Scielo RSS <![CDATA[SA Orthopaedic Journal]]> vol. 18 num. 2 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<b>Tuning stem cells</b>]]> <![CDATA[<b>The South African take on the America-British-Canadian Fellowship</b>]]> <![CDATA[<b>Posterior based circumferential spinal cord decompression in paediatric patients with the vertebral column resection (VCR) technique spares the anterior approach in severe kyphosis</b>]]> INTRODUCTION: Patients with kyphosis and myelopathy have traditionally been managed by combined anterior and posterior surgery with associated morbidity and long theatre episodes. The posterior vertebral column resection (pVCR) technique allows circumferential apical decompression with instrumented correction and stabilisation through a single extra-pulmonary approach. The objective of this study was to review the use of pVCR in the paediatric population as to feasibility, safety and effectiveness METHODS: A retrospective review of prospectively maintained database was undertaken. Twenty-six consecutive paediatric patients (18 females) were reviewed. The median age at surgery was 12.1 years (IQR 7.6-14.2, range 2.1-17.7). The underlying pathology was active tuberculosis in nine patients, healed tuberculosis in seven, congenital in seven, tumour in two and trauma in one. Myelopathy was present in 17 and two had associated syringomyelia. The median surgical duration was 3.3 hours (IQR 3-5.0, range 1.9-6.5) with a blood loss of 20.8 ml/kg (IQR 12.5-38.1, range 6.3-67.6 RESULTS: The median percentage sagittal correction was 65% (IQR 44-79, range 21-100). The correction was best in the thoracolumbar spine at 75%. All non-ambulatory patients improved to an ambulatory status. There was one permanent and one transient neurological deterioration. All intact patients (ASIA E) remained so. One of the two patients that had associated syringomyelia had complete resolution of the syrinx with improved neurological function. There were no related pulmonary complications. One patient developed early (in-hospital) proximal junctional failure requiring revision CONCLUSION: Posterior based circumferential decompression and corrective fusion using the pVCR technique is both feasible and effective in the paediatric population. It avoids the morbidity associated with the trans-thoracic approach and allows improvement both in neurological function and CSF dynamics when they are compromised It remains a technically challenging procedure both for the surgical and anaesthetic team and there needs to be a clear understanding of the risk-benefit relationship when deciding on its implementation. Level of evidence: Level 4 <![CDATA[<b>A survey of the use of traction for the reduction of cervical dislocations</b>]]> BACKGROUND: Literature supports early decompression of low energy cervical spine dislocations. Closed reduction can safely and rapidly achieve this; however, its use and acceptance among specialists is poorly described. This study aimed to assess the training, experience and decision-making of trainees and surgeons who manage cervical spine dislocations with the goal of reinforcing educational programmes as necessary. The objective was to assess the need to implement further training for trainees and specialists involved in the management of cervical spine dislocations METHODS: Orthopaedic and neurosurgery registrars and specialists in South Africa were emailed a questionnaire consisting of 13 questions related to their training, experience and management of cervical dislocations RESULTS: Seventy-nine per cent (n=62) of surgeons were taught closed reduction during specialist training. Ninety-two per cent (n=12) of neurosurgeons covered spine trauma compared to 66% (n=42) of orthopaedic surgeons. Of surgeons covering trauma, 21% (n=16) would refer the patient on, accepting a 2-hour delay in treatment. Forty-two per cent (n=5) of neurosurgeons vs <2% (n=1) of orthopaedic surgeons preferred MRI before closed reduction. Fifty-six per cent (n=40) of surgeons thought that the risk of worsening neurology during traction was up to 25%. Sixty-nine per cent (n=54) of surgeons felt emergency room (ER) doctors could safely perform closed cervical reduction with training. Fifty-one per cent of surgeons do not think cervical reduction is routinely possible in under 4 hours CONCLUSION: The public and specialists have misconceptions around cervical traction which may affect best clinical practice and optimum management. Cervical traction does not require prior MRI and carries a very low risk of worsening a patient's condition. Closed cervical traction reduction is the most rapid, safe mechanism to reduce cervical dislocations and requires specific education of undergraduates, emergency doctors, and specialists to increase awareness of the reduction process Level of evidence: Level 4 <![CDATA[<b>Epidemiology and injury severity of 294 extremity gunshot wounds in ten months: a report from the Cape Town trauma registry</b>]]> AIMS: To describe the epidemiology and injury severity of patients with extremity gunshot injuries in an area with a high rate of interpersonal violence PATIENTS AND METHODS: This is a prospective cohort study of patients who presented with an extremity gunshot injury and were recorded as part of a trauma registry at a large tertiary care hospital in Cape Town, South Africa, between June 2015 and April 2016. Patient demographics, injury severity scores, injury patterns and referral pathways were evaluated. RESULTS: Of 1 123 gunshot trauma admissions in ten months, 290 (25.8%) patients (91.5% males, n=269) with a median age of 26 years (IQR 13.0) presented with extremity injuries. Median injury severity score (ISS) was 4.0 (IQR 8.0). Only one-fifth of patients had an ISS of 15 or more (n=50, 17%). Upper extremity injuries were associated with a higher risk of fractures (Rr 2.15, p=0.05), higher number of nerve injuries (p=0.01), and a two times higher mean ISS (p=0.01). Admissions between 7pm and 7am with limited staffing at the emergency department were twice as high as the day admissions (n=169, 57.5% versus n=79, 26.9% CONCLUSION: There is a high trauma load on the emergency department and orthopaedic service due to extremity gunshot injuries. Although upper extremity gunshot wounds constituted a red flag for higher injury severity, the overall injury severity was low. Inadequate timing and selection of emergency referrals of patients with low ISS are avoidable aggravators of this burden and should be targeted to increase efficiencies in the care of these patients Level of evidence: Level 4 <![CDATA[<b>Management of complex proximal humerus fractures in the elderly: what is the role of open reduction and internal fixation?</b>]]> The ultimate goal of management of proximal humeral fractures in the elderly patient is to get the patient independently mobile. This article will review the current literature regarding this cohort of patient. Recent Cochrane reviews and a large multicentre randomised study question the role of surgical intervention. Implant design is evolving rapidly, and many elderly patients now behave more like the younger patient. There remains little compelling evidence to guide decision-making for the complex proximal humeral fracture in the elderly, and the decision needs to be made on a case-by-case basis taking into account the patient's comorbidities, the fracture pattern and characteristics, the attending surgeon's skill sets, and the availability of equipment. Level of evidence: Level 5 <![CDATA[<b>Proximal fibular resections for primary bone tumours: oncological and functional results of a case series</b>]]> BACKGROUND: Resection of aggressive benign or malignant tumours of the proximal fibula are difficult due to the high number of surrounding anatomical compartments and close association with many important neurovascular and functional structures. For the same reasons malignant tumours behave differently in this area. Before the 1980s results were poor. With the introduction of neoadjuvant chemotherapy and limb salvage surgery, Malawer described a technique of local en bloc resection. This study presents the oncological and functional results of a case series using this technique PATIENTS AND METHODS: A retrospective folder review of 14 patients was done. Six patients with a large active, an aggressive benign or a low-grade malignant tumour had a Malawer type I marginal resection, and eight patients with a stage IIB malignant sarcoma had a Malawer type II wide intracompartmental resection sacrificing the common peroneal nerve. The follow-up at a median of 38 months included the imaging, histology and a functional MSTS score. RESULTS: The median age of the type I resections was 42.5 years; giant cell tumour was the commonest tumour (50%); and the median functional MSTS score at follow-up was 29. The median age of the type II resections was 12 years; osteoblastic osteosarcoma was the commonest tumour (75%); and the median functional MSTS score was 26. All type II resections achieved clear margins at the initial surgery and there were no recurrences or metastases in either group. There were no wound complications and no vascular complications in spite of sacrificing the tibialis anterior artery in some type I and all type II resections, and the peroneal artery in type II resections. No patient complained of knee instability. The main functional impairment was due to loss of common peroneal function which required an AFO in some patients and a tibialis posterior tendon transfer in one patient CONCLUSIONS: Resection of benign and malignant tumours of the proximal fibula achieved good cure rates and functional results, despite the sacrifice of the common peroneal nerve Level of evidence: Level 4 <![CDATA[<b>Intraosseous terminal phalanx epidermoid inclusion cyst: a first case of late recurrence</b>]]> INTRODUCTION: Epidermoid inclusion cysts (EIC) of the terminal phalanx are a rare but relevant cause of lytic lesions, particularly in the context of previous trauma to the finger. We report the first known case of late recurrence, occurring almost three decades after the incident surgery METHODS: A 56-year-old female patient presented to us with what proved to be a histologically confirmed EIC of the terminal phalanx of her ring finger, but mentioned that she was treated for the same problem some 29 years ago. Medical archive reports and the histological slide from the incident surgery confirmed an initial EIC diagnosis, for which she was treated with curettage and iliac crest autograft, recovering uneventfully RESULTS: Despite the 'zero' risk of recurrence, she elected to have ablative surgery through the distal interphalangeal joint and recovered well CONCLUSION: Care should be taken when counselling patients about possible recurrence of an EIC of the terminal phalanx, and that this recurrence may be many years after the index procedure Level of evidence: Level 5