SA Orthopaedic Journal

The use of racial classification in medical research

The Smith & Nephew Orthopaedic Travelling Fellowship: A cross-pollination of knowledge

Complications following acute severe haematogenous osteomyelitis of the long bones in children

BACKGROUND: Acute haematogenous osteomyelitis (AHO) of the long bones is frequently complicated by the development of sequestrum, pathological fracture, chronic osteomyelitis and growth arrest. We aimed to determine the frequency of complications and outcomes of patients with AHO of the long bones requiring surgical evacuation of pus. We furthermore examined the predictive value of clinical, biochemical and radiological variables on the development of complications following AHO METHODS: Eighty-one patients were included. Clinical course, occurrence of complications and eventual outcome were documented. Complications were defined as: development of sequestrum, chronic osteomyelitis, pathological fracture and/or growth arrest. Results were analysed to determine factors predisposing to complications, and the difference in outcome between patients that developed complications and those that did not. RESULTS: The mean age at presentation was 7.5 years, and the mean follow-up was 1.8 years. Thirty-nine patients (48%) developed 67 complications. Twenty-six patients developed sequestrum, 19 pathological fractures, 13 chronic osteomyelitis and nine growth arrest. No presenting feature was associated with an increased risk of developing complications. The percentage of cortex with radiological changes at 6 weeks (66.1% vs 44.9%, p<0.0001) was associated with the development of complications. Duration of admission was significantly longer for those patients that developed complications (21 weeks vs 6 weeks; p<0.001) Thirteen patients that developed complications had a poor outcome, compared to 0 patients that did not (p<0.001 CONCLUSION: AHO may result in severe disability, despite early recognition and adequate treatment. Early recognition of extensive bony involvement warrants increased vigilance to identify and manage complications timeously. Level of evidence: Level 4

Profile of patients with Blount's disease at an academic hospital

BACKGROUND: Despite an apparent increased burden of Blount's disease in South Africa, little is known of its epidemiology and associated features. The aim of this study is to explore the profile of South African patients with Blount's disease seen at an academic hospital, with respect to family history, ethnicity, associated milestones, sex, bilateral involvement and obesity METHODS: We retrospectively evaluated the hospital records of children diagnosed with Blount's disease (infantile, juvenile and adolescent groups) over a 14-year period, from 1 January 2003 to 31 December 2016 at Chris Hani Baragwanath Academic Hospital. Demographic information including family history, ethnicity, attainment of milestones, age when the deformity was first noticed, age at presentation, sex, bilateral involvement and body mass index were documented RESULTS: Data was available for 108 patients with a total of 172 involved limbs. In this series all patients were of black African origin. Data for 60 of the patients regarding family history was available - there were 12 documented cases with a positive family history of significant bow legs (20%). The developmental milestones of patients within all three groups were within normal limits and, in particular, were not early. The majority of the patients in the infantile and juvenile groups were female whereas the adolescent group had a male predominance. There was a similar occurrence of bilateral involvement in all groups (infantile group 64%, juvenile group 53% and adolescent group 61%). There was an increased percentage of individuals who were overweight or obese (according to BMI percentiles) in each of the three groups compared to normative data (infantile 76%, juvenile 86% and adolescent 88%). A greater proportion of male patients were classified as obese compared to female patients (82% versus 50%). There was however no significant difference in the bMi of patients with unilateral or bilateral deformity CONCLUSION: New findings from this large South African population of children with Blount's disease were an increased occurrence of bilateral involvement in all age groups and no association with early walking - both findings are different from the international literature. Similar to other international studies, female preponderance in the infantile group and male preponderance in the adolescent group was confirmed. Other findings include an increased occurrence of obesity in male children in all groups as well as an increasing occurrence of obesity as the groups progressed from infantile (42%), to juvenile (76%), to adolescent (82%) using the CDC percentiles for age. No risk factors were found for unilateral involvement Level of evidence: Level 4

A survey of the management of posterior malleolar ankle fractures in South Africa

BACKGROUND: Posterior malleolus fractures are associated with poorer functional outcomes compared to simpler malleolar fractures. Traditional teaching states that if a posterior malleolus fracture involves less than 25% of the distal tibia, it can be managed without fixation. Current literature has shown that fixation should not be based on the size of the posterior fragment but rather on the fracture pattern, instability and awareness that reduction and fixation is biomechanically advantageous. We hypothesised that current management of ankle fractures with posterior malleolus involvement in South Africa is not evidence-based and is suboptimal. We sought to assess the training, experience and decision-making of surgeons and trainees who are involved in the management of ankle fractures. Another aim was to develop evidence-based algorithms for the management of posterior malleolus and complex ankle fractures. METHODS: An email survey consisting of questions related to the management of ankle fractures was sent to specialists, registrars and medical officers who voluntarily completed an online survey. RESULTS: A total of 103 out of 456 emails sent drew responses to the survey. Responses included 28% from consultants, 54% from registrars and 18% from medical officers. Forty-six per cent of responders believed that posterior malleolus fractures can be managed non-operatively if less than 20% of the tibial plafond is involved. Only 49% would CT scan a posterior malleolus prior to operating. Thirty-eight per cent of the responders were not familiar or comfortable with the posterior-lateral approach used for fixation of the posterior malleolus directly. CONCLUSION: Understanding of ankle fractures has progressed. A significant proportion of responders to the survey are not following best practice and current literature. Posterior malleolus fractures are not benign and have poorer outcomes compared to bi-malleolar or lateral malleolus ankle fractures. All patients with posterior malleolus fractures should receive pre-operative CT scan. All posterior malleolar fractures that can be held with a plate or screws should be fixed. Level of evidence: Level 5

Cross-screw technique for the modified Lapidus procedure using headless compression screws

AIMS: The aim was to evaluate union rates using two cross headless compression screws for the modified Lapidus procedure. This was compared to conventional fixation using solid AO screws and plates, as recorded in the published literature PATIENTS AND METHODS: This is a retrospective study of the modified Lapidus procedure performed in patients with a moderate to severe hallux valgus deformity. Union time and patient demographics were retrieved from medical records. Patient demographics included age, sex, smoking habits and other comorbidities. The union rate was compared to the literature using the two-population probability test, with p<0.05 being significant. RESULTS: Sixty-nine feet in 56 patients were assessed for radiographic union. There were three delayed unions and two non-unions. The union rate of 97% was not statistically different when compared to studies using conventional solid AO screws CONCLUSION: The use of headless compression screws in the fixation of the first tarsometatarsal joint and early mobilisation was found to be comparable to conventional solid AO screws with regard to union rates. The cannulated design enhances ease of insertion and, being headless, minimises the risk of intra-operative fracture and hardware prominence requiring subsequent removal Level of evidence: Level 4

Unrepaired rotator cuff tears following acromioplasty

BACKGROUND: The natural history of rotator cuff tears suggests that not all tears progress and small isolated rotator cuff tears might heal. To date there have been no long-term studies assessing the MRI changes of unrepaired full thickness supraspinatus tears after acromioplasty. METHODS: A database of patients from a single surgeon that have had acromioplasty without rotator cuff repair in the last Ave to 15 years was reviewed. The number of shoulders examined in this study was 17. Patients all completed an Oxford score, Constant score and had an MRI to assess fatty infiltration and atrophy. RESULTS: Mean follow-up time 7.2 years (range, 5-13 years). The patients were divided into three groups depending on the size of the tear at time of surgery: C1 tears (<1 cm) n=5, C2 tears (1-1.9 cm) n=8, C3 tears (2-3 cm) n=4. In the C2 group, MRI evaluation showed there were two patients that had tears that had regressed in size (CI 1.4-36, 4). In the C3 group, MRI evaluation revealed that all (100%) of the rotator cuff tears had significant fatty infiltration and atrophy. There was no statistical difference between groups when assessing Oxford scores (p=0.75) and Constant scores (p=0.69). There was significant association between increase in tear size and fatty infiltration (p=0.028). A possible association was noted between increase in tear size and atrophy (p=0.054). CONCLUSION: Patients had good long-term clinical outcomes irrespective of tear size. It showed that not all tears progressed to significant fatty change and atrophy. Level of evidence: Level 3

Anthropometric differences in the tibial tuberosity to trochlear groove measurement in an African population

BACKGROUND: The tibial tuberosity to trochlear groove (TTTG) is a well-described radiographic measurement around the knee, which is of clinical significance in the assessment of patients with patellar instability. The TTTG is clinically relevant when considering the type of surgical procedures that may be required. The purpose of this retrospective observational study was to measure the TTTG measurement in the black African population and to compare it to the quoted norms in the literature METHODS: A random sample was obtained of 100 consecutive CT scans of lower limbs for vascular pathologies from black African patients. The TTTG was measured by a single observer on the Siemens® syngo.plaza software RESULTS: CT scans of 162 knees from 88 patients met the inclusion criteria. The median age was 34 years (range 19-85 years; interquartile range [IQR] 24-50). The majority of cases were male (75%; n=121). The mean TTTG was 20.3 mm (standard deviation [SD] 16.1; range 1-29.2 mm). The mean TTTG in males was 20.7 mm (95% confidence interval [CI] 19.9-21.5 mm) and 19.1 mm (95% CI 17.6-20.5 mm) in females (p=0.06). There was no correlation found between age and TTTG (p=0.12 CONCLUSION: According to our study, barring some limitations, it appears that there may be a noteworthy difference in the TTTG measurement in the black African population. Larger comparative studies would be required to confirm these findings and to determine the clinical relevance Level of evidence: Level 4

Publication rates of podium presentations at the annual South African Orthopaedic Association Congress from 2010 to 2015

BACKGROUND: International literature shows a discrepancy between presentations at annual general orthopaedic meetings and subsequent publication. The aim of this study was to determine the publication rate of manuscripts presented as podium presentations at the South African Orthopaedic Congress (SAOC) from 2010 to 2015. MATERIALS AND METHODS: All abstracts accepted as podium presentations at the SAOC from years 2010 to 2015 were identified from the archives of the South African Orthopaedic Society (SAOA). Abstract titles and authors were searched using search engines looking for all published manuscripts. The presentations were cross-referenced with publications and the conversion ratio from presentation to publication was compared to international results. Sub-analyses included orthopaedic subspecialty performance and publication rates and the types of research conducted. Record was also made of each publication's journal impact factor and date of publication. RESULTS: A total of 445 abstracts were accepted for podium presentation by the SAOC from 2010 to 2015. Of these, 70 (15.7%) were published in peer-reviewed journals. The mean time from presentation to publication was 16 months with an average journal impact factor of 1.29. Orthopaedic Trauma (21.67%) and Foot and Ankle Surgery subspecialties (21%) were responsible for the most publications in general. The South African Orthopaedic Journal (44.29%), Strategies in Trauma and Limb Reconstruction (6.7%) and the Injury Journal (6.7%) were the three most common publishing journals. CONCLUSION: A lower conversion rate from podium presentation at SAOC to publication exists compared to similar published international findings. A poor publication rate was highlighted across all orthopaedic subdisciplines. Half of the publications appeared only in local journals, with just over 8% of presentations reaching international publication. The results suggest there is a need to identify barriers to publication among South African orthopaedic surgeons. Level of evidence: Level 4.

Proximal humerus fractures - Part 1: Conservative management

Fractures of the proximal humerus are common, especially in osteoporotic females. Despite this, there remains significant debate around their preferred treatment. The difficulties when considering treatment options is the wide array of fracture patterns and multiple patient factors which play an important role in the outcome of the management of these fractures. Fortunately, the vast majority of these fractures can be treated conservatively. The challenge, however, is the 15% of patients in which surgery may be required such as displaced three- and four-part fractures, and fractures in young and active patients. Although various recent studies and review papers show acceptable results with conservative treatment, especially in elderly patients, the decision on when to operate and when to consider conservative treatment remains challenging. The goal of this current concepts paper is to highlight important aspects of the conservative management of patients with proximal humerus fractures, from initial assessment through to treatment, including possible complications. Level of evidence: Level 5