SA Orthopaedic Journal

Outcomes-based evaluations of our patients: A challenge for us all

Reflections on change

I have recently enjoyed reading the recollections of a London based neurosurgeon (Do No Harm, Norman Marsh, Phoenix, 2014) and was intrigued by the similarity of our viewpoints. The author is slightly younger than me, works in a different medical system in a different country and has different stresses (they kill, we cripple), but our psychology as surgeons is the same. Marsh writes of surgery as 'single combat' and I have long known that a challenging operation is like going to war. But the most interesting thing was how we both view the changes that have occurred in our disciplines during our professional lives. Some of them are worth reflection.

Subtotal capsulectomy for idiopathic chondrolysis of the hip: A clinical, radiological and histological study

BACKGROUND: Idiopathic chondrolysis (IC) of the hip is a rare, disabling condition affecting mainly adolescent females. Cartilage necrosis results in a stiff, painful hip which in the majority of cases have a poor outcome. The aetiology still remains unknown and the treatment is controversial and relatively unsuccessful. Subtotal capsulectomy with soft tissue releases has been reported to give good results METHODS: Five female adolescents with IC of the hip were reviewed in order to shed light on the aetiology, delineate the role of magnetic resonance imaging (MRI) pre- and post-operatively and assess the outcome of a subtotal capsulectomy. The surgical technique was performed as originally described with concomitant releases of the deformities. Samples of synovium and cartilage were sent for histology and culture (including tuberculosis culture). Pre- and post-operatively the patients were evaluated regarding pain, deformity and range of motion (ROM). Follow-up radiographs and MRI scans were performed and compared to pre-operative imaging RESULTS: Blood tests for auto-immune markers were negative in all cases. MRI pre-operatively showed erosions and mainly destruction of the superomedial acetabular cartilage. Histology of the synovium showed chronic, non-specific inflammation with a plasma cell infiltrate, suggesting an auto-immune cause. Histology of the cartilage confirmed cartilage necrosis. At follow-up (mean 11 months) four of the five patients were pain free and one patient reported an improvement in pain. There was an improvement in deformity and range of motion in four cases. Post-operative imaging (radiographs and MRI) at a mean of eight months, however, showed deterioration of the pathology with increase of the erosions, joint space narrowing and cartilage destruction CONCLUSIONS: We conclude that the aetiology is most likely an auto-immune process. MRI was helpful in delineating the cartilage pathology. A subtotal capsulectomy offers early post-operative clinical relief. Radiological deterioration however suggests that the surgery does not prevent deterioration of pathology. LEVEL OF EVIDENCE: Level IV: Case series

Case report: A typical presentation of giant cell tumour (GCT) of bone in the distal humerus of a child

INTRODUCTION: Giant cell tumour of bone is a rare entity in children and seldom involves the distal humerus, even in adult patients. We present a case of giant cell tumour in the distal humerus of a child CASE REPORT: A 12-year-old boy presented to our tertiary level tumour unit with progressive pain in his left elbow and was radiologically and histologically found to have a giant cell tumour of his left distal humerus. He was treated with extended curettage, cryotherapy and PMMA cement with the addition of a supportive postero-medial locking plate. There was no recurrence noted at one-year follow-up DISCUSSION: The literature is reviewed to determine the epidemiology of this tumour, the histological and radiological findings unique to the lesion and the current best practice of treatment CONCLUSION: A rare case of giant cell tumour in the distal humerus of a child is presented. Giant cell tumour of bone should be considered in the differential diagnosis of a lytic metaphyseal lesion if the growth plates are open

Hip arthroscopy: What to tell your patient

Hip arthroscopy has gained popularity in recent years. Although femoroacetabular impingement (FAI) is the most common indication for performing the procedure, there are many other conditions affecting the hip joint and its surrounding structures that can also be treated arthroscopically. Before undergoing hip arthroscopy, patients need to be informed about the chances of success of their procedure. In this article we give an overview of the current indications for hip arthroscopic surgery and their clinical outcomes, as revealed in the recent literature.

Adult acquired flat foot deformity: The joint-preserving procedures in stage II tibialis posterior tendon dysfunction

INTRODUCTION: The adult acquired flat foot (AAFF) deformity is a chronic debilitating condition commonly associated with dysfunction of the posterior tibial tendon (PTT). It is often missed unless it is associated with a generalised medical condition such as rheumatoid arthritis. Surgical management is indicated when conservative treatment fails. The joint-preserving procedures have evolved over the years and are preferred for the flexible, non-arthritic deformity. MATERIALS AND METHOD: Twenty-two patients were included in this prospective study. The mean age was 59.8 years with the majority being female. The average BMI was 28.7. The inclusion criterion was symptomatic AAFF deformity due to stage II PTT dysfunction RESULTS: Twenty patients were available for follow-up at one year. The mean AOFAS post-operative score of 89 was significantly improved from the pre-operative score of 42 (p value = <0.001). Likewise most of the radiographic parameters also improved significantly. The complication rate was very low CONCLUSION: This prospective study shows that the joint-preserving procedures for AAFF deformity due to stage II PTT dysfunction are an effective and preferable option to arthrodesis. There is a low complication rate with high patient satisfaction. A certain amount of training and expertise though, is required. Level 2 study.

The pathogenesis of tibial non-union

Bone healing is a unique and complex reparative process that results in fractures healing without scar tissue formation. Multiple factors have been implicated in altering this process. This paper reviews the factors that influence the process of bone healing and predispose to non-union development. Cognisance of these factors will assist orthopaedic surgeons in identifying fractures at risk of altered healing and guide the development of comprehensive management strategies for established non-unions.

Management of tibial non-unions: Prospective evaluation of a comprehensive treatment algorithm

Tibial non-unions represent a spectrum of conditions and are challenging to treat. The optimal management remains unclear despite the frequency with which these diagnoses are encountered. We developed a tibial nonunion treatment algorithm following two retrospective audits of our patient outcomes and evaluated this algorithm in this prospective series. Thirty-seven consecutive patients with 39 uninfected tibial non-unions were treated according to our proposed treatment algorithm. There were 30 men and seven women with a mean age of 34 years. Twenty-three non-unions were classified as stiff hypertrophic, ten mobile atrophic and four mobile oligotrophic. Two non-unions were classified as type B1 defect non-unions. Bony union was achieved after the initial treatment in 37/39 (94.8%) tibias. Two patients had failure of treatment. These patients presented with progressive deformity after the external fixator was removed. One of these patients was successfully retreated according to the tibial non-union treatment algorithm. This resulted in final bony union after treatment in 38/39 (97.4%) tibias. Our proposed treatment algorithm appears to produce high union rates across a diverse group of tibial non-unions. These conditions however, remain difficult to treat and should be referred to specialist units where advanced reconstructive techniques are practised on a regular basis.

Evaluation of the first experience of intramedullary nail lengthening using PRECICE® in a South African limb lengthening and reconstruction unit

BACKGROUND: Limb lengthening is performed through distraction osteogenesis after osteotomy and has traditionally been performed using external fixation. The PRECICE® Limb Lengthening System has recently emerged as an alternative method to control distraction. In this study, the first experience of intramedullary nail lengthening using PRECICE®, in a South African limb lengthening and reconstruction unit, was evaluated in terms of the accuracy of distraction and the number of implant-related complications that were reported METHODS: A total of nine patients underwent the limb lengthening procedure in 11 limb segments. Distraction of the nail was initiated by ERC (external remote controller) around 10 days after surgery at a distraction rate of 1 mm/ day. The distraction was monitored every 2 weeks by clinical and radiographic examinations. Ongoing physiotherapy rehabilitation was performed until consolidation was achieved RESULTS: A mean target distraction length of 45.18 mm (15 to 65 mm range) was obtained over an average follow-up period of 266 days, with an accuracy of 103% ± 18%. All the distraction segments united. Two complications were reported that were successfully treated CONCLUSION: Limb lengthening using the PRECICE® nail system was found to have excellent accuracy of distraction, which is reproducible between different segments and indications. Acceptable complication rates were observed in this study

High rate of popliteal artery injuries and limb loss in 96 knee dislocations

BACKGROUND: Knee dislocations are reported to have an incidence of popliteal artery injuries between 7% and 64%. The purpose of this study was to determine the incidence of injuries to the popliteal artery as well as early limb loss in knee dislocations at a level-1 trauma hospital in South Africa METHODS: Twenty-eight patients with popliteal artery injuries were selected from a prospectively collected database of 96 patients with acute knee dislocations. The incidence of vascular injuries, compartment syndromes and limb loss was determined retrospectively RESULTS: Of 96 knee dislocations 28 had a popliteal artery injury (29.1%). Seven of 28 patients with popliteal artery injuries needed an amputation. Of the 28 patients, ten were documented as a threatened limb. Five of these ten patients (50%) needed an amputation. The documented median delay to revascularisation of patients who presented with threatened limbs was 10 hours CONCLUSION: Overall, one-third of knee dislocations presented with a vascular injury. The prevalence of amputations in knee dislocations with associated popliteal artery injuries was 25% and increased to more than 50% in patients who presented with a threatened limb

Changes in short-term cognitive function following a hip fracture in the elderly and the effect of cognitive function on early post-operative function

OBJECTIVE: To evaluate the changes in short-term cognitive function and the relation between cognition and early post-operative functional outcome in the elderly following a hip fracture DESIGN: Prospective pre-test-post-test observational study SETTING: Two public hospitals in Johannesburg, South Africa PARTICIPANTS: Ninety elderly patients with a first time unilateral hip fracture over the age of 60 years were consecutively sampled. Patients with polytrauma and those with co-morbidities affecting mobility (stroke, Parkinson's disease or a spinal cord injury) were excluded. Patients re-admitted with complications of a previous surgery or those managed conservatively were also excluded. Seventy-two participants completed the study DATA COLLECTION: Pre-operative (baseline), discharge and six weeks post discharge assessments were carried out. Cognitive function was established using the Six-Item Cognitive Impairment Test (6CIT) at each of the three assessment periods. The participants' post-operative functional level was assessed using the Elderly Mobility Scale (EMS) and the Lower Extremity Functional Scale (LEFS) at discharge and at six weeks post discharge RESULTS: This study revealed significant advances in cognition from baseline to six weeks post discharge (z-statistic -5.04, p=0.000). After adjusting for pre-fracture functional mobility and pre-existing co-morbidities, a multivariate regression analysis revealed that cognitive function is also a strong predictor of early post-operative functional outcome (β= -0.14, p=0.036 CONCLUSION: Cognitive function in elderly individuals with a hip fracture does improve over time. Cognitive function is a strong predictor of early post-operative functional outcome, when adjusted for pre-fracture functional mobility and pre-existing co-morbidities

Costotransversectomy in thoracic spinal tuberculosis

BACKGROUND: The escalating global pandemic of tuberculosis infections results in 8 million new cases diagnosed each year. The thoracic and thoracolumbar spine is the most prevalent area involved in musculoskeletal tuberculosis. Deformity with associated neurological compromise, requiring extended in-patient treatment and rehabilitation, is common. Multidrug-resistant tuberculosis is prevalent and tissue samples are needed to obtain bacterial culture and sensitivity. Decompression of the spinal canal, directly or indirectly, should accelerate neurological recovery METHODS: A retrospective study was performed at Tygerberg Hospital to evaluate the efficacy of costotransversectomy in spinal thoracic tuberculosis with regard to neurological recovery and deformity. Neurological status was compared at 6 months post-operatively with the pre-surgical status. The end deformity was compared with Rajasakeran's equation RESULTS: Thirty patients met the inclusion criteria, with an average age of 37 years. Fifteen patients were HIV positive, and ten of them on highly active antiretroviral therapy (HAART). The average CD4 count was 235. The mean neurological status of the group was classified as Frankel C, but this improved to Frankel D at 6 months post-surgery. Initial sagittal deformity was 18.7°, which increased to 26° one year post-operatively. This was not significantly different from the 25.6° kyphosis predicted by the Rajasekaran formula. A 67% positive culture yield for TB was obtained which compared favourably to percutaneous transpedicular needle biopsies performed at the same institute which had a yield of 56% CONCLUSIONS: Costotransversectomy is a simple procedure resulting in indirect decompression of the spinal cord, improving the microbiological diagnosis of spinal tuberculosis, and possibly leading to earlier neurological recovery, without the risk of creating further instability and greater deformity

Cell signalling and bone remodelling Part II: Developments in the pathogenesis and principles of management of selected skeletal disease states

Mapping of the bone remodelling signalling pathways contributed significantly to the establishment of a scientific basis for the development of pharmaceuticals which have the potential to induce or suppress bone formation. Enhancing bone healing and the establishment of a pre-determined skeletal phenotype are now within reach of the medical profession. This manuscript provides practitioners with an overview of recent developments in the quest for uncovering the molecular mechanisms involved in the pathogenesis of selected bone disease states and the role these discoveries play in the future management of bone healing and skeletal health.

Digital photography in orthopaedics: Ethical considerations

Orthopaedic trauma surgery manages soft tissue damage with underlying bony injuries. As a part of the management, many surgeons use photographs to digitally capture the state of the soft tissues in order to plan further surgery. This area relies solely on individuals to regulate as to what is photographed and what happens to these images once they have served their purpose. This article reports a survey of orthopaedic surgeons in South Africa, both in state and private practice, regarding their current views and habits when obtaining digital images of clinical cases. The results demonstrate that digital images form an integral part of orthopaedic practice and are used to aid handovers, referrals and communication with patients and colleagues. The problematic areas identified were those relating to the obtaining and documenting of consent and the secure storage of images.

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