Scielo RSS http://www.scielo.org.za/rss.php?pid=1681-150X20130001&lang=en vol. 12 num. 1 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=S1681-150X2013000100001&lng=en&nrm=iso&tlng=en http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2013000100002&lng=en&nrm=iso&tlng=en STUDY DESIGN: Retrospective study of 31 patients treated for adolescent idiopathic scoliosis utilising posterior double rod constructs with a limited number of strategically placed screws. OBJECTIVE: Review of the radiological and clinical outcomes of strategic screw placement in posterior double rod constructs with respect to implant density. SUMMARY OF BACKGROUND DATA: The trend in scoliosis surgery dictates the use of pedicle screw constructs with anchors at every level. Favourable correction and clinical outcomes have been reported using this technique. The cost burden of such an implant construct is high; with the additional risk of pedicle breach and neurological compromise multiplied by the number of screws. The sustainability of this practice is questionable. METHODS: Thirty-one patients, treated surgically for adolescent idiopathic scoliosis, with a minimum two-year follow-up, were included. Posterior double-rod constructs were used in all cases. Cobb angles were measured pre-operatively, post-operatively and at two-year follow-up. Patient satisfaction and clinical outcome were evaluated through the SRS22 questionnaire. RESULTS: Lenke classification yielded 16 type I, seven type II, four type III, two type IV and two type VI curves. The average Cobb angle pre-surgery was 68.5° (±17.6°), with a flexibility of 38%. This was corrected to an average of 24°±11.9°. The correction was maintained at two-year follow-up. In terms of thoracic sagittal profile, 25 patients measured 'normal' (10°-40°) post-operatively, compared to 17 pre-operatively. This correction was achieved with a 52.2% metal density over an average of nine instrumented segments. Average SRS22 patient satisfaction score was at 89%. CONCLUSION: Strategic screw placement, in adolescent idiopathic scoliosis surgery, yields adequate correction and curve maintenance. High levels of patient satisfaction were achieved at a dramatically reduced cost, with a diminished risk for pedicle violation. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2013000100003&lng=en&nrm=iso&tlng=en Hyperextension at the cervico-dorsal (CD) junction is rare in osteogenesis imperfecta (OI) with no cases being reported in the literature. We report a three-year-old child with OI (Sillence type III²) who presented with: hyperextension at CD junction; low bone mass; thoracolumbar kyphosis; bilateral anterolateral bowing of femora; and failure to thrive. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2013000100004&lng=en&nrm=iso&tlng=en STUDY DESIGN: A retrospective review of adolescent patients undergoing instrumented anterior spinal fusion (ASF) by a single surgeon for thoracolumbar or lumbar (TL/L) scoliosis. OBJECTIVE: The aim of this study is to investigate the efficacy and associated morbidity of anterior instrumented corrective fusion for thoracolumbar and lumbar scoliosis. MATERIALS AND METHODS: The medical records and radiographs of 36 consecutively managed patients who underwent anterior spine surgery for thoracolumbar or lumbar curves by a single surgeon between 2001 and 2011 were retrospectively reviewed. The cohort consisted of 26 female and 10 male patients with idiopathic scoliosis as the commonest aetiology. Data collated and analysed included patient demographics, surgical factors, post-operative management and complications. In addition, radiographic analysis was performed on pre-operative and follow-up X-rays, and Scoliosis Research Society (SRS 22) scores were collated. RESULTS: Thoracolumbar/lumbar curves were corrected from 68.4°±18.8° (34°-120°) to 25.9°±16.6° (7°-66°) (average of 62.1% correction). The thoracic compensatory curve spontaneously corrected from 32.8°±14.0° (12°-53°) to 18.4°±14.2° (4°-44(0)) (average of 43.9% correction). Sagittal imbalance of greater than 4 cm was found in 40% of patients pre-operatively and in 16% post-operatively (85% negative sagittal imbalance, 15% positive sagittal imbalance). Rotation according to the Nash-Moe method corrected by 1.2 of a grade (2.37±0.69-1.17±0.58). Average operative time was 194 minutes and estimated blood loss was 460 ml. The diaphragm was taken down in 34 of the 36 patients but no patients required post-op ventilation. The average high care stay was 1.2 days. Average follow-up was 16.9 months. Good maintenance of correction was shown at most recent follow-up, with the mean thoracolumbar/lumbar curve measuring 27.9°±16.7°, and the mean compensatory thoracic curve measuring 20.9°±16.3°. There were no significant neurological or respiratory complications, and no cases had radiological signs of pseudoarthrosis. Scoliosis Research Society scores were obtained in 75% of the idiopathic scoliosis group (18/24), and improved from 75.91 pre-operatively to 84.72 post-operatively. A total of 93.8% were satisfied/very satisfied with their treatment, and 87.5% would probably/definitely have the same treatment again. CONCLUSION: Anterior corrective fusion for thoracolumbar and lumbar scoliosis is effective in both deformity correction and the maintenance thereof. Spontaneous correction of the thoracic curve can be expected and thus limit the fusion to the lumbar curve. Despite the concerns of taking down the diaphragm, there is minimal morbidity. LEVEL OF EVIDENCE: Level IV. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2013000100005&lng=en&nrm=iso&tlng=en STUDY DESIGN: A retrospective review of adolescent patients undergoing instrumented anterior spinal fusion (ASF) by a single surgeon for thoracolumbar or lumbar (TL/L) scoliosis. OBJECTIVE: The aim of this study is to investigate the efficacy and associated morbidity of anterior instrumented corrective fusion for thoracolumbar and lumbar scoliosis. MATERIALS AND METHODS: The medical records and radiographs of 36 consecutively managed patients who underwent anterior spine surgery for thoracolumbar or lumbar curves by a single surgeon between 2001 and 2011 were retrospectively reviewed. The cohort consisted of 26 female and 10 male patients with idiopathic scoliosis as the commonest aetiology. Data collated and analysed included patient demographics, surgical factors, post-operative management and complications. In addition, radiographic analysis was performed on pre-operative and follow-up X-rays, and Scoliosis Research Society (SRS 22) scores were collated. RESULTS: Thoracolumbar/lumbar curves were corrected from 68.4°±18.8° (34°-120°) to 25.9°±16.6° (7°-66°) (average of 62.1% correction). The thoracic compensatory curve spontaneously corrected from 32.8°±14.0° (12°-53°) to 18.4°±14.2° (4°-44(0)) (average of 43.9% correction). Sagittal imbalance of greater than 4 cm was found in 40% of patients pre-operatively and in 16% post-operatively (85% negative sagittal imbalance, 15% positive sagittal imbalance). Rotation according to the Nash-Moe method corrected by 1.2 of a grade (2.37±0.69-1.17±0.58). Average operative time was 194 minutes and estimated blood loss was 460 ml. The diaphragm was taken down in 34 of the 36 patients but no patients required post-op ventilation. The average high care stay was 1.2 days. Average follow-up was 16.9 months. Good maintenance of correction was shown at most recent follow-up, with the mean thoracolumbar/lumbar curve measuring 27.9°±16.7°, and the mean compensatory thoracic curve measuring 20.9°±16.3°. There were no significant neurological or respiratory complications, and no cases had radiological signs of pseudoarthrosis. Scoliosis Research Society scores were obtained in 75% of the idiopathic scoliosis group (18/24), and improved from 75.91 pre-operatively to 84.72 post-operatively. A total of 93.8% were satisfied/very satisfied with their treatment, and 87.5% would probably/definitely have the same treatment again. CONCLUSION: Anterior corrective fusion for thoracolumbar and lumbar scoliosis is effective in both deformity correction and the maintenance thereof. Spontaneous correction of the thoracic curve can be expected and thus limit the fusion to the lumbar curve. Despite the concerns of taking down the diaphragm, there is minimal morbidity. LEVEL OF EVIDENCE: Level IV. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2013000100006&lng=en&nrm=iso&tlng=en Leiomyomas (smooth muscle tumours) arising in skeletal muscle are extremely rare in children, especially in the extremities. A 3-year-old girl presented with a slow-growing mass in the left calf which had been present since the age of 6 months. Plain radiographs revealed a well-circumscribed mass, fusiform in shape, not attached to bone. There was widespread calcification of the tumour. MRI confirmed extensive calcification and ossification in the soleus and medial head of the gastrocnemius displacing the neurovascular bundle anteriorly. A diagnosis of a sarcoma was suggested. The mass was well defined at surgical exploration, encapsulated and easily dissected from the soleus, gastrocnemius muscles and blood vessels. The tumour was gritty on cutting with a saw and histology confirmed a leiomyoma of the soleus muscle. Immunohistochemical markers for smooth muscle actin and desmin were positive. The recovery was uneventful at five-month follow-up. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2013000100007&lng=en&nrm=iso&tlng=en Segmental upper limb fractures in children are extremely uncommon with the commonest injury described being the 'floating elbow'. In this report a case is described of a 'floating arm' - flexion-type Gartland grade III supracondylar fracture of the humerus and simultaneous ipsilateral Salter Harris type II proximal humerus fracture. The management, outcome and available literature on this rare combination of injuries are discussed. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2013000100008&lng=en&nrm=iso&tlng=en AIM: To describe the clinical and radiological manifestations of tuberculosis of the hip joint and the resemblance to common osteoarticular lesions in children. METHODS: Thirty-six children (1 to 12 years) were reviewed retrospectively between 1990 and 2011. Clinical, laboratory and radiological features were assessed. The hips were classified and the outcome was graded as described by Shanmugasundaram. RESULTS: Common clinical features were a limp, flexion, adduction and internal rotation contractures. Common radiological features were osteopaenia and cystic lesions in the neck and acetabulum. Permeative lesions, focal erosions, pathological fractures and sequestra were less common. Seven children had extra-articular lesions. Of the 29 with osteoarticular involvement, six had purely synovial involvement. Osteoarticular lesions mimicked benign bone and joint conditions. Follow-up was 1 to 6 years, 36% were graded as good, 36% fair and 28% had poor outcome with ankylosis. Other complications included avascular necrosis, coxa vara, coxa magna, growth arrest and flexion-adduction contractures. CONCLUSION: Tuberculosis of the hip can mimic various benign conditions. Biopsy from a bony lesion is important. The initial radiological appearance predicts the outcome, especially in the 'normal' type of hip. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2013000100009&lng=en&nrm=iso&tlng=en Patients in need of total hip or knee arthroplasty are continuously getting younger which produce the need for bearing surfaces that can withstand both the high functional demand as well as the longevity of the patient. New developments are continuously flooding the market and the promotion of these products is directed towards patients themselves who, most of the time, will not have the necessary insight to choose the best possible product. Due to recent introduction into the market, these products all lack long-term independent clinical follow-up, but all have promising results in manufacturer-funded, short-term clinical trials and laboratory simulator trials. This leaves the surgeon with the dilemma of using new untested technology with potentially devastating results or keeping to the tried and trusted. Technological advances in bearing surfaces include modifications of known materials and the introduction of totally new materials, all in an attempt to find the perfect bearing coupling. This paper summarises the most important new developments in bearing surfaces and bearing couples in arthroplasty and puts emphasis on the dangers of using untested technology. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2013000100010&lng=en&nrm=iso&tlng=en The two major radiation crosslinking techniques developed for ultra-high molecular weight polyethylene (UHMWPE) prostheses and the ensuing clinical implications thereof are discussed, indicating the effects of the different techniques on clinical outcomes. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2013000100011&lng=en&nrm=iso&tlng=en Ochronosis is dark pigmentation of connective tissue in patients with alkaptonuria. The dark pigmentation is caused by accumulation of homogentisic acid (HGA) and its metabolites in the connective tissues, due to deficiency of an enzyme that degrades HGA in the tyrosine degradation pathway. The deposition of HGA in connective tissue causes weakness of the tendon and subsequent rupture, especially the large tendons in the body. Rupture of isolated tendons has been reported in many case reports in the literature. We report on a patient with multiple sequential tendon ruptures, and review the literature to see if there is a way of preventing subsequent tendon ruptures after an initial rupture in this condition. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2013000100012&lng=en&nrm=iso&tlng=en Femoral neck fractures are the second most common non-vertebral fragility fracture, and their management is complicated by multiple controversies. This article aims to review the recent literature in an attempt to elucidate current concepts critical to the management of intra-capsular femoral neck fractures. The optimal timing of surgery remains controversial. A recent meta-analysis was able to show that a delay of longer than 24-72 hours resulted in a statistically significant increase in mortality. Internal fixation of undisplaced fractures remains undisputed. In terms of displaced fractures, two well-designed studies have shown significantly higher re-operation rates in patients treated with closed reduction and internal fixation. While there appears to be renewed interest in the use of bi-polar hemiarthroplasty, conflicting evidence has been published with regard to total hip replacement for hip fractures in the elderly, and it may only be indicated in selected subgroups of relatively healthy patients. The peri-operative use of tranexamic acid has recently been shown to result in a reduction in transfusion requirements. Arguably the most important recent development in the management of hip fractures is the decrease in mortality provided by intravenous bisphosphonate therapy. Apart from a reduction in subsequent fractures the therapy also appears to reduce mortality due to cardiovascular and pulmonary causes. Recent investigations into thrombopro-phylaxis have highlighted the fact there is very little data to show that potent anti-coagulation decreases the risk of fatal pulmonary emboli. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2013000100014&lng=en&nrm=iso&tlng=en Femoral neck fractures are the second most common non-vertebral fragility fracture, and their management is complicated by multiple controversies. This article aims to review the recent literature in an attempt to elucidate current concepts critical to the management of intra-capsular femoral neck fractures. The optimal timing of surgery remains controversial. A recent meta-analysis was able to show that a delay of longer than 24-72 hours resulted in a statistically significant increase in mortality. Internal fixation of undisplaced fractures remains undisputed. In terms of displaced fractures, two well-designed studies have shown significantly higher re-operation rates in patients treated with closed reduction and internal fixation. While there appears to be renewed interest in the use of bi-polar hemiarthroplasty, conflicting evidence has been published with regard to total hip replacement for hip fractures in the elderly, and it may only be indicated in selected subgroups of relatively healthy patients. The peri-operative use of tranexamic acid has recently been shown to result in a reduction in transfusion requirements. Arguably the most important recent development in the management of hip fractures is the decrease in mortality provided by intravenous bisphosphonate therapy. Apart from a reduction in subsequent fractures the therapy also appears to reduce mortality due to cardiovascular and pulmonary causes. Recent investigations into thrombopro-phylaxis have highlighted the fact there is very little data to show that potent anti-coagulation decreases the risk of fatal pulmonary emboli. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2013000100015&lng=en&nrm=iso&tlng=en Femoral neck fractures are the second most common non-vertebral fragility fracture, and their management is complicated by multiple controversies. This article aims to review the recent literature in an attempt to elucidate current concepts critical to the management of intra-capsular femoral neck fractures. The optimal timing of surgery remains controversial. A recent meta-analysis was able to show that a delay of longer than 24-72 hours resulted in a statistically significant increase in mortality. Internal fixation of undisplaced fractures remains undisputed. In terms of displaced fractures, two well-designed studies have shown significantly higher re-operation rates in patients treated with closed reduction and internal fixation. While there appears to be renewed interest in the use of bi-polar hemiarthroplasty, conflicting evidence has been published with regard to total hip replacement for hip fractures in the elderly, and it may only be indicated in selected subgroups of relatively healthy patients. The peri-operative use of tranexamic acid has recently been shown to result in a reduction in transfusion requirements. Arguably the most important recent development in the management of hip fractures is the decrease in mortality provided by intravenous bisphosphonate therapy. Apart from a reduction in subsequent fractures the therapy also appears to reduce mortality due to cardiovascular and pulmonary causes. Recent investigations into thrombopro-phylaxis have highlighted the fact there is very little data to show that potent anti-coagulation decreases the risk of fatal pulmonary emboli.