SA Orthopaedic Journal

Artificial intelligence and spine surgery outcomes: the beginning of a new era

Editorial: from August 2002

Orthopaedic education - accreditation: from August 2002

Orthopaedic surgery fellowships: from August 2002

The training of registrars from a consultant's perspective: from August 2002

Remembering Prof. Roelie Grabe (7 February 1930-4 April 2022)

High burnout among the South African orthopaedic community: a cross-sectional study

BACKGROUND: Burnout is epidemic among physicians, with the orthopaedic speciality displaying one of the highest rates of burnout in international studies. The burnout rate of the South African orthopaedic community is unknown. This study aimed to determine the prevalence and causes of burnout, as well as the coping mechanisms and associations with burnout, in South African orthopaedic surgeons and trainees METHODS: We conducted a cross-sectional, secure, online survey of members of the South African Orthopaedic Association. The survey assessed demographic characteristics, workload, professional fulfilment and burnout (utilising the Stanford Professional Fulfilment Index), associated workplace distress conditions, causes of and coping strategies for burnout. A response was not compulsory for any question. Statistical analysis was performed to assess for independent associations with burnout RESULTS: One hundred and fifty-six respondents, with a median age of 46.5 years (interquartile range [IQR] 37-58) participated. Ninety per cent (139 of 155) of respondents were male. Registrars accounted for 17% (27 of 155), while 83% (128 of 155) were qualified specialists. Respondents were in orthopaedic practice for a median of 17 years (IQR 9-28). Sixty per cent (76 of 127) practise in private, 17% (22 of 127) in public and 23% (29 of 127) in both sectors. The overall burnout rate was 72% (113 of 156). Burnout was associated with being the parent of young children and having fewer hours of sleep on call. Registrars were more likely to have burnout than consultants (OR 5.68, 95% CI 1.3-25.2). Gender, practice setting and subspeciality were not associated with burnout. Self-reported causes of burnout that were found to be associated with actual burnout were: 'hours at work', 'lack of free time' and 'work-life imbalance'. No self-reported coping mechanisms were found to be protective in this cohort, but the use of alcohol as a coping mechanism was associated with an increased likelihood of burnout (OR 3.9, 95% CI 1.4-10.7). Respondents felt that the concurrent experience of the COVID pandemic at the time of running the survey reduced their experience of burnout CONCLUSION: The burnout rate in the South African orthopaedic community is 72%. Trainees were found to be particularly vulnerable. There appears to be a need to develop, assess and implement effective system-related initiatives aimed at reducing the burnout rate among orthopaedic surgeons and trainees in South Africa Level of evidence: Level 4

A clinician-run 3D-printing laboratory for orthopaedic preoperative planning: an illustrative case series

BACKGROUND: Orthopaedic surgery often benefits from innovation in biomedical engineering, with 3D printing being one of the latest examples. Proving cost-effectiveness and improved clinical outcomes remains challenging. Because of the reduced cost and increased accessibility, it has been possible to start an orthopaedic 3D-printing laboratory in a South African tertiary hospital, exploring the place for this emergent technology in orthopaedic practice. This case series aims to illustrate the clinical use of 3D-printed anatomical models and investigate the time and cost involved in their manufacture METHODS: The design and manufacturing process is discussed, and a retrospective descriptive case series is presented of all models manufactured from January 2020 to April 2021. Using three illustrative cases, we elaborate on two main usage situations: intraoperative reference models (haptic maps) or rehearsal and templating (simulation models RESULTS: In the study, 3D-printed anatomical models were manufactured for 16 patients. For 12 patients, these were simulation models, and for the other four patients, haptic maps were made. The mean time for manufacture was 33 hours (range 8-62), and the median cost per patient was ZAR 3 257.62 (range ZAR 927.17 to ZAR 7 177.09 CONCLUSION: Considering the decreasing cost and ease of using 3D-printing technology, starting a clinician-run orthopaedic 3D-printing laboratory at a South African training hospital has become possible. In this series we illustrate how 3D printing has been used at our unit for planning and rehearsal of a wide range of orthopaedic cases, and we establish a baseline of time and cost expenditure. The cost-effectiveness of implementing 3D-printing technology in everyday orthopaedic practice warrants further investigation Level of evidence: Level 5

Triceps-off transfascial sleeve approach, functional outcomes and surgical technique in distal humerus fractures

BACKGROUND: We aimed to assess functional and clinical outcomes of patients who underwent open reduction and internal fixation of distal intra-articular fractures of the humerus through a previously undescribed approach through the triceps tendon, called the triceps-off, transfascial sleeve (TOFS) approach METHODS: We conducted an ambispective cohort study of ten patients who underwent open reduction and internal fixation of the distal humerus through the TOFS approach at a tertiary hospital between March 2016 and January 2019. Patients were identified from the prospectively kept surgical database. All had AO type C fractures of the distal humerus. The mean age was 36.7 ± 14.9 years (range 19-68). The assessment consisted of a review of their hospital records, range of motion, triceps strength, ultrasound evaluation of triceps tendon integrity, X-rays for union rates and adequacy of reduction, and DASH scores RESULTS: The mean time of follow-up was 10.8 ± 4.7 months (range 6-19). The mean arc of motion was 114.7 ± 25.1 degrees (range 80-150). There was a decrease in mean triceps muscle strength compared to the uninjured side: 66% at 45° of flexion, 70% at 90° and 86% at 120° of elbow flexion. The mean DASH score was 15.7 ± 8.9, indicating mild residual impairment (range 5-31). The DASH score had a strong correlation (r = 0.71; p < 0.05) with the follow-up period. All tendons were intact on ultrasound evaluation. One patient had deep surgical site infection, treated with surgical debridement, antibiotics and plate removal with resolution of sepsis and healing. All fractures united by six months CONCLUSION: TOFS is a successful surgical approach for reduction and fixation of AO type C intra-articular distal humerus fractures, with excellent tendon healing rates. It is, however, associated with mild residual functional impairment and residual triceps weakness Level of evidence: Level 4

Halo-external fixator frame-assisted correction to treat severe kyphotic deformity in children younger than 4 years old

BACKGROUND: Severe kyphotic deformity in young children may have devastating outcomes when neglected. Halo-pelvic traction has been shown to be very effective as part of the treatment for severe kyphosis, but little is known about application of this technique in very young individuals. The aim of this case series was to provide novel insights into the surgical technique associated with halo-external fixator frame (HEFF) treatment for severe spinal deformity in patients younger than 4 years old, along with the associated radiologic outcomes and complications METHODS: Clinical and demographic characteristics including the duration in the HEFF, HEFF-associated change in kyphosis angle (KA) and final KA following definitive surgery were extracted from medical records RESULTS: Five female patients with a mean age of 36 months (range 30-44) were included. Three patients had thoracic spinal tuberculosis (mean KA 82°), one had lumbar spinal tuberculosis (KA 42°) and one had iatrogenic post-laminectomy cervical kyphosis (type 1 neurofibromatosis)(KA 112°). The HEFF was applied for a mean of six weeks and resulted in a mean thoracic deformity correction of 29° (38%), a lumbar correction of 23° (55%) and cervical correction of 47° (42%). Definitive surgery resulted in a further mean overall deformity correction of 28, and patients had a satisfactory KA angle (23° lordosis to 31° kyphosis) at the last follow-up. HEFF-associated complications included pin-site infection, pneumonia and frame dislodgement CONCLUSION: HEFF appears to be an effective method for correcting severe kyphotic spinal deformity in very young patients where other options are limited. It allows for independent mobilisation and can provide for spinal stabilisation while awaiting bony healing after definitive surgery. However, healthcare providers should be aware of the potential dangers of HEFF hardware, such as difficulty in establishing an airway due to the fixed position of the neck Level of evidence: Level 4

Short-term outcomes of one-stage bilateral total hip arthroplasty in a South African setting

BACKGROUND: Total hip arthroplasty (THA) is one of the most successful orthopaedic surgical procedures that dramatically improves function, pain relief and quality of life for the patient. In South Africa, we have a high prevalence of osteonecrosis of the femoral head (ONFH) and inflammatory arthropathy affecting a young population. This subgroup of patients is usually between the ages of 30 and 50 years (young) and they require bilateral total hip replacements (BTHA) to allow them to return to their previous level of function and employment. The study aimed to assess the short-term outcomes and complications in patients with bilateral hip pathology managed surgically with a one-stage BTHA METHODS: We retrospectively reviewed a series of 33 patients who underwent a one-stage BTHA at a high-volume arthroplasty unit in a central hospital in South Africa between January 2016 and December 2018. The mean age was 38 years (standard deviation [SD] 9 years), and the most common diagnosis was ONFH (76%). In this cohort, 12 patients (36%) tested HIV positive. We assessed patient folders for diagnosis, perioperative details, postoperative follow-up and complications. Radiographic analysis was also performed RESULTS: There were no revisions or planned surgical interventions for any of the patients at a median follow-up of 22 months (interquartile range [IQR] 11-45 months). Thirty patients reported no hip pain and walked unaided at their most recent follow-up visit. Two patients reported groin pain and continued to walk with a single crutch. One patient demised from unrelated causes approximately one year post-surgery. The only perioperative complication was a urinary tract infection (UTI) in one patient. The median postoperative length of stay was six days (IQR 4-7 days), and no other medical or surgical complications were reported. Radiographic analysis revealed four patients (12%) with Brooker grade 1 heterotopic ossification in six hips CONCLUSION: Our results suggest that surgical treatment with a one-stage BTHA is a good alternative to a two-stage BTHA when performed in a high-volume arthroplasty centre and carefully selected patients. The 30-day mortality rate was 0%, and the complication rate was low Level of evidence: Level 4

Epidemiology of primary bone tumours in Nigeria: a systematic review

BACKGROUND: Primary bone tumours, although rare, are an important rising cause of morbidity and mortality in Africa. Late presentation, delayed diagnosis and failure to obtain consent for surgical procedures are important causes of loss of limb and life especially in the West African subregion. Existing data on primary bone tumours in Nigeria have been based on studies performed at various regional levels. The aim of this study is to determine the epidemiological pattern of primary bone tumours in Nigeria in general, including demographics, predominant tumour types and predominant skeletal location by reviewing existing data METHODS: A search of the following databases: University of Edinburgh Library, PubMed, CINAHL and SCOPUS from 2000 till January 2021 following PRISMA guidelines was conducted to identify studies conducted in Nigeria with relevant epidemiological data on primary bone tumours in Nigeria RESULTS: The search yielded a total of 952 hits from which seven hospital-based retrospective studies met the inclusion criteria for review. The estimated incidence rate of primary bone tumours ranged from 0.08 to 0.31 per 100 000 population. All studies showed a male preponderance. The peak age group of individuals presenting with both benign and malignant primary bone tumours was 11-20 years. Overall, benign tumours were more common. Osteochondromas were the most common benign tumours, while the commonest malignant tumours identified were osteosarcomas. The most common location for both benign and malignant tumours were the tibia and fibula CONCLUSION: Nigeria shares some similar epidemiological characteristics of primary bone tumour with other countries; however, some peculiar differences have been identified in this study. Population-based studies are required to obtain more accurate epidemiological data about this disease Level of evidence: Level 2

Wide awake local anaesthesia no tourniquet: a review of current concepts

BACKGROUND: Wide awake local anaesthesia no tourniquet (WALANT) is a local anaesthetic technique that employs lignocaine combined with adrenaline to maintain a pain-free and bloodless field during surgery on an awake patient, without the use of a tourniquet METHODS: This article is a narrative review of the literature on the use of this mode of anaesthesia in orthopaedic and hand surgery RESULTS: The review summarises the existing research pertaining to WALANT. It discusses the anaesthetic solution constituents, administration technique and applications of WALANT, highlighting the safety profile and benefits to patients and healthcare systems alike CONCLUSION: The WALANT technique is safe, economical, and acceptable to patients. It should form part of the orthopaedic surgeon's armamentarium. Future research should investigate the benefits of intraoperative functional assessment of the awake patient Level of evidence: Level 5