SA Orthopaedic Journal

Expanding the orthopaedic training programme to improve the management of lower extremity trauma

Open fractures of the tibia continue to be a challenging problem in orthopaedics. This is particularly so in our country because of the high incidence of motor vehicle accidents. The results of the management of these injuries are not universally good, with non-unions and infections being the major complications. At the recent South African Orthopaedic Association Congress (2015), we learned that in some centres in our country the infection rate is as high as 40%.

Cell signalling and bone remodelling: The skeleton as an endocrine relay organ - Part 1

As knowledge on the signalling pathways involved in bone remodelling unfolds, maintenance of skeletal health and the management of skeletal diseases will increasingly focus on the manipulation of the autocrine, paracrine and endocrine mechanisms involved in the process. This overview is aimed at providing practitioners with an update on recent advances on cell signalling in bone remodelling and highlights the role of the skeleton in systemic metabolism.

Subclinical hypoperfusion in trauma patients and its influence on surgical fracture fixation: Systematic review and meta-analysis

Complications in the surgical management of femur fractures in children with non-ambulatory cerebral palsy

Children with severe non-ambulatory cerebral palsy (CP) are at high risk of sustaining a pathological femur fracture.1,2 These fractures are rare. In a review of the epidemiology of femur fractures in children from Cape Town, the prevalence of femoral pathological fractures related to cerebral palsy was less than three per cent.³ These patients often have multiple co-morbidities which predispose them to pathological femur fractures.3-6 The gold standard of treatment for these fractures is conservative management with either traction or cast immobilisation. The incidence of complications has been reported as extremely high in a number of studies after surgical management of these fractures.1,7 The objectives of this case report are to discuss the aetiology of these fractures, emphasise the role of conservative management as the gold standard of treatment, and highlight complications of surgical treatment in children with non-ambulatory cerebral palsy.

Outcome of displaced supracondylar fractures in children after manipulation and backslab

AIM: To assess the functional and cosmetic outcome of displaced supracondylar fractures in children treated by closed reduction and plaster backslab. METHOD: We retrospectively reviewed 53 patients with Gartland type II and type III fractures that were treated by closed reduction (Blount's technique) and immobilisation in a collar and cuff and above-elbow plaster backslab between December 2011 and May 2012. The mean age was 6.6 years. The mean follow-up time was 12 weeks (range, 6-20). All open injuries and undisplaced fractures were excluded from the study. Flynn's criteria were used to assess functional and cosmetic outcome. RESULTS: The median loss of motion was 10 degrees and the median change in carrying angle was 4 degrees. Fifty-one patients (96.2%) had satisfactory results, with 87% graded as excellent or good according to the Flynn's criteria for grading of the carrying angle. A range of motion of 100 degrees was achieved in 92.5% of patients at 12 weeks. CONCLUSION: This method appears to produce less satisfactory results in comparison to closed reduction and fixation with Kirschner wires (K-wires), but it does provide satisfactory results according to Flynn criteria with regard to cosmetic deformity and range of motion at short-term follow-up. It is an acceptable and safe option with which to treat displaced supracondylar fractures.

How does pre-reduction MRI affect surgeons' behaviour when reducing distraction-flexion (dislocation) injuries of the cervical spine?

STUDY DESIGN: Retrospective review AIM: To identify factors affecting surgeons' management decisions regarding acute cervical distraction-flexion dislocation reduction and the consequences thereof. SUMMARY OF BACKGROUND DATA: There is clinical benefit when early (<24 hours) decompression in distraction-flexion dislocation (DF) injuries with cord injury is performed. The risk of secondary cord injury during awake closed reduction is low. The need for MRI scanning prior to reduction is controversial but it may identify patients with an uncontained herniated 'disc at risk' that may be drawn into the spinal canal during reduction, causing further cord injury. Surgeons' belief regarding the importance of pre-reduction MRI varies. Thus in many clinical scenarios, treatment algorithms are chosen individually by the surgeon on the merits of each case as well as limited access to MRI facilities in the remoter areas of this large country. METHODS: Analysis was performed on 110 consecutive patients with a mean age of 37.1 years with DF dislocation injuries of the cervical spine. Pre-reduction MRI scans were assessed by two independent, blinded teams to determine patients with a 'disc at risk'. This subgroup was then investigated as to the management decisions, neurological status and outcome. RESULTS: Nineteen patients (21%) were identified to have a perceived 'disc at risk'. Six of these patients underwent anterior surgery. Initial closed reduction was attempted in the other 13. None deteriorated neurologically. Presenting neurological status was found to have a large impact on surgeons' choice of reduction. Of the nine ASIA A patients, seven had initial closed reduction, while in the three ASIA E group only one had closed reduction. CONCLUSION: Patients with agreed MRI features of a perceived 'disc at risk' had no increased risk of secondary cord injury. The presence of these disc lesions only influenced our surgeons to choose open reduction in four cases (21%). Neurological status had a much greater effect on surgical decision-making in that those with neurological deficit (most to gain) were reduced closed and ASIA E (most to lose) tended to open reduction. Early reduction need not wait for MRI imaging and should be performed as soon as possible in cord-injured patients.

Iliopsoas tendon impingement following total hip replacement surgery

We have recently seen and successfully treated four patients with iliopsoas-related groin pain post total hip replacement. Their clinical pictures were all typical of iliopsoas-related groin pain. After the exclusion of other causes, surgical release of this tendon resulted in successful treatment with complete resolution of symptoms. We subsequently carried out an anatomic dissection of the iliopsoas tendon on a cadaver torso to better understand the relationship between the iliopsoas tendon and the acetabular component in total hip replacement surgery. It was apparent that cup position and placement were critical to prevent contact of the iliopsoas tendon with the rim of the acetabular component. We have subsequently modified our positioning of the acetabular component.

Achilles tendinopathy Part 2: Surgical management

Although non-surgical management is the mainstay of treatment for non-insertional Achilles tendinopathy, many patients fail to respond to conservative measures. If symptoms persist after an extended period of conservative management, usually at least six months, surgery should be considered. Classically, open surgery was performed with excision of the diseased areas of the tendon. Due to a high rate of complications, as much as 10%, less invasive surgical techniques have been developed and are widely employed with good surgical outcomes and far fewer complications. The reported success rates of open and minimally invasive surgery are comparable and range from 46-100%. Considering the significant morbidity associated with open surgery, minimally invasive surgery is recommended as initial intervention, followed by open surgery if symptoms persist.

The accessory soleus muscle causing tibial nerve compression neuropathy: A case report

The accessory soleus muscle is a rare anatomic variant which may present as a mass in the posteromedial aspect of the ankle, causing compression of the tibial nerve or an exertional compartment syndrome. It should be considered in the differential diagnosis of all soft tissue masses in this area. Treatment options include conservative treatment, excision of the whole muscle and fasciotomy. We report a case of an accessory soleus in a cyclist presenting with activity-related paraesthesia in the foot and discuss the pathology and management of this condition.

Epithelioid haemangioendothelioma of the scapula in a child: A case report and review of the literature

Epithelioid haemangioendothelioma (EHE) is a vascular tumour which rarely affects bone. A 10-year-old girl presented with slow onset of swelling of the scapula for 6 months. Radiology revealed a destructive lesion of the scapula. Histology confirmed epithelioid haemangioendothelioma. Pre-operative transarterial embolisation was performed to decrease the vascularity of the tumour. The tumour was completely resected with the entire scapula. Post-operatively the child improved with useful function and a stable shoulder 13 months later. Large, isolated EHE of the scapula has not been reported in children.

Rosai-Dorfman disease of the distal radius in a child: A case report and review of the literature

Rosai-Dorfman disease (RDD) is a non-neoplastic self-limiting disease of bone marrow stem cell origin characterised by cervical lymphadenopathy. Primary osseous lesions are rare and the condition can mimic various solitary bone lesions radiologically. A 15-month-old child presented with an isolated, well-defined, lucent lesion of the distal radius. Histology demonstrated numerous large histiocytes with intracytoplasmic lymphocytes, plasma cells and neutrophils. Immunohistochemistry showed CD 68 immunopositivity, confirming RDD. Healing of the lesion was seen 6 months post-operatively following curettage. Isolated extranodal osseous lesions are very rare in children and can mimic several osseous conditions.

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