Scielo RSS <![CDATA[SA Orthopaedic Journal]]> vol. 20 num. 4 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>Mentorship: a two-way street</b>]]> <![CDATA[<b>Impact of correctable mediolateral tibiofemoral subluxation on unicompartmental knee arthroplasty implant survival in patients with anteromedial osteoarthritis</b>]]> BACKGROUND: Medial unicompartmental knee arthroplasty (UKA) is advocated for treating symptomatic anteromedial osteoarthritis (AMOA). Correctable mediolateral tibiofemoral (TF) subluxation can be safely ignored according to the UKA enthusiasts. However, no clinical studies compare the results in AMOA patients with and without subluxation. This study reports the early prospective clinical outcomes of medial UKA in AMOA, with and without correctable mediolateral TF subluxation and the comparison to the retrospective larger patient cohort. METHODS: The results of an initial retrospective study (R) consisting of 436 consecutive UKA cases (patients treated from May 2012 to October 2017) were compared to a prospective study (P) consisting of 272 consecutive UKA cases in 248 patients with AMOA (evaluated from November 2017 to May 2020). All patients in both cohorts underwent cementless Oxford UKA and were classified into two groups: group 1 (AMOA without mediolateral subluxation) and group 2 (AMOA with mediolateral subluxation) on anteroposterior (AP) radiological knee stress views. Survival analysis methods (Kaplan-Meier and logrank test) were utilised to compare implant survival between the two groups (1 and 2) and the cohorts (R and P). The multivariable Cox proportional hazards model was used to determine risk factors for time to revision. RESULTS: The two cohorts, R and P, had patient groups (group 1 vs group 2) matched for age, sex, wear pattern, preoperative Oxford Knee Score and follow-up period. The overall implant survival for the P cohort that had at least 20 months of follow-up was 98%. The overall implant survival for group 1 (99%) was significantly better compared to group 2 (93%). These results are amplified in the R cohort with an average follow-up of 54 months, and with the group 1 survival at 97% and group 2 at 86%. Subsequent months of follow-up show more failures in group 2 compared to group 1. Patient-reported outcome measures (PROMs) and range of movement were similar for both groups. CONCLUSION: Patients with AMOA and correctable mediolateral TF subluxation have a significantly higher risk of implant failure compared to those without subluxation. This study establishes this association, which has an important implication on patient selection, but does not confirm causality. Level of evidence: Level 4. <![CDATA[<b>Preoperative asymptomatic bacteriuria in patients undergoing total joint arthroplasty in South Africa</b>]]> BACKGROUND: Periprosthetic joint infections (PJIs) are a leading cause of revision for total hip arthroplasty (THA) and total knee arthroplasty (TKA), worldwide. Asymptomatic bacteriuria (ASB) is an independent risk factor for PJIs; however, a paucity of data relevant to developing countries exists. The aim of this study was to describe the prevalence of preoperative ASB and the subsequent incidence of PJIs in patients undergoing total joint arthroplasty (TJA) in South Africa. METHODS: We retrospectively reviewed primary THA and TKA patients. All patients were screened for ASB preoperatively. Patients with positive urinalysis for ASB were identified and treated prior to surgery (treated-ASB). The primary outcome was ASB prevalence and the incidence of PJIs and other perioperative complications. Secondary outcomes included risk factors for ASB and subsequent PJIs in treated-ASB patients, respectively, compared to those with no evidence of ASB (non-ASB). Lastly, we aimed to compare the infective microorganisms cultured from preoperative urinalysis and perioperative sampling of PJIs. RESULTS: We included 179 patients (67 THA; 80% female) with mean follow-up of 2.45 years. ASB prevalence was 22% (n = 39). Patients older than 70 years were 3.5 times more likely to have ASB compared to younger patients (p = 0.005). The prevalence of ASB was 22% (n = 10) for human immunodeficiency virus (HIV) positive and 22% (n = 29) for HIV-negative patients (p = 0.084). PJI incidence was 8% (n = 3) in the treated-ASB and 1% (n = 1) in non-ASB. Treated-ASB patients had an 11.6-fold increased likelihood of PJIs than non-ASB patients (p = 0.046). pJi microorganisms cultured did not correlate to isolates from urine cultures. CONCLUSION: The prevalence of ASB in a TJA population in South Africa is 22% which is higher than reported findings worldwide. Although the value of preoperative antibiotic therapy for ASB remains controversial, there is a role for routine urinalysis preoperatively to identify patients predisposed to PJI. This is of specific significance in the management of HIV-positive patients and in developing countries to guide healthcare providers in resource-constrained environments. Level of evidence: Level 2. <![CDATA[<b>Patient-reported outcomes following plantar incisions in foot surgery</b>]]> BACKGROUND: Plantar incisions may be used in a variety of surgical procedures. Despite numerous studies reporting on procedures which use plantar incisions and thus inadvertently demonstrating good results with plantar incisions, most surgeons still avoid this approach due to the fear of developing a painful plantar scar. There is a shortage of studies demonstrating a clear correlation between plantar scar formation and poor patient-reported outcomes. The aim of this study is to assess the clinical outcome of plantar incisions in various procedures. METHODS: In this retrospective study we identified all patients who underwent surgery using a plantar incision between January 2000 and December 2019. A total of 23 patients were available for assessment. Three common procedures were identified: lesser metatarsal head resection, plantar fibromatosis excision and lateral sesamoidectomy. Demographic data was collected, and clinical outcome was assessed using the Self-Reported Foot and Ankle Score (SEFAS) questionnaire. Twenty-one female (22 feet) and two male patients (two feet) were included. The mean follow-up was 124 (range 8-231) months in the plantar fibromatosis group, 111.5 (range 28-177) months in the lateral sesamoidectomy group and 106.3 (range 42-157) months in the lesser metatarsal head excision group. The study included 12 patients in the sesamoidectomy, nine patients in the plantar fibromatosis and two patients in the lesser metatarsal head excision groups. The mean age of the study population was 45 (range 20-71) years. RESULTS: The mean postoperative SEFAS score in our series was 44 (range 22-48). Nineteen (82%) patients scored as excellent, two (10%) patients as good, one (4%) patient as fair and one (4%) as poor. All wounds healed well with no symptomatic callosities on clinical examination requiring revision. CONCLUSION: This study demonstrates that plantar incisions, irrespective of indication and orientation (21 longitudinal and three transverse), heal well and with good patient-reported outcomes. We believe that it would be erroneous to 'avoid plantar incisions at all costs' and that plantar incisions must be considered if deemed technically superior and with less risk than a dorsal approach. Level of evidence: Level 4 <![CDATA[<b>Do anatomical contoured plates address scapula body, neck and glenoid fractures? A multi-observer consensus study</b>]]> BACKGROUND: The surgical management of scapula body, neck and glenoid fractures remains a challenge. This study focuses on templating an available anatomical pre-contoured plating system using three-dimensional (3D)-printed scapulae to assess the ability of these plates to address the aforementioned fractures and to determine consensus on classifying scapula body, neck and glenoid fractures. METHODS: We used a cohort of 22 3D-printed scapulae prototypes and an available anatomical pre-contoured plating system to determine anatomical congruency and fit. Nine investigators templated the scapulae using four pre-contoured plates, and the investigators classified the 22 scapulae using the Ideberg and AO/OTA classification system. RESULTS: Eleven out of 22 fractures were found to be fixable using the plates under study. The long lateral plate addressed 83% of fractures involving the lateral border, while the glenoid plate was unable to adequately address any glenoid fractures. We observed good to excellent (p < 0.001) interobserver reliability for three of the four plates. The interobserver reliability was moderate (ICC = 0.74) for the AO/OTA classification and good (ICC = 0.88) for the Ideberg classification. CONCLUSION: We believe that the anatomical pre-contoured plating system does not address all the fracture patterns encountered in clinical practice and further development in plate design is required. There is good to moderate interobserver reliability using the Ideberg fracture classification for intra-articular fractures and the AO/OTA classification for extra-articular fractures involving the body. Level of evidence: Level 3 <![CDATA[<b>Incidence of radius shortening following intramedullary nail fixation for gunshot fractures: a retrospective radiological audit</b>]]> BACKGROUND: Intramedullary nail fixation is an option to manage highly comminuted fractures of the radius shaft resulting from gunshot wounds. However, complications including nail migration and malunion are well documented. We have noticed some patients presenting to our clinic with radiological shortening following nail fixation. This may result in chronic pain, reduced pronation and supination, poor grip strength and early onset arthrosis. This study aimed to quantify the incidence of radiological shortening following fixation of isolated gunshot wound (GSW) fractures of the radius with an intramedullary nail. Our secondary objectives were to identify if length of the zone of comminution and anatomical location of the fractures were risk factors for shortening, and to assess whether shortening was a result of surgical error, or whether shortening occurred over time. METHODS: We performed a retrospective review of all (n = 40) isolated radius nails performed between January 2012 and January 2019. Two doctors assessed the latest anterior-posterior forearm X-ray of every patient, using the rule of perpendiculars to calculate ulnar variance (UV). Shortening was defined as a UV > 5.0 mm. If the radius was deemed shortened by consensus, then the immediate postoperative X-ray was also assessed to gauge when shortening occurred. Anatomical location in thirds and length of comminution (mm) were also assessed. RESULTS: Forty patients with a mean age of 32 years (range 15-59) were included. Twelve patients' radiuses were assessed as radiologically short. All 12 were deemed to have been fixed short. One case shortened further over time. We found the incidence of shortening being dependent on the fracture location (p = 0.03), with the fractures occurring in the middle third of the arm shortening more. The measured zone of comminution between the shortened and non-shortened groups was not found to be statistically significant (p = 0.55). CONCLUSION: The radius nail remains useful to manage comminuted radius shaft fractures following GSW. Meticulous technique is needed to avoid radiological shortening, seen in 30% of our series. This can lead to chronic pain, reduced grip strength and early onset arthrosis. We found no evidence that shortening develops over time. We found that the incidence of shortening is dependent on fracture position but did not And any causative relationship between length of the zone of fracture comminution and shortening. Level of evidence: Level 4 <![CDATA[<b>Minimally invasive subcutaneous anterior fixation of pelvic fractures in the elderly: case report and literature review</b>]]> BACKGROUND: As our population ages, the incidence of pelvic fragility fractures will rise accordingly. Despite these fractures having similar mortality rates to proximal femur fractures, there exist discrepancies between the management of these injuries. Although a number of pelvic fragility fractures can be treated successfully with conservative means, early treatment with appropriate surgical means should be considered in those failing conservative treatment or with unstable fracture patterns. CASE REPORT: We present an 84-year-old female who sustained a pelvic fragility fracture after a low-energy fall. Despite adequate conservative treatment, she was unable to mobilise. She was taken for anterior and posterior fixation, using our modified minimally invasive subcutaneous technique (the Bridging Infix) for anterior fixation. At the six-week follow-up she had regained full independent mobility. She had three syncope-related falls during this period, but radiographs revealed no sign of implant displacement. One year after her surgery she had complete union of her fracture, good function and no desire to have the implant removed. DISCUSSION: With the expected increase in pelvic fragility fractures due to the growing elderly population, our understanding of these injuries has begun to change. Occult posterior ring injuries have been described in up to 80% of cases, while fracture progression to unstable patterns can occur in up to 15% of stable patterns. Despite conservative management being the primary treatment of choice, these patients suffer morbidity and mortality rates comparable to proximal femur fractures. Early appropriate surgical management should be considered in patients failing to mobilise. Various surgical techniques have been described, each with their own advantages and disadvantages. Newer minimally invasive techniques are gaining favour, especially for use in elderly patients. These constructs combine the low profile benefits of internal plate fixation with ex-fix principles. CONCLUSION: The Bridging Infix is a modified technique for minimally invasive subcutaneous anterior pelvic fixation. Its use can strongly be considered by even the general orthopaedic surgeon in cases where patients are too frail for extensive or invasive surgeries, such as open reduction and internal fixation with plate and screws. Level of evidence: Level 5 <![CDATA[<b>The short-term outcomes of hip arthrodesis in children and adolescents with end-stage hip disease</b>]]> BACKGROUND: The management of end-stage hip disease in children and adolescents is a challenging clinical problem. While total hip replacement (THR) offers the benefit of improved mobility, this is offset by the risk of multiple revisions. Hip arthrodesis remains a salvage option to relieve pain and restore function at the cost of hip movement. This study aimed to determine the short- to medium-term outcome of hip arthrodesis in paediatric and adolescent patients in a developing world setting. METHODS: All children and adolescents under the age of 18 years who underwent hip arthrodesis between 2010 and 2014 were included in the study. Measurements included diagnosis, preoperative deformity, fusion position, fusion rate and functional outcomes. Our surgery involved transarticular compression screw fixation and subtrochanteric osteotomy. Postoperative skeletal traction maintained optimal limb position for two weeks, after which spica cast immobilisation was used. RESULTS: Nineteen patients (11 female) had hip fusions at a mean age of 12 years (range 5-18). The mean follow-up period was 5 years (range 1-8). Most cases were due to end-stage TB arthritis (12/19; 63%). Other causes were septic arthritis (3/19; 16%); neglected slipped capital femoral epiphysis (1/19; 5%); post-traumatic avascular necrosis (1/19; 5%); and idiopathic chondrolysis (2/19; 11%). Primary fusion was achieved in 68% (13/19) of cases. Six patients developed complications. Complications included adduction drift (3/19), failed fusion (3/19), screw malpositioning (1/19) and screw breakage (1/19). Eight reoperations were required in six patients. In two of these patients, one additional surgery had to be performed to achieve fusion or correct limb position. The mean fusion position was 31° (range 20 to 50) flexion, 2° (range 10 to -10) abduction, and 1° (range 10 to -10) external rotation. Mean leg length discrepancy was 1.8 cm (range 0 to 4.5) of shortening. All except one patient reported relief of hip pain and satisfaction with the procedure. CONCLUSION: While hip arthrodesis is a technically challenging procedure, high fusion rates and reliable pain relief may be expected in these patients. However, complications should be anticipated, and reoperation may be required to achieve fusion and an optimal limb position Level of evidence: Level 4 <![CDATA[<b>Distal radius fractures: current concepts</b>]]> Distal radius fractures (DRFs) are commonly encountered in the elderly population, secondary to low-energy injury mechanisms. In the younger population, DRFs are mainly secondary to high-energy trauma. Stable DRFs can be treated conservatively. However, in the elderly population group, DRFs are often unstable and are likely to benefit from surgical intervention. They are often compounded by comorbid medical conditions requiring optimisation. When treating the elderly group, one should be aware of sarcopaenia, as this may have a bearing on return to function. Recent literature reports an increasing trend in the surgical management of these fractures. Current classification systems fail to consistently guide the management of these fractures. Although evidence is still limited in guiding decision-making in the treatment of these fractures, one should consider the economic implications of prolonged immobilisation in young patients in addition to defined indications for surgery. Improvement in implants allows safe dorsal fixation in patients with dorsal comminution, with low complication rates reported. This narrative review summarises current trends and the body of evidence. Level of evidence: Level 5