Scielo RSS <![CDATA[SA Orthopaedic Journal]]> vol. 17 num. 2 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<b>New frontiers in the battle against the burden of musculoskeletal trauma from motor vehicle accidents</b>]]> <![CDATA[<b>The silent killer: myocardial injury after non-cardiac surgery (MINS)</b>]]> INTRODUCTION: Recent work into the causes of death after non-cardiac surgery has identified a new clinical concept, namely myocardial injury after non-cardiac surgery (MINS). The pathophysiology is related to a supply-and-demand mismatch in the peri-operative period and differs from the traditional model of myocardial ischaemia and infarction. METHODS: Literature review of current body of knowledge and recent large multicentre clinical trials. RESULTS: MINS is associated with increased morbidity and mortality at 30 days' post-surgery. A large international multicentre trial found that a troponin T level of greater than 0.3 ng/ml was associated with a mortality rate of 16.9%. Moreover, 84.2% of MINS would probably go undetected if systematic troponin monitoring after surgery was not performed CONCLUSION: This review examines the current body of knowledge and provides practical guidelines on how to identify and manage patients with MINS. LEVEL OF EVIDENCE: Level 5. <![CDATA[<b>Ability of the Schatzker classification to predict posteromedial fragmentation in tibial plateau fractures</b>]]> <![CDATA[<b>Open tibial fractures: risk factors for infection in conversion of external fixator to intramedullary nail at a tertiary academic hospital</b>]]> <![CDATA[<b>The management of low velocity transarticular gunshot injuries: A pilot study</b>]]> OBJECTIVES: To prospectively evaluate the incidence of superficial and deep wound sepsis in a cohort of patients who sustained low velocity transarticular gunshot wounds. METHODS: We performed a prospective, randomised, non-blinded pilot study of all adults presenting to a single institution between November 2011 and January 2015 that sustained a transarticular gunshot injury with no definite indication for surgery. We defined indications for surgery as: retained bullet or bullet fragments that warranted surgical removal or the presence of skeletal injuries that required surgical intervention. Patients were randomised into two treatment groups. The conservative treatment group received antitetanus toxoid and antibiotics alone, and the surgical treatment group received anti-tetanus toxoid and antibiotics, as well as formal arthrotomy, debridement and irrigation. SETTING: Single Level 1 University Hospital Trauma Centre. MAIN OUTCOME MEASUREMENTS: The two groups were assessed for development of septic arthritis or superficial wound infection. RESULTS: We identified 30 transarticular gunshot wounds in 29 patients with an average age of 29.5 years (range 18-74). Sixteen (53%) were treated conservatively and 14 (47%) had a formal arthrotomy and washout. The median follow-up period was 20 days (range 5-84) for the conservative group and 30 days (range 8-84) for the operative group. No wound or intra-articular sepsis was observed for any of the 30 gunshot wounds. CONCLUSION: It can be concluded, with appropriate caution, that there may be a place for non-operative treatment of low-velocity transarticular gunshot injuries without a demonstrable increased risk of infection. LEVEL OF EVIDENCE: Level 2. <![CDATA[<b>Fracture patterns and complications related to pedestrian-vehicle collision victims in a public Level-1 Trauma Centre ICU population</b>]]> INTRODUCTION: Death and injury associated with road traffic collisions are global phenomena that require urgent attention. Approximately 1.2 million people worldwide are killed each year. Pedestrian collisions remain one of the single largest causes of injury, disability, and death in the developing world and contribute significantly to trauma centre activity, especially in urban areas. MATERIALS AND METHODS: The study aim was to describe the fracture patterns in pedestrians, and to highlight the epidemiology, spectrum, and outcomes of orthopaedic injuries identified in pedestrian vehicle collision (PVC) victims admitted to a major trauma intensive care unit (TICU). This retrospective analysis of 405 PVC victims, retrieved from an Ethics Approved Trauma Registry (BE360/13 and BE207/09) admitted to the TICU at Inkosi Albert Luthuli Central Hospital, Durban, South Africa, spans a six-year period from 2007 to 2012. RESULTS: Four hundred and five pedestrian-vehicle collision patients were admitted over the six-year study period. Missing data were found in two patients. The mean age was 25.8 ± 17.49 years, with 135 (33.3%) female patients and 270 (66.7%) males. One hundred and eleven patients were referred directly from the scene; the others were inter-hospital transfers. Two hundred and eighty-five patients had fractures and from this group, 63 (22%) patients died in ICU. The most common fracture site was femur (122), followed by tibia (112) and pelvis (95). The mortality was related mainly to the age of the victims; none of the fractures were found to be associated directly with increased mortality. CONCLUSION: Diverse fracture patterns are seen in PVC patients. The leading cause of death is head injury, followed by chest injury. Increased age of the patients was associated with increased mortality. The predominance of specific fractures, in specific sex and age groups, were noted, and some fractures were found to be associated with more complications; however, none of the fractures were linked directly to mortality. LEVEL OF EVIDENCE: Level 4. <![CDATA[<b>The management of acute lateral ankle sprains: a survey of South African surgeons and best evidence available</b>]]> INTRODUCTION: Ankle sprains remain the single most frequent injury in modern sports with increasing evidence that it is not as innocuous as previously thought. Conservative treatment options include various forms of immobilisation such as casts, moonboots and stirrup braces, followed by a rehabilitation period involving different modalities. Despite clinical evidence there seems to be a divergence between research and practice with an increase in acute surgical repair especially with regard to professional athletes. The aim of the study was to assess the approach on management of acute ankle sprains by orthopaedic surgeons in South Africa, by means of a descriptive cross-sectional survey analysis METHODS: This was a two-part study. First, a questionnaire was emailed to participating orthopaedic surgeons, consisting of eight treatment options for a grade three lateral ankle sprain in a non-professional athlete. Secondly, a literature review was undertaken to establish the current best practice concerning ankle sprain management RESULTS: A total of 129 responses was received out of the 719 that were sent out. Surgical repair was offered in 24 (19%). Conservative treatment including either cast or moonboot for a period of six weeks was chosen by 49 (38%) and two to four weeks by 55 (43%) as their preferred treatment. Only 39 (30%) of responding South African Orthopaedic Association members chose a short period of immobilisation followed by functional rehabilitation in accordance with the current best evidence available, based on the literature review done CONCLUSION: Despite good clinical evidence, there seems to be a lack of consensus in the management of grade three lateral ankle sprains LEVEL OF EVIDENCE: Level 5 <![CDATA[<b>Contemporary treatment of chronic osteomyelitis: implementation in low- and middle-income countries</b>]]> AIM: Chronic osteomyelitis is still a difficult problem to treat in the developed world, but even more so in low- and middle-income countries. Contemporary treatment options result in satisfying outcomes in a setting with abundant resources, but the question is whether these treatment options can be translated to other, less supported health care systems and if they obtain the same results. METHODS: Eighteen patients with established chronic osteomyelitis (eight type III, ten type IV) were prospectively enrolled and treated in a one-stage procedure with radical debridement and dead space management using bioactive glass S53P4 granules, together with adjuvant antibiotic therapy. RESULTS: Thirteen patients were assessed at 24 months. Infection control was achieved in Ave patients (38%). Eight patients (61.5%) had persistence or recurrence of infection. Loss to follow-up was substantial (Ave patients, 28%). CONCLUSION: Due to specific challenges treating chronic osteomyelitis in low- and middle-income countries, contemporary treatment options cannot be 'copy-pasted' with the same results in these settings. LEVEL OF EVIDENCE: Level 4. <![CDATA[<b>Short-term outcomes of single event multilevel surgery for children with diplegia in a South African setting</b>]]> BACKGROUND: Although single event multilevel surgery (SEMLS) is well supported in the literature for walking children with cerebral palsy (CP) there is little evidence to show the outcomes in developing countries with limited resources. Further there is no literature reporting on the use of SEMLS in walking children with HIV encephalopathy (HIVE). The primary aim of this study was to investigate whether SEMLS can have good short-term outcomes in a South African setting, and the secondary aim was to compare the outcomes of SEMLS in children with diplegia secondary to CP and HIVE. METHODS: A prospective cohort study of ten children with spastic diplegia was enrolled (six with CP, four with HIVE) and followed up for 12 months. All children underwent SEMLS and received peri-operative therapy at a local clinic, hospital or a special-needs school. The primary outcome measures were the Edinburgh Visual Gait Score (EVGS), Gross Motor Function Measure-66 (GMFM-66) and the Functional Mobility Scale (FMS) measured pre-operatively (T1), at six months (T2) and at one year (T3) RESULTS: There was an overall mean improvement of 6.4 in the EVGS and 3.2% in the GMFM-66 at the one-year follow-up assessment. The FMS revealed an initial deterioration in function at six months, with return to pre-operative function at the one-year assessment. Improvements in the GMFM-66 were found to be clinically significant. When comparing children with CP to those with HIVE the improvements were similar. CONCLUSION: The results of this study indicate that the early outcomes of SEMLS in a South African setting, with scarce resources, are similar to those seen in developed countries. It may also be possible to use the same SEMLS treatment principles seen in the management of children with CP for children with static HIVE. Further follow-up is however needed in both of these areas. LEVEL OF EVIDENCE: Level 4. <![CDATA[<b>Necrotising fasciitis following a supracondylar fracture and an open radius fracture in a child</b>]]> BACKGROUND: Necrotising fasciitis is a rare, rapidly progressing soft-tissue infection with a high mortality rate. Historically, necrotising fasciitis has been associated with penetrating injuries, and more recently with immunocompromise and severe comorbidities. This case report highlights the association of necrotising fasciitis in a child with an open distal radius fracture and a supracondylar fracture. METHOD AND RESULTS (CASE REPORT: A 10-year-old boy was admitted 24 hours after falling from a tree with a Gustilo and Anderson grade II distal radius fracture and a Gartland grade III supracondylar humerus fracture. The wound was debrided and the fractures reduced and stabilised with Kirschner wires. Within 48 hours of admission he developed a necrotising fasciitis that extended onto the chest and eventually resulted in a shoulder disarticulation. The tissue defects were covered with flaps and skin grafts and the patient was discharged home. CONCLUSIONS: This case highlights the importance of having an early and high index of suspicion for necrotising fasciitis in a child with an open contaminated fracture and delay to both antibacterial chemotherapy and surgical debridement. Tissue trauma due to open fractures may obscure the early skin signs of necrotising fasciitis as well as laboratory risk factors. In the South African context, urgent administration of cephazolin and surgical exploration must be done to prevent the devastating complication of necrotising fasciitis. LEVEL OF EVIDENCE: Level 5.