Scielo RSS <![CDATA[SA Orthopaedic Journal]]> vol. 16 num. 4 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<b>The value of belonging</b>]]> <![CDATA[<b>Teaching and training in orthopaedics</b>]]> This article aims to review the current trends in the pedagogy of orthopaedic surgery, with specific reference to teaching philosophies, training methods and assessments tools that may be used. Our expanding knowledge base and the complexity of skills required, combined with the pressure created by medical negligence litigation increases the emphasis on knowledge of disease in contrast to pure competency in practical procedures. At specialist level, the drive now appears stronger than ever to develop less- or non-invasive ways to treat musculoskeletal disease. As a disease specialist the trainee, therefore, needs to develop a wider vision than one held by a competent technician. A combination of educational philosophies can be employed to achieve these objectives. Cognitive task analysis (CTA) and constructivism may be useful strategies for skills acquisition. In terms of theoretical knowledge, the emphasis remains on an evidence-based approach, delivered in an active student-centred environment. Clinical teaching as a whole, however, demands the promotion of critical thinking and a problem-oriented approach in a situated learning setting. The pedagogy of skill and knowledge assessment in orthopaedics remains unresolved. However, the educational impact of assessment through its value as a driver for learning has been recognised. Level of evidence: Level 5 <![CDATA[<b>HIV seroprevalence and its relation to bone infection, bone tumours and limb reconstruction patients in a South African tertiary hospital</b>]]> BACKGROUND: HIV infection causes a relative immunodeficient state, potentially predisposing patients to osseous infection. It is also associated with non-AIDS defining cancers, and has been described in patients with limb girdle sarcomas and malignant fibrohistiocytic tumours. HIV is further known to suppress cells important in bone healing; however, it is unclear whether bone tumours and mal- or non-unions are more prevalent in patients with HIV. This study aimed to determine the HIV seroprevalence of patients attending a tumour, sepsis and reconstruction (TSR) unit, and explore its relationship to bone infection, bone tumours and patients undergoing limb reconstruction. METHODS: A retrospective review of all adult patients treated over a three-year period was performed. Patients were stratified according to pathology into bone infection, bone tumour, and limb reconstruction categories. Each patient had an opt-in HIV test as part of routine workup. Recruitment, prevalence and statistically significant relationship were then calculated relative to the HIV-uninfected cohort. RESULTS: Nine-hundred-and-six patients were included, 21.3% of whom were HIV positive. There were 313 patients with bone infection, 263 patients with bone tumours, and 330 limb reconstruction patients. All groups were similar in HIV prevalence. There was no statistically significant difference between the HIV-positive or -negative patients in any of the groups. CONCLUSION: This series found no significant difference in the incidence of bone infections, bone tumours or the need for limb reconstruction, between HIV-positive and -negative patients. Level of evidence: Level 4 <![CDATA[<b>A rare case of angioleiomyoma around the ankle: case report and review of literature</b>]]> Angioleiomyoma is a slow-growing benign tumour that originates from the tunica media layer of vessel walls. It represents 4.4-5% of all benign soft tissue tumours and 0.2% of all tumours in the foot and ankle. Excisional biopsy of the tumour is both diagnostic and curative, with a low recurrence rate reported in the literature. Malignant transformation has been described in 1 % of cases. We present a case of a 67-year-old female diagnosed with angioleiomyoma at the lateral malleolus. Level of evidence: Level 5 <![CDATA[<b>Indications for surgical reintervention following reverse shoulder arthroplasty: a retrospective audit from 2006 to 2015</b>]]> BACKGROUND: Reverse shoulder arthroplasty (RSA) has increased in popularity and its indications have subsequently been expanded. With its increased use, the complication rates have also increased. Complications requiring additional surgeries have the highest morbidity and cost. The aim of this study was to determine the indications for additional surgery following RSA. METHODS: All the surgical and clinical notes of patients treated with an RSA at our institution over a nine-year period were retrospectively reviewed. Sixty-seven RSAs met the inclusion criteria and their records were reviewed to assess their indication for surgery, complications, as well as microbiology results if infection was present. RESULTS: Surgical reintervention was required in 16 (23.9%) RSAs. The prevalence was lowest in rotator cuff arthropathy and glenohumeral arthritis (nine RSAs or 18.4%), followed by failed hemi- or total shoulder arthroplasty (four RSAs or 36.4%) and highest if performed for uncommon conditions (two RSAs or 66.7%). Instability was an early complication, occurring in 10.7% of cases and accounting for 37.8% of all reinterventions. Infection was a late complication, occurring in 6.0% of cases and accounting for 48.6% of all reinterventions. The most common organisms identified were Staphylococcus epididermidis (n=4), Escherichia coli (n=3), Staphylococcus aureus (n=2) and Klebsiella pneumonia (n=2). CONCLUSIONS: RSA has the most reliable outcomes if performed for rotator cuff arthropathy and glenohumeral osteoarthritis. Instability and infection are the most common indications for surgical reintervention, and once present, often require repeated surgeries to be successfully treated. These complications should be avoided, as they are major contributors to morbidity and cost Level of evidence: Level 4. <![CDATA[<b>Incidence of deep vein thrombosis following shoulder replacement surgery: a prospective study</b>]]> BACKGROUND: The incidence of deep vein thrombosis (DVT) after shoulder replacement surgery is not well documented. Evidence that exists on thromboprophylaxis for upper limb surgery is based on level III and level IV studies. The hypothesis for the current study was that the incidence of DVT following shoulder replacement would be less than the published prevalence in hip and knee arthroplasties METHODS: All participants who received shoulder arthroplasty surgery at the institution from 1 July 2013 to 30 June 2015 and who met the inclusion criteria were eligible for inclusion in the study. A duplex Doppler study was done on the affected limb of all participants on average ten days after the surgery. A study of all four limbs was done in selected participants RESULTS: Fifty-seven participants (28 males and 29 females) with 30 reverse shoulder replacements, 22 hemiarthroplasties, and five resurfacing shoulder replacements were included. The incidence of DVT was 12.3% (7/57). Two axillary vein and three brachial vein DVTs account for the upper limb DVTs. Two DVTs were reported in the lower limb CONCLUSION: The study demonstrates that the incidence of DVT after shoulder replacement surgery was higher than anticipated and is similar to the DVT rates in lower limb arthroplasty Level of evidence: Level 4 <![CDATA[<b>Introduction of the angle of shoulder slope in a South African population</b>]]> BACKGROUND: The angle of shoulder slope has been reported in accordance with the specific occupational activities of the aviation and textile industries. However, as no accurate definition nor standardised anatomical landmarks exist within the medical field, this study aimed to devise an appropriate definition with preplaced reference landmarks. In addition, the vertebral level of the acromial tip was also determined. METHODS: The sample series comprised 260 posterior radiographs of the shoulder, of which 127 were males and 133 females. The ethnic distribution included ten black, 13 coloured, 49 Indian and 188 white individuals. In accordance with the trapezial line, the angle of shoulder slope was defined and measured as the angle between the line from the spinous process of C7 to the acromial tip and the line from the acromial tip directly across to the median plane of the vertebral column. RESULTS: The standard mean angle of shoulder slope was approximately 13.56±3.70°. Left and right sides appeared to have mean angles of 13.81±3.41° and 13.33±3.95°, respectively. Mean angular values were also calculated in accordance with the demographic representation - sex: male 13.64±3.71°, female 13.48±3.71°; ethnic groups: black: 13.81±3.81°, coloured: 12.18±3.82°, Indian: 12.97±3.09°, white: 13.64±3.96°. Although the acromial tip was commonly aligned to the level of the spinous process of T3, the incidence of the vertebral level of the acromion was categorised into seven groups, viz. i) intervertebral disc between T1 and T2; ii) intervertebral disc between T2 and T3; iii) intervertebral disc between T3 and T4; iv) spinous process of T1; v) spinous process of T2; vi) spinous process of T3; vii) spinous process of T4. CONCLUSION: Since a statistically significant P value was recorded for the comparison between the angle of shoulder slope and the acromial vertebral level, it was postulated that the magnitude of the angle may determine the acromial vertebral level. As the present study incorporated standard osteological landmarks into the definition and calculation of the angle of shoulder slope, it may provide reference data regarding the position of the acromion which may be indicative of shoulder asymmetry and distorted shoulder setting. Level of evidence: Level 3. <![CDATA[<b>Intramedullary femoral lengthening with an 'unstable' hip without prior stabilisation: preliminary results of a case series</b>]]> BACKGROUND: Leg length discrepancy due to proximal migration of the femur commonly presents with a short leg gait and symptoms of hip and low back pain. The most common causes are chronic hip dislocation due to developmental dysplasia or the late sequelae of neonatal hip sepsis. It is usually recommended that the hip is stabilised prior to performing limb lengthening, and various techniques have been described. Unfortunately, these methods are not without complications, such as anatomical distortion making future arthroplasty more complex. We recognised a subgroup of these patients in whom the hip appeared unstable on plain film radiography, but in whom there was no proximal migration on weight bearing. METHODS: We report on three of these patients who underwent limb lengthening with an intramedullary device, without prior stabilisation of the hip. RESULTS: The desired length (range 55 to 60 mm) was achieved in all patients without further migration of the proximal femur. In all cases shoe raises were discontinued, and patient satisfaction was high. There was an improvement in gait in all patients. CONCLUSION: Femoral lengthening is possible without prior stabilisation of the hip in certain so called 'unstable' hip situations. The proximal femoral anatomy is not further altered and future salvage procedures such as a total hip replacement are not compromised. Level of evidence: Level 4 <![CDATA[<b>The aetiology of acute traumatic occupational hand injuries seen at a South African state hospital</b>]]> BACKGROUND: Acute traumatic occupational hand injuries are the second most common cause of all traumatic hand injuries worldwide and the most commonly injured body part during occupational accidents. Traumatic hand injuries account for approximately one-third of all traumatic injuries seen at state hospitals in South Africa. The aetiology of occupational hand injures in South Africa is unknown. AIM: The purpose of this research was to highlight the patient demographics and types of hand injuries sustained on duty and to identify the most common causes and risk factors for these injuries METHODS: An observational cross-sectional study was done at a state hospital in Johannesburg, South Africa, between January and July 2016. A total of 35 patients over the age of 18 years were interviewed using a specially designed questionnaire. RESULTS: The patients were predominantly male (88.5 %) between the ages of 20 and 61 years (average 35), 54% had dropped out of school before Grade 11. The average monthly income was low (R1 000-R9 000 pm) and 85% were the primary breadwinner in the household. Only 51 % of the patients had 'formal' employment, the rest were either self-employed, contract workers or had intermittent 'piece' jobs. The majority of injuries occurred to machine operators, general manual labourers and construction workers. Eighty per cent of the patients had never received any occupation-specific training. Seventy-one per cent of the patients were not using any protective gloves at the time of injury. The most common sources of injury were power tools, powered machines and building material. Lacerations, crush injuries and fractures were the most common type of injury seen, involving predominantly the index, middle and ring finger. Twenty-eight per cent sustained minor injuries, 34% moderate, 20% severe and 17% major as defined by the Hand Injury Severity Score. CONCLUSION: Patients with traumatic work-related hand injuries are poorly trained and often are not provided with protective gloves. They typically injure their index, middle and ring fingers using either a power tool, powered machine or by handling building material. The injuries sustained are most commonly lacerations, fractures and crush injuries. As a result, occupational health and safety must be improved to reduce the socio-economic burden of these injuries. Novel ways of improving safety in the informal labour market are required. Level of evidence: Level 4 <![CDATA[<b>A preliminary comparison between intramedullary interlocking nail and minimally invasive plate osteosynthesis in extra-articular distal tibia fractures: a retrospective study</b>]]> AIMS: To compare functional outcome between intramedullary interlocking nail (IMIL) versus minimally invasive plate osteosynthesis (MIPO) in the distal one-third extra-articular tibia fracture. PATIENTS AND METHODS: We retrospectively analysed 42 cases (21 each) of the IMIL nail versus locking plate by MIPO technique. All patientswere followed for at least one year since the last case operated. This study included closed distal tibia fractures above 4 cm to 10 cm and fibula fractures. Fibula fractures within 7 cm of the tibial plafond were fixed with Kirschner wire (K-wire). We excluded all comminuted open fractures, intra-articular extension, and isolated fracture of the tibia from the study. Foot function index, union time, rotational and angular malalignment, rate of infection, secondary interventions and complications were compared between the groups. RESULTS: All patients were retrospectively analysed. Coronal (P=0.259) and sagittal plane malalignment (P=0.147), distraction (P=0.147), rotation (P=0.147), delayed union (P=0.549), non-union (P=0.311), infection (P=0. 549), malunion (P=0.147), amputation (P=0.311), secondary intervention (P=0.116), and foot function index (P=0.217) were all similar between the groups. Time to union was earlier in the MIPO group (P=0.033). We, however, used the MIPO technique in the younger age groups (P=0.042). Coronal plane deformity in both groups was associated with a higher rate of complications, which was also statistically significant (P=0.012). CONCLUSION: Our study suggests that similar outcomes appear through IMIL nail and MIPO of distal extra-articular tibia fractures. Time to union was faster in the MIPO cases, but other factors, such as age, might have played a role. Level of evidence: Level 3 <![CDATA[<b>Treatment of distal radius metaphyseal fractures in children: a case report and literature review</b>]]> BACKGROUND: The management of displaced distal metaphyseal radius fractures in children is controversial - specifically the prevention of redisplacement. The aim of this article is to establish the indications for the use of Kirschner wires (K-wires) in the management of distal radius fractures in children by reviewing the current literature. The objectives were to establish the remodelling potential in children, factors associated with redisplacement, indications for using K-wires and potential complications of K-wires in distal radius fractures METHODS AND RESULTS: A 7-year-old boy with a displaced distal radius fracture was taken to theatre for manipulation and percutaneous fixation with K-wires and subsequently developed a chronic osteomyelitis secondary to the K-wire insertion CONCLUSION: Children under 10 years of age have excellent remodelling potential. The most important risk factors for redisplacement are complete initial displacement, non-anatomic reduction and poor plaster technique. In light of a complication rate of up to 17%, selective use of K-wire fixation in uncomplicated closed fractures should only be considered in children over the age of 10 years in fractures with complete displacement where anatomical reduction cannot be achieved Level of evidence: Level 5