Scielo RSS <![CDATA[SA Orthopaedic Journal]]> vol. 20 num. 2 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>Here we go again: is this our new normal?</b>]]> <![CDATA[<b>'The Art of War'</b>]]> <![CDATA[<b>Treatment outcomes of civilian gunshot tibia fractures at a major trauma centre</b>]]> BACKGROUND: The aim of this retrospective longitudinal study was to describe the overall burden and outcomes of surgically managed gunshot tibia fractures at a major trauma centre. Secondary objectives were to identify possible risk factors for complications including non-union and infection and to highlight any differences in outcomes between treatment modalitiesMETHODS: All consecutive patients who sustained gunshot injuries to the tibia between January 2014 and December 2017 including children and multiple gunshots injuries were considered for inclusion. Information related to patient demographics, injury characteristics, treatment information and treatment outcomes with respect to rate of fracture union and occurrence of infection were obtained from patient records. All patients with insufficient medical records were excludedRESULTS: The records of 197 patients who sustained gunshot tibia fractures were reviewed. The mean follow-up was 4.1 months (interquartile range [IQR] 2.5-6.8). The majority of cases were young males (89%) with a mean age of 29.2±10.2 years. Extra-articular diaphyseal fractures were observed in the majority of cases (91%). Definitive treatment included formal debridement in theatre and plaster cast immobilisation (44%), intramedullary nail fixation (27%), circular external fixation (22%) and plate fixation (7%). The study revealed an overall fracture-related infection (FRI) rate of 11% and bone union rate of 91%. Circular external fixation showed the lowest fracture union rate (86%) and highest FRI rate (21%) of the modalities included in this study. No associations between independent risk factors and presence of complications were identifiedCONCLUSION: The study reports encouraging outcomes for tibia fractures caused by civilian gunshot injuries. Various definitive surgical stabilisation techniques showed high proportions of union and low burden of FRILevel of evidence: Level 4 <![CDATA[<b>The association between HIV infection and periprosthetic joint infection following total hip replacement in young adults</b>]]> BACKGROUND: The HIV burden in South Africa is high. HIV-positive patients are at risk of developing avascular necrosis of the femoral head, necessitating total hip arthroplasty (THA) at a relatively young age. The primary aim of this study was to investigate the relationship between HIV infection and the risk of periprosthetic joint infection (PJI) in young adults following total hip replacement. Secondly, we aimed to evaluate the association of HIV infection with venous thromboembolic events, reoperation and revision surgeryMETHODS: We undertook a retrospective cohort study involving patients under the age of 55 years who underwent THA between 2009 and 2016 at a tertiary level arthroplasty unit. In total, 290 cases in 213 patients were analysed, with 77 patients requiring bilateral THA. The median age of patients was 43 years (interquartile range [IQR] 39-48, range 26-54 years). Sixty-two per cent of patients were HIV positive (n=180) with a median CD4 count of 520 cells/mm³ (IQR 423-659, range 238-1308 cells/mm³). Seventy-eight per cent (n=141) of the HIV-positive patients were on antiretroviral medication before surgery. Almost all cases performed in the HIV-positive group were for avascular necrosis (n=178, 99%RESULTS: At a median follow-up of four years (range 2-10) there were no revisions in either group. The incidence of PJI was 1.1% in the HIV-positive group vs 0.9% in the HIV-negative group. The odds ratio for the development of PJI in HIV-positive patients was 1.22 (95% CI 0.11 to 13.67, p=0.869). There was no association between the CD4 count of HIV-positive patients and the development of PJI (p=0.171). There was no difference in the rate of venous thromboembolic events between the HIV-positive and HIV-negative groups (4% vs 6%, p=0.340CONCLUSION: We report on a cohort of young adult patients who underwent THA. Patients living with HIV infection were not found to be at increased risk for PJI following THA, when compared to HIVnegative patients. The premise that HIV infection increases the risk for PJI following THA remains to be substantiated. This study was underpowered in terms of the primary outcome measure and larger studies are required to verify these findingsLevel of evidence: Level 4 <![CDATA[<b>Adherence to a standard operating procedure for patients with acute cervical spine dislocations</b>: <b>review of a tertiary, referral, academic hospital in South Africa</b>]]> BACKGROUND: To analyse the impact that the adoption of our institutional standard operating procedure (SOP) for cervical spine dislocations had on the timing of closed reduction at our hospital METHODS: The study was a retrospective review of patients who presented to our institution with cervical dislocation injuries and who were managed with closed reduction. The patient records of acute cervical spine dislocations from 2015 to 2018, data from the Acute Spinal Cord Injury database along with patient's demographic information were gathered and compared. Participants within the study time frame were diagnosed with a cervical facet dislocation based on clinical examination findings and radiological confirmation. Patients who had reduction performed at other referring hospitals were excluded from the study. RESULTS: The practice within all tertiary hospitals in the Western Cape is to perform closed reduction of cervical fracture dislocations as soon as possible after injury. In this study the time between injury and closed reduction before introducing the SOP was 13 h 13 min and after introducing the SOP, the time increased to an average of 14 h 28 min. The main cause of delay was the transfer time from the site of injury to the emergency ward. Other reasons for the delay include missed diagnosis, orthopaedic registrar unavailability and incomplete reduction bedCONCLUSION: This study found that the time taken for orthopaedic management of cervical dislocations increased by an hour after introduction of the SOP. Additionally, the overall time to reduction also increased. This was due to delays in transfer to the emergency ward and referral to Orthopaedics. We recommend that, in our setting, reduction could be initiated within an hour of patient arrival, if emergency ward doctors rapidly identified the problem and commenced cervical traction when the orthopaedic team was not immediately available. Our impression was that there was poor adherence to the new SOP guidelines on time management by the trauma team, and possibly transport delays prior to hospital admission. A further study to investigate the bottlenecks of the referral system is advisableLevel of evidence: Level 4 <![CDATA[<b><i>Mycobacterium xenopi </i>osteomyelitis of the spine: a case report</b>]]> BACKGROUND: Mycobacterium xenopi (M. xenopi) osteomyelitis is an uncommon infection which is found in immunosuppressed patients. It is reported to be a slow-growing, nonchromogenic or scotochromogenic nontuberculous mycobacterium. The lungs constitute the most common site for infection and extrapulmonary manifestations, and disseminated forms of the disease are rare. Only a few cases of spontaneous spinal involvement have been reported. We report a case of M. xenopi vertebral osteomyelitis of the spinePATIENT AND METHODS: A 41-year-old female patient, HIV reactive on antiretroviral therapy with a low CD4 count of 183 cells/mm³, presented with clinical and radiological features in keeping with thoracic spinal tuberculosis, complicated with thoracic myelopathy. She was managed surgically with costo-transversectomy and drainage of the paraspinal cold abscess. The Ziehl-Neelsen staining was negative for acid-fast bacilli. However, the histology result revealed a necrotising granulomatous inflammation. A delayed result of polymerase chain reaction (PCR)/line probe assay for Mycobacterium genus testing revealed the presence of M. xenopi, as the cause for the spine osteomyelitis and thoracic myelopathy. However, no M. xenopi susceptibility testing, and no specific photoreactivity techniques for strain identification, were performed. Anti-tuberculosis therapy (ATT) consisting of a two-month initiation phase using rifampicin, isoniazid, ethambutol and pyrazinamide, followed by a seven-month continuation phase using rifampicin and isoniazid, was initiated according to national guidelines. She was fitted with a thoraco-lumbar-sacral orthosis, and underwent a spinal rehabilitation programme. Upon receipt of the PCR result, and considering the good clinical and radiological response to ATT, a consensus was reached with the Infectious Disease Unit (IDU) to continue with ATT until 18 months due to the atypical nature of the pathogen.RESULTS: The patient was successfully treated with the standard TB regimen, but for a period of 18 months, and made full clinical neurological recovery, without any back pain. Furthermore, her CD4 count had also improved to 707 cells/mm³ with a viral load reported lower than 1 000 copies/mlCONCLUSION: This case report emphasises the importance of biopsy in suspected spinal tuberculosis and highlights the concerns with laboratory testing and the prognostic and therapeutic implications of a positive strain identificationLevel of evidence: Level 5 <![CDATA[<b>Growth modulation may decrease recurrence when used as an adjunct to osteotomy in infantile Blount's disease</b>]]> BACKGROUND: This study aimed to determine whether the addition of a lateral proximal tibial tension band plate, combined with proximal tibial dome realignment osteotomy, would decrease the recurrence rate in a group of children younger than 7 years with infantile Blount's disease (IBD) and high recurrence risk, defined as a medial physeal slope >60°METHODS: We reviewed the records of 14 children (22 limbs) under the age of 7 years with IBD and a medial physeal slope >60° that were treated with a combination of tibial osteotomy and tension band plates (group 2) to determine the recurrence rate and time to reoperation. These results were compared with a matched group of eight children (12 limbs) with IBD and a medial physeal slope >60° that were treated previously with tibial osteotomy alone (group 1RESULTS: The two groups were matched in terms of age, sex, obesity, Langenskiöld stage, tibio-femoral angle and medial physeal slope. The recurrence rate was 92% (11/12) in group 1 and 77% (17/22) in group 2 (odds ratio 0.31; 95% CI 0.03-3.01, p=0.312). The mean time to reoperation was 2.4 years in group 1 and 1.9 years in group 2 (p=0.319). There were two implant-related complications: one broken screw and one case of epiphyseal fixation failure in the tension band plate group, both in cases of recurrenceCONCLUSION: The addition of a lateral tension band plate to a proximal tibial realignment osteotomy may be an option to consider in children younger than 7 years with IBD and a high risk of recurrence. Further research is required to determine recurrence risk in IBD and to develop and evaluate surgical strategies to mitigate this risk with well-designed, multicentre controlled trialsLevel of evidence: Level 4 <![CDATA[<b>Polio-like deformity: a diagnostic dilemma</b>]]> BACKGROUND: Significant advances have been made in the global effort to eradicate polio. Vaccine-associated poliovirus, or other enteroviruses, may still affect the anterior horn cell and cause acute flaccid paralysis. Following the acute disease, residual paralysis results in lower motor neuron weakness, altered growth and deformity. Our study aims to describe the clinical manifestations of a group of children that mimic that of classic paralytic poliomyelitisMETHODS: We identified six children from our paediatric orthopaedic database that presented with polio-like deformities. Their clinical and imaging records were reviewed and described, together with the clinical manifestations of paralytic poliomyelitisRESULTS: Limb hypoplasia, pathological gait patterns and foot deformities were consistent features. The median leg length discrepancy was 2.5 cm (range 2-4 cm). The gait patterns observed included a Trendelenburg gait in 33% (n=2), a short limb gait in 50% (n=3), and one case with a combination of Trendelenburg, short limb and steppage gait. Tensor fascia lata contracture was present in 50% (n=3) of our patients. Foot deformities ranged from calcaneo-cavo-valgus to equino-cavo-varus deformitiesCONCLUSION: Despite significant advances made in the global fight to eradicate polio, we still see children with clinical manifestations reminiscent of the disease. Orthopaedic surgeons should remain familiar with the assessment and diagnosis of the sequelae of paralytic poliomyelitisLevel of evidence: Level 5 <![CDATA[<b>Culturally competent patient-provider communication with Zulu patients diagnosed with osteosarcoma</b>: <b>an evidence-based practice guideline</b>]]> BACKGROUND: This guideline was developed as a response to patients with osteosarcoma presenting late for treatment thereby significantly affecting their prognoses. Healthcare providers recognised the role of culture and the importance of culturally competent communication in addressing this problem The aim of this guideline is to present healthcare providers treating Zulu patients diagnosed with osteosarcoma with evidence-based recommendations that can facilitate culturally competent communication regarding the diagnosis, treatment and prognosis of osteosarcoma.METHODS: The AGREE II (Appraisal of Guidelines, Research and Evaluation) appraisal instrument was used as a guide for developing the evidence-based practice guideline. An integrative literature review, focus groups with healthcare providers, and in-depth interviews with Zulu patients were conducted to gather the evidence for the evidence-based practice guideline. The guideline was reviewed by four content and methodological experts using the AGREE II toolRESULTS: The guideline specifies generic aspects such as the awareness, knowledge, skills and provider attitudes required for culturally competent communication as well as the type of healthcare system that can support and cultivate such communication. Specific recommendations for communicating the diagnosis, treatment and prognosis of osteosarcoma to Zulu patients were also includedCONCLUSION: Healthcare providers will require cultural competence and communication training in order to facilitate the implementation of the guideline. Some of the challenges identified in the focus group interviews are not addressed in this guideline, leaving room for further development of the guideline. Evidence-based practice can contribute to improving culturally competent communication with cancer patients receiving treatment at culturally discordant healthcare facilitiesLevel of evidence: Level 5 <![CDATA[<b>Chronic lateral ankle instability: a current concepts review</b>]]> Injuries to the lateral ankle ligaments are quite common, with a reported incidence of up to 22% of all sports injuries, and 85% of all ankle sprains. Most of these are effectively managed using nonoperative measures in the acute setting. Approximately 20% of patients will, however, develop chronic lateral ankle instability (CLAI). Although the anatomy and biomechanics are well documented, more recently, the concepts of the lateral talofibular calcaneal ligament (LTFCL) and microinstability have been described. For those who develop CLAI, a full assessment is mandatory to not only search for correctable risk factors (malalignment), but also to differentiate between functional and mechanical instability. Associated injuries need to be excluded, such as osteochondral lesions of the talus. Rotational ankle instability is a new concept that needs to be considered. Patients who present with CLAI are initially managed conservatively in the form of functional rehabilitation. This management is especially effective in patients with functional instability. Surgery is generally indicated after failed conservative management in patients with objective mechanical instability. The elite athlete is a relative indication to performing surgery early. The choice of surgical procedure is made on an individualised basis, although open anatomical procedures remain the gold standard. Non-anatomical procedures are no longer recommended. Newer minimally invasive and endoscopic techniques show promise in experienced hands but there is only limited evidence to support its use at present. The use of a suture tape as an augment is reserved for specific indications and should not be used routinely.Level of evidence: Level 5