Scielo RSS <![CDATA[SA Orthopaedic Journal]]> vol. 16 num. 1 lang. pt <![CDATA[SciELO Logo]]> <![CDATA[<b>Communication and perceptions</b>]]> <![CDATA[<b>The changing landscape of evidence-based orthopaedics</b>]]> It is difficult to find fault with the reasoning behind the move towards an evidence-based approach in the teaching and practice of orthopaedics. With numerous options available, treatment strategy selection has to be based on more than just intuition and prior experience. Furthermore, there are several strong arguments for the need to practice Evidence-Based Orthopaedics (EBO). We have seen novel implant technologies enter the market, only to exit relatively shortly afterwards. Recall metal-on-metal articulations being hailed as the solution to all our problems? Less than five years later we saw reports of 49% failure rates at six-year follow-up.¹ In addition, research continues to disprove longstanding orthopaedic axioms. We can now say, with relative confidence, that debriding an open fracture within six hours is not as important as previously believed.² This principle is also illustrated by a recent randomised study that found no advantage in the damage control concept in the treatment of femur shaft fractures in polytrauma patients.³ Interestingly, patients treated with external fixation in this series had an increased time in ICU on ventilation compared to patients treated by reamed nailing of the femur. And thus, the evidence-based tenet remains largely intact. <![CDATA[<b>The role of interventional angiography and embolisation in the management of high-energy pelvic ring injuries with uncontrolled haemorrhage</b>]]> BACKGROUND: The availability of and advances in interventional angiography and embolisation for the management of high-energy pelvic ring injuries with uncontrolled haemorrhage have expanded considerably during the last decade. Its routine use, however, still remains controversial. The delay in performing angiography is often cited as a major limitation for this intervention. PURPOSE OF THE STUDY: We aim to determine the mean time to interventional angiography and embolisation and report on the success rate thereof in patients with pelvic ring injuries and associated haemorrhage in a Level 1 Trauma Unit. METHODOLOGY: Between 1997 and 2012, we identified a total of seven patients who were managed with interventional angiography for the treatment of pelvic ring injuries associated with massive haemorrhage that did not respond to fluids and blood products resuscitation alone. Data was collected retrospectively, with respect to the injury pattern, resuscitative parameters, survival rates and efficacy of the angiography. RESULTS: All seven patients presented with high energy injuries and had rotationally as well as vertically unstable pelvic fractures. The average systolic blood pressure on admission was 80 mmHg (range 60-140). On average 8.75 (range 2-21) units of packed red blood cells were transfused per patient. Three patients required a laparotomy for associated intra-abdominal injuries. The time from admission to an emergency laparotomy was 4.5 h (range 2-12). The time from admission to angiography was 14 h (range 4-24). Three of the seven patients had a successful pelvic angio-embolisation. Six patients survived until discharge and one patient demised due to multi-organ failure on day 14 after embolisation. DISCUSSION: Only seven patients with pelvic ring injuries were managed with angiography and embolisation in a period of 15 years, suggesting that we seldom use this modality for haemorrhage control. The delay from admission to angiography was 14 hours (range 4-24). An arterial bleed was successfully identified and embolised in three patients (43%). CONCLUSION: While it is used with greater frequency in other centres, in our hospital setting angiography in the management of haemorrhage in pelvic ring injuries is rarely used. Our success rate with this intervention is fair. <![CDATA[<b>Major disruption of the pelvic ring during normal vaginal delivery: A case report</b>]]> Open-book pelvic fractures are generally associated with high energy trauma. Occasionally these fractures are seen as a complication of normal vaginal delivery. We report the case of a 25-year-old female with a 77 mm symphysis pubis diastasis with associated disruption of the sacroiliac joints following delivery, which was successfully treated with open reduction and internal fixation. <![CDATA[<b>Calcific myonecrosis following snakebite</b>]]> Calcific myonecrosis is a rare condition and is believed to be a late sequela of untreated compartment syndrome. Patients usually present with a progressively enlarging mass, years after the initial injury, that can be misdiagnosed as a soft tissue sarcoma. Calcific myonecrosis following snakebite is extremely rare. The anterior compartment of the leg is most frequently involved and appears to be especially vulnerable to developing this complication. Conservative management should be considered in asymptomatic patients but spontaneous soft tissue breakdown with sinus formation may develop and prolonged surveillance is advised. We report two similar cases of calcific myonecrosis of the anterior compartment of the lower leg that developed decades following snakebite. <![CDATA[<b>Gunshot tibia fractures treated with intramedullary nailing: A single centre retrospective review</b>]]> BACKGROUND: Open tibia fractures are notoriously difficult to treat, with a high rate of union problems and infection. Gunshot wound-associated fractures of the tibia compound these issues further by causing extensive bone comminution and soft tissue damage. No universally accepted management protocol exists, but intramedullary (IM) nailing of these injuries is an attractive treatment strategy. It provides stable internal fixation and limits further insult to the soft tissue envelope. It also allows complete access for wound management and early range of movement of the adjacent joints. This study aims to review the results of patients treated with IM nailing for gunshot wound (GSW) tibia fractures to assess whether this is a viable treatment option for this injury. METHODS: A retrospective folder review was performed of all adult patients who sustained a GSW tibia fracture treated with intramedullary nailing between January 2009 and December 2014. Parameters evaluated included time to theatre, time to wound closure, radiographic extent of fracture comminution, anatomical alignment, time to union and incidence of chronic osteomyelitis. RESULTS: Twenty-two patients were eligible for inclusion; however, nine were lost to follow-up. The remaining 13 patients achieved union over an average of 26 weeks. Three cases developed osteomyelitis, all of which had radiographic zones of comminution exceeding 120 mm. No cases of malunion were reported and no other significant trends noted. CONCLUSION: Treatment of tibial gunshot fractures must be individualised according to both the soft tissue injury and radiographic zone of comminution in order to achieve a favourable outcome. Intramedullary nailing is an effective treatment strategy for low Gustilo-Anderson grade injuries, with minimal complications. <![CDATA[<b>Sarcomas other than Kaposi's sarcoma in HIV</b>]]> INTRODUCTION: Kaposi's sarcoma and lymphoma are some of the malignancies known to be associated with HIV infection and afflict many people living with HIV/Aids, as published widely in previous literature. In contrast, scarce information is available with regard to the occurrence of other primary musculoskeletal malignancies and whether there may be a causal relation between the occurrence of these malignancies and HIV. The aim of this study is to describe which sarcomas (other than Kaposi's) occur in patients living with HIV. METHODS: A retrospective chart review was performed of consecutive adult individuals who presented to our tumour unit with musculoskeletal sarcomas other than Kaposi's sarcoma. The histological diagnosis of tumours in HIV-positive patients were then compared to that of an age-matched cohort of HIV-negative patients. RESULTS: A total of 59 patients were included in the study. Thirty patients were positive and 29 patients negative. We recorded a wider variety of sarcomas in HIV-positive individuals than previously reported. There was a tendency towards an increased number of cases of rhabdomyosarcoma in the HIV-positive group and chondrosarcoma in the HIV-negative group although this did not reach statistical significance, p=0.05 and 0.08 respectively. There was no difference in the prevalence of metastasis at the time of presentation with 16 cases having metastases in the HIV-positive group (53.3%) and 14 cases (48.2%) in the HIV-negative group, p=0.69. CONCLUSION: The prevalence of musculoskeletal sarcomas other than Kaposi's sarcoma in HIV-positive patients and a tendency towards an increased prevalence of rhabdomyosarcoma requires further investigation. Long-term studies to assess the influence of antiretroviral therapy on the prevalence and prognosis of these sarcomas are required. <![CDATA[<b>Primary leiomyosarcoma of the first metatarsal bone: A case report</b>]]> INTRODUCTION: Primary leiomyosarcoma of bone is a rare entity which has never been reported in the foot. We report a case of primary leiomyosarcoma of metatarsal bone. CASE REPORT: A 60-year-old male presented with a history of pain, progressively increasing swelling and a non-healing ulcer over the dorsomedial aspect of his right foot. Plain radiograph showed an osteolytic, destructive lesion of the first metatarsal with involvement of surrounding soft tissue and bones. Magnetic resonance imaging showed a lesion that was hypointense on T1- and heterogeneous on T2-weighted images. Histology of the tumour with immunohistochemistry features aid in making the diagnosis of primary leiomyosarcoma of the first metatarsal bone, which was rare for this location. DISCUSSION: A brief review of the literature is done to determine the epidemiology, radiological and histological features and management of this tumour. CONCLUSION: Primary leiomyosarcoma of bone is a rare tumour and should be kept in the differential diagnosis of primary malignant osteolytic, destructive neoplasms especially in the older age group LEVEL OF EVIDENCE: therapeutic, IV <![CDATA[<b>Early onset scoliosis: The use of growth rods</b>]]> BACKGROUND: Early onset scoliosis (EOS) is defined as scoliosis occurring before the age of 5 years. The management presents a unique challenge where both natural history and fusion lead to impaired cardiopulmonary function of the child. AIM: To assess the outcome of the use of non-fusion instrumentation and repetitive elongation ('growth rods') in EOS. METHODS: A retrospective review of 14 consecutive patients who underwent growth rod implantation and lengthening procedure for EOS was performed. Growth rod constructs were constructed predominately from modular commercially available sets using laminar hooks, pedicle screws and connection blocks, with single or double rod constructs. Vertical expanding prosthetic titanium ribs (VEPTR) were used in two patients. Patients returned to theatre at six-monthly intervals for a lengthening procedure. Patients were assessed with regard to type of scoliosis, age at surgery, number of lengthenings done, progression of Cobb angle, amount of construct lengthening, amount of spine growth achieved and complications. RESULTS: The most common type of scoliosis seen was idiopathic (five), followed by neuromuscular (four), conjoined twins (two), syndromic (two), and congenital (one). Five patients were followed until final fusion, one procedure was stopped due to wound complications and one patient was lost to follow-up. The 14 patients had a median of seven lengthenings each. The median pre-operative Cobb angle was 56° (IQR 46.5°-59.5°) and median last follow-up Cobb angle of 32.5° (IQR 27.0°-44.5°). The median spine growth achieved was 97 mm (IQR 69-122 mm). Eight of the 14 patients (57%) experienced 14 complications during their lengthening procedures. CONCLUSIONS: The growth rod instrumentation provides spinal deformity correction and control, while allowing ongoing growth of the spine. It is a labour-intensive process with significant incidence of complications. There is however very little other choice in these patients due to concerns of early fusion restricting pulmonary development. <![CDATA[<b>Thromboprophylaxis in spinal surgery: A survey of current practice in South Africa</b>]]> BACKGROUND: Patients undergoing spinal surgery are at risk of developing venous thromboembolism (VTE) because of co-morbidities and immobilisation, but the morbidity of bleeding and haematoma formation complicates prophylaxis. A balance between VTE prevention and haematoma formation is therefore critical. Adding to the complexity is that there are currently no clear guidelines on managing these patients and little evidence in the literature. In order to improve management, it is imperative to first establish the current practice of thrombopro-phylaxis in spinal surgery in South Africa. METHODS: A survey of surgeons' peri-operative thromboprophylactic management was conducted with 112 spinal surgeons. RESULTS: The results indicated that a large group of surgeons did not follow a standardised protocol. Mechanical prophylaxis was not used optimally and more surgeons used chemical prophylaxis routinely than mechanical prophylaxis. The surgeons mostly agreed on the type of chemical prophylaxis used and the time of commencement thereof. Contrary to the literature, the surgeons in this study did not differentiate between the surgical approaches used. CONCLUSION: There is currently no consensus on the management of thromboprophylaxis, as evident from the varying responses regarding treatment and complications. It is clear that mechanical prophylaxis is currently under-utilised. Spinal surgeons would benefit from a standardised protocol, and the vast majority of participants in the study agreed with this recommendation. <![CDATA[<b>Clinical outcomes following reduction and pinning of lesser arc injuries without repair of the scapholunate interosseous ligament</b>]]> BACKGROUND: Purely ligamentous lesser arc, Mayfield grade 3 and 4, perilunate dislocations (PLDs) are uncommon. Current recommendations are for open reduction and repair of the interosseous ligaments to prevent the development of scapholunate dissociation and degeneration to a scapholunate advance collapse (SLAC) wrist. This study proposes a less invasive treatment method which includes closed reduction and pinning alone without repair of the scapholunate interosseous ligament. We propose that most patients will obtain good function and pain scores and the few that develop instability may still have a reconstruction performed through a naïve surgical field METHODS: Dislocations were reduced anatomically and held with buried K-wires which were removed at 6 weeks with no specific rehabilitation protocol observed. Subjective assessment included Mayo wrist scoring system, wrist range of movement, instability and grip strength testing. Radiological measurements included scapholunate distance, scapholunate angle, radiolunate angle and osteoarthritis RESULTS: Ten male patients, median age of 35 years, were followed up for a median of 22 months. Seven patients underwent a closed reduction and anatomical pinning while three underwent open reduction due to unachievable reduction by closed means. All of these patients presented at a median of 14 days after the injury occurred. None of the patients had their scapholunate ligaments repaired or reconstructed. Mayo scores included three excellent scores, two good scores and five fair scores. Instability was found clinically in one asymptomatic patient who had a positive Watson shift test. Radiological scores include a median scapholunate distance of 2 mm, a scapholunate angle of 70° and a radiolunate angle of 15°. Osteoarthritis was found in two patients, all of whom were asymptomatic DISCUSSION: Current recommendations in the literature are that PLDs should be reduced via an open surgical technique with repair of the scapholunate interosseous ligament (SLIL) and percutaneous pinning. However, the results of this treatment strategy are not optimal and do not confer uniformly good results. We propose a closed anatomical reduction and percutaneous pinning of the PLD. Our study shows that most patients will demonstrate good function and pain scores when managed this way. A smaller number of these injured wrists will go on to develop instability. However, the advantage of our method over the current recommendations is that when this happens the reconstruction of the SLIL will be made easier through a naïve surgical field CONCLUSION: We recommend the closed reduction and anatomical pinning of a purely ligamentous lesser arc injury. This treatment strategy yields good results at medium term follow-up and preserves the option for the reconstruction of the scapholunate interosseous ligament should instability develop