SA Orthopaedic Journal

Introduction of new hip and knee prostheses

Periprosthetic fungal infections: Be alert (Clinical cases and review of the literature)

The increasing rate of arthroplasty, revisions and resistance to antibiotics has increased the risk for fungal infections. Different treatment modalities exist: suppressive therapy, debridement with retained prosthesis, Girdlestone procedures and 2- or even 3-stage revision arthroplasty. Fungal infections after joint replacements are rare but devastating. PURPOSE OF THE STUDY: The aim was to see if there was any trend that could help with the diagnosis and management of patients with fungal infections. The literature was reviewed in order to assist with diagnosis and treatment. MATERIALS AND METHODS: A retrospective study was performed and all the cases seen and treated by a tumour and sepsis orthopaedic specialist from 1999 to 2015 were evaluated. INCLUSION CRITERIA: Patients had to be diagnosed with a fungal infection in any specimen which was sent for histology or culture. EXCLUSIONS: none RESULTS: Four patients were identified. All of them were males. Mean age 58 (35-71) years. The primary surgical indications were: vertebral osteomyelitis; post primary knee replacement; pig bite with lower limb sepsis and osteoarthritis knee, and a septic total hip replacement. Three cases cultured Candida parapsilosis and one Candida albicans of which three were tissue cultures and one a blood culture. Currently 75% have failed treatment - one passed away, one developed systemic sepsis, and one had an above-knee amputation and is still struggling with subsequent bacterial infections in the amputation stump. CONCLUSION: As long as there are higher incidences of fungal infections with devastating complications more evidence is needed. Numerous small case studies have been published, with the purpose of looking for the correct treatment: monotherapy, combination therapy, newer antifungals, higher dosages, implant retention or removal. It appears that the correct answer is unclear as yet. It is important to always have a high index of suspicion and good pre-operative planning together with a team approach: infectious diseases specialist, microbiologist and histologist. This approach will optimise the probability of making a diagnosis and to appropriately manage the fungus cultured.

Ulnar impaction syndrome: A case series and imaging approach

Ulnar-sided wrist pain can be attributed to many pathological processes. This can include traumatic, inflammatory or degenerative conditions. Ulnar impaction syndrome is a group of syndromes that are degenerative conditions of the wrist caused by an abnormal joint configuration or due to abnormal use. This leads to an increase in axial loading across the ulnar side of the wrist with resultant joint degeneration. The structures in the wrist concerned in this syndrome are the triangular fibrocartilage complex, the distal radio-ulnar joint and the lunate triquetral bones at their ulnar articulations. Even though a number of modalities exist to image the wrist, the options for accurately assessing ulnar impaction syndrome are limited and may be challenging. Accurate assessment of the triangular fibro-cartilage complex is essential, as it lies central in the classification of the disease.

Early clinical outcomes of isolated low velocity gunshot radius fractures treated with closed reduction and locked intramedullary nailing

BACKGROUND: The treatment goals in diaphyseal radius fractures are to regain and maintain length and rotational alignment and stability. Open reduction and plating carries the inherent problems of soft tissue disruption and periosteal stripping. Intramedullary nailing offers advantages of minimally invasive surgery and minimal soft tissue trauma. AIMS: To investigate the outcomes of locked intramedullary nailing for isolated gunshot diaphyseal radius fractures in adults. METHODS: A cross-sectional review of prospectively collected clinical and radiological data was performed. All adult patients with isolated gunshot radius fractures treated with closed reduction and locked intramedullary nailing between 2009 and 2013 were reviewed. Twenty-two nails were inserted in 22 patients, all males with a mean age of 28.9 years (range 19-40). All surgeries were performed between 2 and 12 days after injury (average 4 days). Follow-up was for an average of 11 weeks (range 8-24). RESULTS: All fractures united with the index procedure. Mean time to union was 10 weeks (range 8-24). Using the Anderson classification, the clinical outcome was excellent in 14 patients (64%), satisfactory in six (27%) and unsatisfactory in two (9%). CONCLUSION: Closed reduction and intramedullary nail fixation of gunshot radius fractures shows promising results without significant complications.

Independent segmental bone transport of the radius and ulna: A case report

Significant bone loss in the forearm involving both the radius and ulna is a difficult problem to manage. The functional outcome may be limited due to loss of pro- and supination. We present a case where significant bone loss of both the radius and the ulna in an adult patient was successfully reconstructed using segmental bone transport. The radius and ulna were transported independently from each other to try and maintain function. A reasonable functional result was achieved.

Debilitating sciatica following a sacral fracture: A case report

Following a horse-riding accident, a 16-year-old female sustained a minimally displaced sacral fracture extending into the S1 and S2 foramina on the left. The patient was initially treated conservatively but neuropathic pain, dysaesthesia and weakness in the L5 and S1 distributions developed and persisted. CT and MRI revealed a fracture fragment abutting the L5 nerve root. Epidural anaesthesia and aggressive neural mobilisation by physiotherapy failed to improve symptoms. Surgical decompression via the sub-iliacus approach was then performed 6 weeks following the injury. Symptoms resolved immediately but recurred in the L5 distribution, presumably due to neuritis, and were successfully managed conservatively. Six weeks following surgery, all symptoms had resolved and the patient mobilised independently and returned to her pre-injury level of activity.

Radiation exposure to orthopaedic registrars in the Pietermaritzburg Metropolitan Complex

INTRODUCTION: Modern orthopaedic surgery increasingly involves the use of fluoroscopic imaging in theatre. This has led to an increase in radiation exposure to the orthopaedic surgeon and other theatre staff. There is very little research as to which orthopaedic subspecialty may lead to higher exposures. This study aims to demonstrate whether radiation exposure levels in orthopaedic registrars in the Pietermaritzburg Complex are within safety limits and also to determine which subspecialty rotations lead to increased exposure levels. MATERIALS AND METHODS: A retrospective quantitative observational study analysed the dosimeter readings of 20 registrars over a one-year period. Dosimeter readings were also analysed per subspecialty rotation, namely orthopaedic trauma, spinal surgery, arthroplasty, ortho-paediatrics, upper limb surgery, and tumour sepsis and reconstruction. RESULTS: No registrar was found to have a dosimeter reading exceeding the International Commission on Radiological Protection guidelines. Rotations in which registrars received measureable readings were orthopaedic trauma, upper limb surgery, spinal surgery and arthroplasty. CONCLUSION: Trauma rotations appeared to produce to highest radiation exposure readings, although these were still within international safety limits. Knowledge of radiation safety, staff education and safety measures to limit any unnecessary exposure should be employed.

Endoprosthetic treatment of primary bone sarcomas with pathological fractures

BACKGROUND: Primary bone sarcomas that are associated with a pathological fracture are rare and as a group have a worse prognosis than their non-fractured counterparts. QUESTIONS/PURPOSES: Traditionally limb ablation was advised; however, recent evidence suggests that limb salvage is a safe and acceptable form of treatment for both surgeon and patient. PATIENTS AND METHODS: We present a retrospective review of a series of six patients referred to our unit with pathological fractures. These were treated by initial traction and neo-adjuvant chemotherapy where indicated with subsequent resection and endoprosthetic replacement. RESULTS: The age range of our series is from 20 to 81 years, with four males and two females. All had distal femur involvement with a 60% incidence of osteosarcoma and 40% chondrosarcoma. Three patients required total femur resection due to extensive tumour involvement. Our results show 100% of patients had clear margins at postoperative histology. Due to the aggressive nature of these types of tumours they carry a worse long-term prognosis and as such we had three deaths in our series. One patient died of a myocardial infarction post-operatively, and two patients developed lung metastases and died 2 years later. CONCLUSION: Our conclusion is that with careful planning, a safe margin can be achieved. Endoprosthetic replacement allows for rapid reconstruction and mobilisation in this group of patients facilitating further oncological management.

Do Ponseti plasters delay gross motor milestones of South African children treated for idiopathic clubfeet?

INTRODUCTION: The Ponseti method for the treatment of idiopathic club foot is the gold standard of treatment in South Africa. A study in New York reviewed attainment of eight gross motor milestones in these children and found that independent ambulation was delayed on average by 2 months compared to unaffected children. METHODS: A retrospective review of gross motor milestones was performed in patients treated at a South African clubfoot clinic. All patients were ambulating independently at review and ages at attainment of three motor milestones were recorded (sitting, crawling and walking independently). The World Health Organisation (WHO) published the normal range for achievement of these milestones in six regions across the world. We compared the results of our patients to the 50th percentile in that study. RESULTS: Results show that patients in our study sat at a mean of 5.8 (standard deviation ± 1.3) months and crawled at a mean of 8.3 (SD ± 1.7) months, both equal to the WHO 50th centiles for unaffected children. Independent walking, however, was achieved at a mean of 15.3 (SD ± 2.3) months which is statistically significantly different to the 50th centile for unaffected children in the WHO study (p<0.05). In our study, 86% of children achieved independent walking within 18 months. No statistical difference was found between unilateral and bilateral cases. CONCLUSION: Children treated for idiopathic clubfoot (unilateral or bilateral) can expect no delays in sitting or crawling. Minimal delays in achieving independent walking of about three months can be expected with an 86% chance of walking within the accepted normal range for unaffected children.

Traumatic simultaneous bilateral femoral neck fracture in a child: A case report

BACKGROUND: Traumatic bilateral fracture of femoral necks in healthy children is a rare occurrence. A delay in surgery can impair anatomic closed reduction of a femoral neck fracture. CASE PRESENTATION: The authors report a rare case of a traumatic bilateral fracture of the femoral neck in a 9-year-old schoolgirl. This case was an unusual association of a transcervical fracture and an intertrochanteric fracture. This is the first known case of these two fracture types described in the same patient. Primary skin traction and a late closed surgical management gave a good result, although if possible early surgery is advised. CONCLUSION: The main mechanism of injury in this case is a two-step trauma. In this case, a delay to surgery by closed reduction and internal fixation by percutaneous screw fixation led to an acceptable outcome.

Osteomyelitis in an infant with proximal focal femoral deficiency

We present the case of a 6-week-old neonate with proximal focal femoral deficiency (PFFD) complicated by osteomyelitis of the right femur with no preceding trauma or surgical intervention.

Expert opinion on published articles

We present the case of a 6-week-old neonate with proximal focal femoral deficiency (PFFD) complicated by osteomyelitis of the right femur with no preceding trauma or surgical intervention.