND: Pin site-related problems remain one of the most common complications in the realm of limb reconstructive surgery. Several factors determine the integrity of the bone-pin interface, including the insertion technique, the mechanical forces applied through the frame and the selected pin site care protocol. Pin site complications can be catastrophic as they may lead to failure of the bone-pin interface and, possibly, osteomyelitis. METHODS: Between July 2008 and July 2011, 111 patients at our Limb Reconstruction Unit were treated with circular external fixators. These patients' records were reviewed with regard to pin site complications, treatment thereof and outcome. RESULTS: Eighty patients met the inclusion and exclusion criteria. Pin site infection was found in 21 patients (26.25%). One patient had a major infection, which required debridement of the pin tract. The remaining 20 cases were all minor infections that responded to local treatment and oral antibiotics. CONCLUSION: Circular external fixation remains a safe treatment method, with the majority of pin site complications being of a minor nature that respond readily to local treatment and oral antibiotics <![CDATA[<b>The value of CRP in infection</b>]]> Lumbar pain is ubiquitous. Due to the health burden and the fact that most axial lumbar pain is self-limiting, we cannot investigate all patients with expensive investigations. We rely on the 'red flags' and inflammatory parameters. This case highlights that one investigation does not override the rest. Despite a normal CRP on two occasions, lumbar pain can be due to a pathological cause. In the end the surgeon needs to evaluate all information, with the patient's history being equally important in planning management. Unfortunately what works most of the time is not correct all of the time, and repeated examination may be necessary to get to the root of the problem <![CDATA[<b>Is procalcitonin useful in diagnosing septic arthritis and osteomyelitis in children?</b>]]> BACKGROUND: Early diagnosis of septic arthritis (SA) and osteomyelitis (OM) in children is essential to prevent long-term sequelae. The diagnosis for these orthopaedic emergencies can be difficult and challenging especially in infants. Standard blood tests used for diagnosis have a low specificity. Procalcitonin (PCT) is significantly elevated in bacterial infections and remains low in viral infections and inflammatory conditions. Good positive predictive values for PCT have been obtained in various studies used in paediatric infections but limited studies have examined the role in orthopaedic infections. METHOD: All children under 14 years of age presenting with signs and symptoms of SA or OM from 1 June 2009 to 31 June 2010 were subjected to standard blood tests with the addition of PCT. The definitive diagnosis was made by clinical, surgical and microbiologic data obtained. A cut-off level of 0.2 ng/mL was used. RESULTS: Thirty-three patients were included from which 12 were subdivided into the SA/OM group and 21 into an Other diagnosis group which acted as a control. Of the 12 patients in the SA/OM group, eight patients were diagnosed with SA and four with OM. In the SA/OM group, 11 from 12 patients had an increased PCT level compared to four in the Other diagnosis group. The calculated sensitivity of PCT was 92% with a confidence interval of 62-100%; the specificity was 81% with a confidence interval of 58-95%. In this study the sensitivity of CRP was 100% while the specificity 26%. The positive predictive value for PCT in this study was 73% and the negative predictive value was 94%. The accuracy for PCT in SA and OM in this study was 85%. CONCLUSIONS: The calculated sensitivity and specificity in this study has proved that PCT testing can aid in the diagnosis of SA/OM in children by using 0.2 ng/mL as cut-off level. PCT is also more specific for bacterial infections in this study compared to CRP. Staphylococcus aureus is the most common organism isolated in this series with no resistant organisms seen. Further research is needed with larger numbers to conclusively prove that this specific cut-off for PCT is significant. <![CDATA[<b>Bacteriology and epidemiology of hand infections</b>]]> Infection is one of the most serious and important causes of hand swelling. Neglect or incomplete treatment of hand infections will usually lead to involvement of other parts of the hand resulting in stiffness, loss of hand function, and possibly amputation (Figure 1). Hand infections are common conditions that have significant morbidity. Referral is often delayed and infections present late. Hand infections should be managed by an experienced surgeon. The aims of the investigation were: to identify the spectrum of organisms and appropriate antibiotics for hand infection; and to characterise the patterns and sites of hand infections. This information was collected against the background of a high prevalence of HiV-infected patients and increasing antibiotic resistance. A total of 66 patients treated for hand infections over a period of six months in Pelonomi Hospital, Bloemfontein, South Africa, was prospectively recruited for the study. Staphylococcus aureus was the commonest isolate. Results show that cloxacillin is still an effective first line antibiotic for community-acquired hand infections in the absence of immunosuppression. Alternative empiric therapy would be clindamycin - especially in the beta-lactam intolerant patient. Erythromycin also proved to have a favourable profile. HIV-positive patients were more prone to Gram-negative infections. <![CDATA[<b>High-pressure injection injury of the thumb</b>]]> High-pressure injection injuries of the hand are relatively rare but potentially devastating injuries. We highlight a clinical case that presented to the Chris Hani Baragwanath Academic Hospital Hand Unit. The pathophysiology of this phenomenon, as well as the risk factors associated with a poor prognosis, is discussed. Management strategies are explored after a review of the literature. This case demonstrates the results from delays in early surgical management and the lack of education about high-pressure injection injuries amongst employers, employees and primary health care physicians. <![CDATA[<b>Burn scar squamous cell carcinoma of both hands</b>]]> BACKGROUND: We describe a very unusual presentation of bilateral post-burn contracture of hands that complicated into Marjolin's ulcers - squamous cell carcinoma. MATERIAL: A patient with bilateral squamous cell carcinoma post-burn scar. METHOD: The patient, with post-burn contractures of both hands, and chronic ulcerations, presented as a referral from one of our peripheral hospitals. A biopsy had been done at the referring hospital with histologic results of squamous cell carcinoma. The patient later had an excisional biopsy in our hospital that confirmed the diagnosis of squamous cell carcinoma of both hands. The patient also had a satellite lesion on the axilla; a biopsy was done that confirmed squamous cell carcinoma. RESULTS: The right hand was treated with a free flap that later sloughed on the periphery. CONCLUSION: To our knowledge bilateral squamous cell carcinoma of hands post-burn has not yet been reported in the literature and its presentation is a matter of discussion.