Scielo RSS <![CDATA[SA Orthopaedic Journal]]> vol. 21 num. 1 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>Modern orthopaedics and the forgotten child</b>]]> <![CDATA[<b>Orthopaedic surgical career path - where's the plan?</b>]]> <![CDATA[<b>Evaluating the design modifications of an intramedullary forearm nail system: a cadaver study</b>]]> BACKGROUND: Current orthopaedic practice requires a forearm nail that is length and rotationally stable and which can restore functional anatomy. A forearm nailing system was designed based on clinical need. This nailing system features unique designs and locking holes that offer a larger approach and escape angle for ease of interlocking. The aim of the present study was to test the prototype and evaluate the design changes in cadaver bonesMETHODS: A cross-sectional cadaveric study, including ten cadavers with normal forearm anatomy (n = 20 forearms) was conducted. Both forearms of the cadavers were used to evaluate the locking times and exposure time during i) insertion; ii) locking; and iii) removal of the nails, resulting in the evaluation of a total of 40 procedures. All nails were assessed for insertions of interlocking screwsRESULTS: The nail was successfully inserted into 38 bones. Inserted nails were available for locking (n = 38), and all locking attempts at both driving ends (n = 38, 100%), as well as the non-driving ends (n = 76, 100%), were successful. Freehand locking at the non-driving end of the nail (38 cases, 76 locking holes) took a median of 44.5 seconds (interquartile range [IQR] 33.0-59.0), while the number of exposures ranged from 2 to 12 with a median of 5.5 exposures (IQR 4.0-8.0). The freehand locking procedure's exposure time was 0.09 minutes (IQR 0.07-0.23CONCLUSION: The proposed forearm intramedullary nail design modifications allowed for successful implantation, interlocking and removal of nails in both radius and ulna cadaver bones, with acceptable radiation exposureLevel of evidence: Level 5 <![CDATA[<b>A retrospective file audit of preoperative anaemia in patients referred to an anaesthesiology clinic before elective orthopaedic surgery</b>]]> BACKGROUND: Preoperative anaemia has been shown to be associated with increased postoperative morbidity and mortality, prolonged hospital stay, and increased allogeneic blood transfusions. With elective surgery there is time to manage preoperative anaemia. The aim was to determine the prevalence of preoperative anaemia and evaluate how anaemia was investigated and managed in adult patients who were referred from the Orthopaedic Clinic to the Universitas Academic Hospital Anaesthesiology Clinic between January 2016 and December 2018METHODS: The retrospective file audit included patient demographics, comorbidities and chronic medication, indication for elective surgery, haemoglobin level at first clinic visit, laboratory investigations done for anaemia, dates of clinic visits and surgery, whether the anaemia was corrected before surgery, and if there were any perioperative red cell transfusionsRESULTS: A total of 178 patients were included. The cut-off value for anaemia was 13 g/dL in both sexes. Forty-four patients (25%, 95% CI 19-32%) had preoperative anaemia with a median haemoglobin of 12.25 g/dL (IQR 11.2; 12.7). Their mean age was 63.3 (SD ± 10.0) years. Fifteen patients (34%) were booked for knee arthroplasty and 24 patients (55%) for hip replacement surgery. No workup was done for the anaemia, and only 15/44 (34%) anaemic patients received any form of treatment. Eighteen anaemic patients (41%) received perioperative red cell transfusions. Eight of the transfused patients (44%) developed postoperative sepsis, while five were still anaemic postoperativelyCONCLUSION: The prevalence of preoperative anaemia before elective orthopaedic surgery (25%) was the same as that reported before patient blood management was introduced internationally. None of the anaemic patients had a diagnostic workup and therefore did not receive therapy targeted at the cause of the anaemia. Perioperative red cell transfusions could have been significantly reduced. The clinic now focuses on managing preoperative anaemiaLevel of evidence: Level 3 <![CDATA[<b>Orthopaedic surgical training exposure at a South African academic hospital - is the experience diverse and in depth?</b>]]> BACKGROUND: With increasing pressure on our training hospitals, we undertook to ascertain whether our clinical orthopaedic surgery training platform is providing adequate surgical exposure, both in diversity and the level of trainee participationMETHODS: The orthopaedic surgery database was interrogated for theatre procedures logged for the 12-month period 1 January to 31 December 2018. Each theatre case was assessed as to the level of trainee participation, whether it was performed during or after hours, and categorised as being elective or trauma in nature, as well as the orthopaedic subdisciplineRESULTS: A total of 3 147 orthopaedic surgical procedures were logged with an even split of elective (51.1%) and trauma (49.9%) cases. Adults predominated in the trauma group while the paediatric service contributed most to the elective cases, followed by arthroplasty and spine. Overall, 25.5% of procedures were performed by consultants and 74.5% by registrars. Registrars were more frequently the primary surgeon in trauma cases (90%) compared to elective procedures (59%) (p < 0.001). Of the elective cases, 37% were performed by registrars as supervised unscrubbed and 22% as supervised scrubbed operations. In total, 17.5% of cases were performed after hours, with 31.7% of trauma surgeries and only 2.9% of elective surgeries occurring after hours. Registrars were the primary surgeon in 98.7% of after-hours trauma cases and 58% of after-hours elective cases under unscrubbed supervisionCONCLUSION: Our study presents the surgical experience and level of participation available to orthopaedic surgical trainees in a South African training hospital where their exposure was an equal number of elective and trauma cases. The vast majority of the cases were performed by the registrars in their supervised unscrubbed capacity although the more complex, elective cases were performed by consultants. Almost all after-hours trauma cases were performed by registrars. This suggests the platform allows for a high level of registrar surgical participation and training despite the challenges. Further review is required to assess achievement of trainee competency and whether in fact the current experience is adequateLevel of evidence: Level 4 <![CDATA[<b>Not strong enough? Movements generated during clinical examination of sagittal and rotational laxity in a cadaver knee</b>]]> BACKGROUND: Injury to the anterior cruciate ligament (ACL) is associated with sagittal and rotational laxity, which is exacerbated by damage to the anterolateral capsuloligamentous structures, also known as the anterolateral ligament (ALL). The amount of laxity reported in biomechanical studies might be clinically insignificant during a surgeon's examination, possibly influencing clinical judgement. We aimed to measure whether the motion generated by clinicians in a cadaver model after the ACL and ALL were transected is clinically significantMETHODS: A group of orthopaedic surgeons and trainees examined a cadaver knee for sagittal and rotational laxity at 30° and 90° with intact ligaments, after the ACL was transected, and after the ACL and ALL were transected. The examiners were blinded to the dissection process. Rotational and sagittal movements during these examinations were recorded by a computer-assisted surgery (CAS) systemRESULTS: Twenty-four orthopaedic surgeons took part in the study. The median sagittal plane motion captured by CAS at 30° flexion was 7 mm (IQR 2 mm, p-value 0.32) in the intact knee, 9 mm (IQR 1 mm, p-value 0.34) after the ACL was cut and 9 mm (IQR 3 mm, p-value 0.63) after ACL and ALL were cut. The median arc of rotational motion at 30° was 19° (IQR 7°, p-value 0.12) in the intact knee, 24° (IQR 5°, p-value 0.56) after the ACL was cut, and 22° (IQR 6°, p-value 0.8) after the ACL and ALL were cut. None of the differences in these movements was significantCONCLUSION: The surgeons could not generate significant differences in sagittal or rotational motion in a cadaver model, which could be objectively detected by CAS, when examining the intact knee, ACL deficient (only), or combined ACL and ALL deficient knee. This challenges the utility of known clinical tests and calls for improved objective laxity assessment tools to provide input in clinical decision-making and measure outcomes of these injuriesLevel of evidence: Level 5 <![CDATA[<b>The Fassier technique for correction of proximal femoral deformity in children with osteogenesis imperfecta</b>]]> BACKGROUND: Children with osteogenesis imperfecta frequently present with coxa vara. Skeletal fragility, severe deformity and limited fixation options make this a challenging condition to correct surgically. Our study aimed to determine the efficacy of the Fassier technique to correct coxa vara and determine the complication rateMETHODS: We retrospectively reviewed the records of a cohort of eight children (four females, 12 hips) with osteogenesis imperfecta (6/8 Sillence type III, 2/8 type IV) who had surgical treatment with the Fassier technique for proximal femoral deformity between 2014 and 2020RESULTS: The mean age at operation was 5.8 years (range 2-10). The mean neck-shaft angle (NSA) was corrected from 96.8° preoperatively to 137° postoperatively. At a mean follow-up of 38.6 months, the mean NSA was maintained at 133°, and 83% (10/12) of hips had an NSA that remained greater than 120°. There was a 42% (5/12) complication rate: three Fassier-Duval rods failed to expand after distal epiphyseal fixation was lost during growth; one Rush rod migrated through the lateral proximal femur cortex with recurrent coxa vara; and one Rush rod migrated proximally and required rod revisionCONCLUSION: The Fassier technique effectively corrected coxa vara in children with moderate and progressively deforming osteogenesis imperfecta. The deformity correction was maintained in the short term. The complication rate was high, but mainly related to the failed expansion of the Fassier-Duval rods. Further studies are required to determine the long-term outcome of this techniqueLevel of evidence: Level 4 <![CDATA[<b>Patient satisfaction following wide awake local anaesthetic no tourniquet hand surgery</b>]]> BACKGROUND: Wide awake local anaesthetic no tourniquet (WALANT) hand surgery is a rapidly growing technique for hand surgery whereby a lignocaine/adrenaline/bicarbonate mixture is injected into the hand or fingers where the procedure is to be carried outMETHODS: This was a retrospective study with prospective recall analysing satisfaction of patients who underwent WALANT hand surgery at our academic hospital in the first year of its inception. Data collection included a questionnaire to analyse demographics, comparison to dental procedures, subjective and objective experience of the procedure, overall experience, expectations, pain and surgical outcomeRESULTS: We included 80 procedures in 67 patients; 87% would prefer WALANT in the future, and 87% would recommend WALANT to friends or family. For 79% of patients (who had dental procedures before), the pain was less or the same as a dental procedure, and 70% of patients said the experience was better than expected. Average pain scores were 3.89/10 during local anaesthetic injection, 1.25/10 during the procedure and 5.20/10 postoperatively; with postoperative pain starting at an average of nine hours. Eighty-five per cent of conditions were cured at follow-up and no cases of digital ischaemia or infection were notedCONCLUSION: Our study suggests WALANT hand surgery is a safe, effective and satisfactory method of performing hand surgery in the South African contextLevel of evidence: Level 4 <![CDATA[<b>Transarticular gunshot injuries: a systematic review of 150 years of management</b>]]> BACKGROUND: This review aims to collate all published work on the management of transarticular gunshot injuries to better inform decision-making when managing these injuriesMETHODS: A systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was undertaken. A literature search of major electronic databases was conducted to identify journal articles relating to the management of transarticular gunshot injuries published from database inception until 31 January 2021RESULTS: Sixty-eight publications reporting on the management of 544 patients were included. Injuries to the lower limbs were reported in 438 cases (81%), while injuries to the upper limb accounted for 106 cases (19%). A total of 145 patients (27%) developed a deep infection. Following the routine use of antibiotics, 6% of patients (14/251) developed an infection. A significantly higher hip joint infection rate was seen in patients who sustained associated hollow viscus injury (11/30, 37%CONCLUSION: The management of transarticular gunshot injuries is currently based on limited high-quality evidence. Modern antibiotic and surgical management practices have resulted in low overall septic complications; however, different joints have different injury and complication profiles. Future research should be aimed at identifying joint-specific evidence-based care pathwaysLevel of evidence: Level 4 <![CDATA[<b>A rare occurrence of ganglion cysts on the posterolateral aspect of the elbow without neurological manifestations: a case series and review of the literature</b>]]> BACKGROUND: The occurrence of ganglion cysts around the elbow is rare, and the occurrence of these lesions without any symptoms of compression to the nearby structures is even rarer. Most published cases of elbow ganglions have reported patients with symptoms relating to compression of the radial nerve, or branches thereof secondary to anteriorly located cysts. We present two cases of ganglions occurring on the posterolateral aspect of the elbow with no pressure symptoms to the radial nerveCASE SERIES: The first case is a 33-year-old male, with a seven-month history of a spontaneous, slow-growing mass on the posterolateral aspect of his left elbow. The second case is a 38-year-old female, with a 12-month history of a spontaneous mass on the posterolateral aspect of her left elbow. In both cases, the reason for presentation was the unsightly elbow with an enlarging mass. The lesions were painless and both patients were neurologically intact with no restriction on range of motion of the joint. Both patients underwent excision of the mass for aesthetic reasonsDISCUSSION: Patients with elbow ganglions usually have cysts located anterior to the radiocapitellar joint and almost invariably present with an associated motor, or less commonly, a sensory deficit of the radial nerve. Various treatment modalities have been reported; however, the vast majority undergo open surgical excision due to their association with progressive neurological symptoms. This usually leads to resolution of symptoms, and recurrence is rareCONCLUSION: The clinical presentation of the two patients reported in this case series seems to be far less frequent than patients presenting with a neuropathy of the radial nerve due to an anteriorly located elbow ganglion. It cannot, however, be excluded that there is an underreporting of asymptomatic elbow ganglions. According to our review of the English literature, this is only the third report of an asymptomatic elbow ganglion in the lateral compartment of the elbowLevel of evidence: Level 5