SA Orthopaedic Journal

Changing world yet business as usual?

Primary malignant bone tumours: Epidemiological data from an Orthopaedic Oncology Unit in South Africa

INTRODUCTION: Limited data is available with regard to the epidemiology of primary malignant orthopaedic tumours in the South African clinical setting. As a result, orthopaedic surgeons have to rely on data from other countries when formulating differential diagnoses for malignant bone lesions. Existing data, however, demonstrates variance in the incidence between different geographic regions. By analysing the tumour epidemiology at our centre and comparing it to published data from other parts of the world, we aim to better define the local prevalence of primary malignant bone tumours. Materials and methods: A retrospective review of all patients with biopsy confirmed malignant primary bone tumours that presented between January 2008 and June 2015 were conducted. Patients with multiple myeloma and lymphoma were excluded. Epidemiological data pertaining to patient demographics, tumour location and histological diagnosis were recorded and analysed. RESULTS: Included for review were 117 patients with biopsy-confirmed primary malignant bone tumours. Tumours involving the proximal humerus, distal femur, proximal tibia and pelvis accounted for 80% of all tumours. Osteosarcoma was the most common histological diagnosis (72.6%) and higher than reported figures from any other country. It was followed by chondrosarcoma (11.4%), Ewing's sarcoma (9.4%), spindle cell sarcoma (4.2%) and malignant giant cell tumour (GCT) (1.7%). A single patient was diagnosed with adamantinoma. HIV infection had no significant association with primary bone tumour incidence. CONCLUSION: Epidemiological data from this review reflect small but significant differences compared to international literature. The incidence of osteosarcoma appeared to be higher than in previous reports from other regions. Future study in this area may identify a reason for this difference, socio-economic reasons may be responsible.

Giant cell tumour of bone: A demographic study from a tumour unit in South Africa

INTRODUCTION: Giant cell tumour of bone (GCT) is a rare primary bone tumour. Little is known about the epidemiology of this tumour in South Africa as most demographic information is based on research from Asia, Europe and North America. This research aims to raise awareness and promote early recognition of these tumours. Materials and methods: A retrospective analysis was conducted of all patients with biopsy-confirmed GCTs that presented between January 2010 and December 2014. Information pertaining to patient demographics, tumour location, treatment and outcome was recorded and analysed. RESULTS: Twenty-two patients were included in the study. The mean age of patients was 32.4 years (range 12-63), and a slight male predominance (1.2:1) was observed. Tumours were mainly located at the end of long bones (91%) with the distal femur and proximal tibia being most commonly affected (55%). Two patients (9%) were diagnosed with primary malignant giant cell tumours. We observed a higher rate of lung metastases (18%) than previously reported. The median tumour volume was significantly higher in patients who developed lung metastases (467.4 cm³ vs 137.8 cm³; p=0.03). Three of the patients with lung metastases were HIV-positive (odds ratio [OR] = 10.5, 95% confidence interval [CI] = 0.84-130.66, p=0.076). All patients were treated surgically with extended curettage, local adjuvant therapy, polymethyl methacrylate (PMMA) and internal fixation or en-bloc resection with prosthetic or osteochondral allograft replacement. CONCLUSION: Giant cell tumours of bone are uncommon. Demographics from South Africa emulate international statistics. No recurrence of GCTs was observed in our cohort despite the relatively large tumours at time of presentation compared to international literature that report recurrence rates of approximately 2%. The incidence of metastases and primary malignant GCT was higher than in previous reports. The association of these findings with HIV infection warrants further investigation. Metastases appear to be associated with the size of the primary tumour.

Orthopaedic research activity in South Africa measured by publication rates in the 15 highest impact journals related to population size and gross domestic product

BACKGROUND: The purpose of this study was to investigate the number of publications and impact of South African surgeons in the 15 highest impact orthopaedic journals over a five-year period. METHODS: The abstracts between January 2010 and December 2014 were screened and the total number of publications and impact points were collated. Normalisation to population size, GDP and per capita GDP was performed. RESULTS: Of the 23 021 orthopaedic articles from 66 countries, South Africa published 19 articles and ranked 41st overall for the number of publications and 40th for impact. When compared to the other African countries it ranked 2nd. The following ranks were calculated for adjusting population (51st overall, 2nd in Africa), GDP (51st overall, 3rd in Africa), GDP per capita (31st overall, 3rd in Africa). CONCLUSION: This study demonstrated that South Africa ranked in the lower third of all countries that published in the top 15 highest impact orthopaedic journals. In Africa, Egypt was the leading country for total publications and impact factor maintaining the first rank even when adjusted for population size, GDP, GDP per capita and research funding in percentage of GDP.

Meta-analysis: Everything you wanted to know but were afraid to ask

The perceived ability of systematic reviews and meta-analyses to concisely and definitively summarise existing literature regarding a specific medical issue has made them the most highly read and cited form of academic literature. However, the evidence they provide is only as good as the data evaluated and the methodology followed when doing them. In order to conduct a rigorous systematic review, all the elements of the research question should be clearly stated, all relevant studies should be identified, the inclusion criteria should be appropriate and the included studies valid, heterogeneity should be identified, and finally the results of the meta-analyses should be appropriately presented. This paper aims to provide an overview of systematic reviews and meta-analyses. Furthermore, we examine the rationale for conducting such a study, overview the methodology, and highlight pitfalls and weaknesses inherent in the process.

Comparative study of children with calciopaenic and phosphopaenic rickets seen at Chris Hani Baragwanath Hospital

INTRODUCTION: The majority of causes of rickets can be divided into two large pathogenic groups, namely calciopaenic and phosphopaenic. Few studies have compared the clinical and biochemical presentations of the two forms of rickets. The aim of this study was to compare the demographic, clinical and biochemical presentations and response to therapy of children with calciopaenic and phosphopaenic rickets. METHODOLOGY: The study is a retrospective chart review of children diagnosed with rickets at Chris Hani Baragwanath Academic Hospital (CHBAH) in Johannesburg, South Africa, between 2006 and 2012. The radiological response to therapy was evaluated using the Thacher scoring system to assess the severity of rickets. RESULTS: The study comprises 112 patients from 2 months to 18 years of age diagnosed with rickets (53% with calciopaenic rickets and 47% with phosphopaenic rickets). The calciopaenic group was younger than the phosphopaenic group (20 [7-26] vs 36 [24-51] months; p<0.001), but the phosphopaenic group was more severely stunted than the calciopaenic group at presentation (HAZ scores -3.3 [-4.5 to -2.1] vs -2 [-3.4 to 0.7]; p<0.001. Following treatment, 75% of patients in the calciopaenic group had biomarkers that had normalised completely within a median of 13 (9-18) weeks while only 10% in the phosphopaenic group had normalised within a median of 17 (17-50) weeks. Radiological healing in response to treatment was better in the calciopaenic group compared to the phosphopaenic group (67.5% vs 18%; p-value <0.01). CONCLUSION: Calciopaenic rickets (mainly vitamin D deficiency) presented at a younger age and response to therapy was better compared to phosphopaenic rickets (mainly X-linked hypophosphataemic rickets). This study highlights the significant differences between calciopaenic and phosphopaenic rickets, which may be helpful to attending orthopaedic surgeons and paediatricians in differentiating between these two groups of rickets and in the management thereof. SUMMARY OF ABSTRACT: This study highlights the differences between calciopaenic and phosphopaenic rickets, which may be of assistance to attending orthopaedic surgeons and paediatricians in the management of rickets. The study shows that in children with calciopaenic rickets, the majority are vitamin D deficient, and present at a younger age with craniotabes and less severe lower limb deformities compared to children with phosphopaenic rickets who mainly have X-linked hypophosphataemic rickets and are severely short in stature and have genu valgum deformities. The medical management of the two types of rickets differs and response to medical therapy is better in the calciopaenic compared to the phosphopaenic group.

Vitamin D status in patients undergoing arthroplasty

Vitamin D deficiency has, in recent literature, been associated with poorer outcomes following arthroplasty. This is a retrospective chart review of 209 patients presenting to a local arthroplasty unit in one year. The aim was to identify the prevalence of undiagnosed vitamin D deficiency in this group of patients. The results showed a 10% prevalence. In this study, Indian and Coloured female patients were most at risk (15-16% prevalence) and Black patients had the lowest prevalence (6.9%). In conclusion, the population presenting for arthroplasty at this unit is at risk of vitamin D deficiency, and we advocate vitamin D levels to be part of a standard metabolic workup in our environment.

Clinical anatomy of the anterior cruciate ligament and pre-operative prediction of ligament length

BACKGROUND: Ligament grafts used in anterior cruciate ligament (ACL) reconstruction need to be the correct length for proper functioning. If the graft length is incorrect, the patient could risk knee instability, loss of range of motion, or failure of graft fixation. Easier and time-efficient reconstruction will be facilitated if the length of the ACL is predicted in advance. Apart from examining the morphological properties of the ACL, this study aimed to determine whether the epicondylar width of an individual can be used to predict ACL length and thereby assist in restoring the normal anatomy of the ACL. METHODS: Ninety-one adult cadavers were studied. Patellar ligament (PL) length, ACL length, ACL width and the maximum femoral epicondylar width (FECW) were measured. RESULTS: The morphology of the ACL and PL was determined. The results revealed that FECW was the most reliable predictor of ACL length. A linear regression formula was developed in order to determine ACL length by measuring maximum FECW. CONCLUSIONS: ACL and PL morphology compared well with the results found in previous studies. An individual's FECW can be used to predict ACL length pre-operatively. These results could improve pre-operative planning of ACL reconstruction.

Early complications of human bites to the hand in HIV-positive patients

BACKGROUND: Human-inflicted bite wounds to the hand are serious injuries that may result in significant morbidity and permanent impairment. Irrespective of the mechanism, they are associated with a high complication rate and this has been attributed to the unique anatomy of the hand and the pathogens involved in human bites. HIV (human immunodeficiency virus) infection is known to compromise the immune system through immune exhaustion and senescence. This potentially increases the risk of complications following human bites to the hand in HIV-positive patients. The aim of this study was to determine if HIV infection is associated with an increased risk for the development of early complications following human bites to the hand. PATIENTS AND METHODS: We retrospectively reviewed the records of a cohort of consecutive patients treated between June 2013 and October 2014. Patient charts were reviewed and information extracted with regard to demographics, the location and mechanism of the bite, occurrence of complications, HIV status and CD4 counts, as well as whether they were taking ARV (antiretroviral) medication at the time. The time from injury to presentation was recorded, as well as the time from injury to surgical intervention. RESULTS: Thirty-nine patients were included in the study and there were no exclusions. The mean age of patients was 31.5 years (range 14-60 years), with an approximately equal distribution between males and females. Sixteen patients (41%) in our study cohort were found to be HIV-positive, 15 patients were HIV-negative (38%), and in eight cases (21%) the HIV status was unknown. Of the HIV-positive patients, 44% had CD4 counts below 350 cells/mm³ but only four (25%) were on ART (anti-retroviral therapy) at the time of injury. Complications occurred in 88% (14/16) of the HIV-positive patients compared to 80% (12/15) in the HIV-negative group (risk ratio [RR] = 1.09; 95% confidence interval [CI] = 0.8-1.5; p=0.65. CONCLUSIONS: HIV infection was not associated with an increased risk of developing complications following human bites to the hand in this series. An increase in the time from injury to presentation was however associated with an increased risk of amputation.