Scielo RSS <![CDATA[SA Orthopaedic Journal]]> vol. 20 num. 1 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<b>Advocacy for sporting injury prevention and care</b>]]> <![CDATA[<b>2020, a year of challenges and achievements on our path together into the future</b>]]> <![CDATA[<b>Prevalence of pathological neck of femur fractures in patients undergoing arthroplasty at a tertiary referral hospital</b>]]> BACKGROUND: This study aimed to determine the prevalence of pathological neck of femur (NOF) fractures at a tertiary referral hospital through histological examination of specimens in all NOF fracture patients undergoing hip arthroplasty. A secondary aim was to determine whether the current practice of sending all femoral heads for histological evaluation, to avoid missing unsuspected malignancies, is financially warranted. METHODS: A retrospective folder review of patients who underwent arthroplasty for NOF fractures was conducted. Patients with suspected pathological fractures were managed by the divisional Bone Tumour Unit while fragility traumatic fractures were managed by the Arthroplasty Unit. All femoral heads were sent for histological analysis regardless of suspicion of pathological fracture. Quotes from the public and private sector were sought to determine cost implications of sending femoral head specimens for histology. RESULTS: A total of 311 patients were included. Of these, 11 patients (4%) had suspected pathological fractures, with fragility/traumatic fractures being diagnosed in the remaining 300 patients (97%). Histology results were available for 195 patients (63%), including all the patients with suspected pathological fractures. No unexpected malignant histological results were observed, while nine of the suspected pathological fracture group had pathological fractures, confirmed with histology. CONCLUSION: Pathological lesions were identified in 3% of patients undergoing arthroplasty for NOF fractures in our population, which is higher than other reports in the literature. Routine histological screening of femoral heads to exclude pathological fracture might not be necessary and cost effective, as pathological lesions can accurately be identified by clinical and radiographic evaluation. Level of evidence: Level 4 <![CDATA[<b>Intraprosthetic dislocation after a revision hip replacement: a case report</b>]]> BACKGROUND: The dual mobility cup (DMC) was initially design in 1974. It was designed to offer additional stability in total hip arthroplasty (THA) and to prevent dislocations. The dissociation of a DMC has been termed an intraprosthetic dislocation (IPD) and is a rare complication. It is defined as separation of the articulation between the polyethylene and head articulation in the DMC. As the utilisation of DMCs in orthopaedic surgery increases, we can expect an increase in this rare complication. We report a case of an IPD in the setting of revision hip arthroplasty in a 72-year-old female. CASE REPORT: The report is on a 72-year-old female patient who underwent revision hip arthroplasty. The articulation utilised was of the dual mobility type. Some eight months later she dislocated her hip. An attempted closed reduction under general anaesthesia with muscle relaxant was unsuccessful. Thereafter she was taken to surgery to perform an open reduction of the hip. Intra-operatively it was found that the dual mobility head had dissociated, with the polyethylene component remaining in the metal liner. A revision of the components was performed. DISCUSSION: We postulate on the mechanisms of dissociation of the dual mobility head. We review the current literature related to IPD and discuss the risk factors associated with this rare complication. CONCLUSION: The diagnosis of IPD is an indication for revision surgery of the DMC. When utilising a DMC, care should be taken to mitigate against the known risk factors for IPD. All dual mobility dislocations should be reduced under general anaesthesia with muscle relaxant Level of evidence: Level 4.. <![CDATA[<b>Tuberculosis of the extra-axial skeleton in paediatric patients</b>]]> BACKGROUND: Musculoskeletal tuberculosis (MSK TB) is a disease entity that often mimics other orthopaedic conditions in its radiographic and clinical presentation, which can delay diagnosis and treatment. The purpose of this study is to examine the clinical and radiographic presentation as well as the accuracy of various diagnostic tests, treatment, complications and outcome in paediatric patients diagnosed with MSK TB. We aim to provide insight into typical presenting features in order to expedite diagnosis in this perplexing disease. METHODS: We retrospectively reviewed 77 consecutive patients with extra-axial MSK TB treated at our institution over a ten-year period from 2008 to 2018. We collected data on initial clinical presentation, laboratory values, radiographic findings, diagnostic testing, treatment and outcomes. We performed quantitative and qualitative analysis to look for patterns in presentation that can help with diagnosis and factors affecting the clinical outcomes. RESULTS: The most common clinical presentation was pain of the affected limb. Constitutional symptoms were uncommon. Our patients presented with thrombocytosis and anaemia, but normal white cell counts. Inflammatory markers were mildly elevated. Of diagnostic tests employed, the Mantoux skin test yielded the most positive results (70%) followed by tissue PCR (53%). The hip was most frequently involved, followed by the knee and elbow. Most patients presented with normal appearing X-rays. We had a medical compliance rate of 94% with all patients followed up to completion of treatment having resolution of active disease. Thirty-nine per cent of our patients had residual joint stiffness or deformity following completion of treatment, ranging from ankylosis to mildly decreased joint range. CONCLUSION: Patients with MSK TB usually present with non-specific symptoms and signs, and a high index of suspicion should be maintained in endemic areas. Typical haematological findings are an elevated ESR and CRP accompanied by anaemia and thrombocytosis. Radiographs at presentation are non-specific in more than 50% of patients. A combination of diagnostic modalities should be employed as no single test is 100% sensitive or specific. Compliance with medical treatment reliably leads to resolution of the disease. Residual joint pathology is common and needs to be addressed secondarily. Level of evidence: Level 4 <![CDATA[<b>Short-term comparison of the use of static and expandable intramedullary rods in the lower limbs of children with osteogenesis imperfecta</b>]]> BACKGROUND: Children with osteogenesis imperfecta suffer from frequent fractures and deformities due to skeletal fragility. Stabilisation of fractures, correction of deformity and intramedullary rodding result in decreased pain and improved function. Modern expandable intramedullary rods aim to provide lasting stability during growth, without an increase in complications. The aim of our study was to determine and compare the outcome of static Rush rods and expandable Fassier-Duval rods in terms of complications and reoperation rate. METHODS: We reviewed the records of a cohort of 17 children (seven female) with osteogenesis imperfecta (11 Sillence type III, six Sillence type IV) who were treated with intramedullary rods in the lower limb between 2011 and 2017. They had 64 rodding (38 femoral and 26 tibial) procedures (26 Rush rods and 38 Fassier-Duval rods). These were a primary procedure in 46, and a revision procedure after previous Rush rodding in 18 cases. RESULTS: The overall complication rate was 66% (n=42). There was a higher complication rate in the Rush rod group (81%, n=21) when compared to the Fassier-Duval group (55%, n=21)(p=0.035). The most frequent complication in the Rush rod group was distal deformity as the rod is outgrown (69%, n=18). The most frequent complication in the Fassier-Duval rod group was intramedullary migration due to a failure to expand (45%, n=17). Factors that were associated with increased risk of complications included younger age (p=0.031), type of rod (p=0.035), and deformity as an indication for surgery (77% complications, p=0.033). At a mean follow-up of 3.1 years, the reoperation rate in the Rush rod group was 58% (n=15). Comparatively, at a mean of 3.7 years follow-up, there were no reoperations in the Fassier-Duval group. CONCLUSIONS: Despite the numerous innovations, the surgical management of lower limb deformities and fractures in children with osteogenesis imperfecta remains challenging with a relatively high complication rate. The use of Fassier-Duval rods may result in a lower reoperation rate when compared to Rush rods, in the short term. Level of evidence: Level 4 <![CDATA[<b>The management of chronic osteomyelitis in adults: outcomes of an integrated approach</b>]]> BACKGROUND: This study presents the outcomes of the management of chronic osteomyelitis of the appendicular skeleton according to an integrated approach at a dedicated bone infection unit in South Africa. METHODS: A retrospective record review identified 80 patients who were treated between January 2016 and December 2018. RESULTS: Sixty patients (75%) presented with fracture-related infections, 17 patients (21%) developed chronic osteomyelitis following haematogenous spread and three (4%) from contiguous wounds. According to the Cierny and Mader classification, 21 patients presented with anatomical type I, 14 with type II, 24 with type III and 21 with type IV chronic osteomyelitis. Positive microbial cultures were obtained in 63 (79%) cases. Follow-up for the cohort ranged from 1 to 29 months, with a mean follow-up of 10.4 months. The overall complication rate for the cohort was 6% and included sterile drainage from the surgical site after management with bioactive glass (S53P4), refracture after hardware removal, and development of non-union. Five patients experienced recurrence after the initial procedure to eradicate infection, resulting in an overall resolution rate of 94%. CONCLUSION: Using single-stage surgeries and tailored dead space management strategies according to a comprehensive integrated approach developed in South Africa, results comparable to international literature can be achieved. Level of evidence: Level 4. <![CDATA[<b>Radiation-induced pathological fractures of the proximal femur: a case series considering an endoprosthetic solution</b>]]> BACKGROUND: Radiation-induced pathological fractures of the proximal femur are difficult to treat due to frequent non-union and hardware failure using standard fracture fixation techniques. This case series investigates endoprosthetic replacement as a treatment option METHODS: A retrospective folder review from a private hospital in Cape Town, of patients who had sustained a radiation-induced pathological fracture, was reviewed using descriptive statistics. RESULTS: Six patients met the inclusion criteria. One patient was excluded as the minimum follow-up time of six months was not met. Of the Ave patients that were analysed, all Ave sustained transverse, subtrochanteric femur fractures. Prior to definitive treatment with a proximal femoral replacement, three patients were treated with standard trauma instrumentation prior to referral to the unit, and one patient was treated with a vascularised fibular graft as their initial treatment while at the unit. One patient was treated with an endoprosthetic replacement as their first procedure at the unit. Among the three patients treated with standard trauma fixation and the one patient treated with a vascularised fibular graft, there was a 100% failure rate. One standard trauma instrumentation patient had an ablation due to free musculocutaneous flap failure and periprosthetic infection after endoprosthetic replacement. This was the only complication of endoprosthetic replacement. At a median follow-up of 15 months (min 7, max 55) the median Musculoskeletal Tumour Society score was 74% (min 63%, max 93%. CONCLUSION: This case series seeks to highlight the high failure rates seen when treating this condition with standard trauma instrumentation or biological methods. Further research is needed, but endoprosthetic replacement may be a viable alternative solution Level of evidence: Level 4. <![CDATA[<b>Intra-operative extracorporeal radiation therapy for skeletally immature patients with malignant bone tumours</b>]]> BACKGROUND: Management of malignant bone tumours has changed dramatically in recent years. Neoadjuvant chemotherapy, irradiation and conservative surgery have improved local control as well as functional outcome. Depending on the histology of the lesion, other modalities like chemotherapeutic agents or radiation can be selected in place of surgical intervention. Operative intervention is the main modality with wide marginal excision and fixation of bone graft from different sources or mega prosthesis to maintain congruity of the bone anatomy. Reconstruction, optimum fit and stability at the affected site are the major areas of concern with this modality. Radiation given outside the body to kill the tumour cells in the bone is called extracorporeal radiotherapy (ECRT). After resection of the bone, it is cleaned of all the surrounding soft tissue and marrow contents and placed in a container. It is then subjected to 50 Gy of radiation which kills all the tumour cells. METHODS: The study was conducted from June 2014 to May 2020, and included 15 patients (out of 18) diagnosed with either Ewing's sarcoma or osteosarcoma. They were followed up for an average of 4.44 years, up to May 2020. All 15 cases were analysed for bony union at the osteotomy sites. Cases reported with poorly differentiated sarcomas (total three) were subjected to immunohistochemistry and managed with other modalities of treatment. RESULTS: The average time for union of irradiated bone was 8.1 months (range 5-10; the metaphyseal end united faster than the diaphyseal end). At the final follow-up, the functional status was determined using the Musculoskeletal Tumour Society (MSTS) scoring system. Ninety-three per cent of patients had involvement of the lower limb (14 out of 15). All patients (except one who developed recurrence) did not have symptoms of the disease and no one had died at last follow-up. CONCLUSION: Biological limb salvage procedures are considered a successful treatment and a welcome alternative for patients who either cannot afford or be treated with an endoprosthesis. Early diagnosis and referral to specialised unit is of vital importance. This procedure can be used for selected patients with malignant bone tumours. Cost factors, and social and cultural considerations also play a role Level of evidence: Level 4.