Pub Date : 2020-08-26DOI: 10.17159/2309-8309/2020/V19N3A1
Megan P. O’Connor, L. Nieuwoudt, L. Marais
Background: The coronavirus disease of 2019 (COVID-19) pandemic is taxing South Africa’s already over-burdened healthcare system. Orthopaedics is not exempt; patients present with COVID-19 and musculoskeletal pathology and so surgeons should be familiar with the current evidence to best manage patients and themselves. The aims of this scoping review were firstly to inform peri-operative decision-making for COVID-positive patients as well as the routine orthopaedic milieu during the pandemic; secondly to assess the outcomes of orthopaedic patients managed in endemic areas; and finally to determine the effect the pandemic has had on our orthopaedic peers. Methods: A scoping review was conducted following the PRISMA-ScR guidelines of 2018. The search terms ‘Orthopaedics’ or ‘Orthopedics’ and ‘COVID-19’ or ‘Coronavirus’ were used to perform the search on Scopus, PubMed and Cochrane databases. All peer-reviewed articles utilising evidence-based methodology and addressing one of the objectives were eligible. A thematic approach was used for qualitative data synthesis. Results: Seventeen articles were identified for inclusion. All articles represented level 4 and 5 evidence and comprised ten review-type articles, one consensus statement, two web-based surveys and four observational studies. Most articles (n=11) addressed the objective of peri-operative considerations covering the stratification and testing of patients, theatre precautions and personal protective equipment (PPE). Evidence suggests that patients should be stratified for surgery according to the urgency of their procedure, their risk of asymptomatic disease (related to the community prevalence of COVID-19) and their comorbidities. The consensus is that all patients should be screened (asked a set of standardised questions with regard their symptoms and contacts). Only symptomatic patients and those asymptomatic patients from high prevalence areas or those with high-risk contacts should be tested. Healthcare workers (HCWs) in theatre should maintain safety precautions considering every individual is a potential contact. In the operating room in addition to the standard orthopaedic surgery PPE, if a patient is COVID positive, surgeons should don an N95 respirator. The three articles that addressed the effects on the orthopaedic surgeon showed a significant redeployment rate, effects on monetary renumeration of specialists and also effects on surgeons in training causing negative emotional ramifications. Of the surgeons who have contracted the illness and have been investigated, all showed mild symptomatology and recovered fully. The final three articles concentrated on orthopaedic patient considerations; they all showed high mortality rates in the vulnerable patient populations investigated, but had significant limitations. Conclusion: Orthopaedics is significantly affected by the COVID pandemic but there remains a dearth of high-quality evidence to guide the specialty. Level of evidence
{"title":"Orthopaedics and COVID-19: The surgery, the surgeon and the susceptible - a scoping review","authors":"Megan P. O’Connor, L. Nieuwoudt, L. Marais","doi":"10.17159/2309-8309/2020/V19N3A1","DOIUrl":"https://doi.org/10.17159/2309-8309/2020/V19N3A1","url":null,"abstract":"Background: The coronavirus disease of 2019 (COVID-19) pandemic is taxing South Africa’s already over-burdened healthcare system. Orthopaedics is not exempt; patients present with COVID-19 and musculoskeletal pathology and so surgeons should be familiar with the current evidence to best manage patients and themselves. The aims of this scoping review were firstly to inform peri-operative decision-making for COVID-positive patients as well as the routine orthopaedic milieu during the pandemic; secondly to assess the outcomes of orthopaedic patients managed in endemic areas; and finally to determine the effect the pandemic has had on our orthopaedic peers. \u0000Methods: A scoping review was conducted following the PRISMA-ScR guidelines of 2018. The search terms ‘Orthopaedics’ or ‘Orthopedics’ and ‘COVID-19’ or ‘Coronavirus’ were used to perform the search on Scopus, PubMed and Cochrane databases. All peer-reviewed articles utilising evidence-based methodology and addressing one of the objectives were eligible. A thematic approach was used for qualitative data synthesis. \u0000Results: Seventeen articles were identified for inclusion. All articles represented level 4 and 5 evidence and comprised ten review-type articles, one consensus statement, two web-based surveys and four observational studies. Most articles (n=11) addressed the objective of peri-operative considerations covering the stratification and testing of patients, theatre precautions and personal protective equipment (PPE). Evidence suggests that patients should be stratified for surgery according to the urgency of their procedure, their risk of asymptomatic disease (related to the community prevalence of COVID-19) and their comorbidities. The consensus is that all patients should be screened (asked a set of standardised questions with regard their symptoms and contacts). Only symptomatic patients and those asymptomatic patients from high prevalence areas or those with high-risk contacts should be tested. Healthcare workers (HCWs) in theatre should maintain safety precautions considering every individual is a potential contact. In the operating room in addition to the standard orthopaedic surgery PPE, if a patient is COVID positive, surgeons should don an N95 respirator. The three articles that addressed the effects on the orthopaedic surgeon showed a significant redeployment rate, effects on monetary renumeration of specialists and also effects on surgeons in training causing negative emotional ramifications. Of the surgeons who have contracted the illness and have been investigated, all showed mild symptomatology and recovered fully. The final three articles concentrated on orthopaedic patient considerations; they all showed high mortality rates in the vulnerable patient populations investigated, but had significant limitations. \u0000Conclusion: Orthopaedics is significantly affected by the COVID pandemic but there remains a dearth of high-quality evidence to guide the specialty. \u0000Level of evidence","PeriodicalId":32220,"journal":{"name":"SA Orthopaedic Journal","volume":"19 1","pages":"129-137"},"PeriodicalIF":0.0,"publicationDate":"2020-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67480150","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-08-26DOI: 10.17159/2309-8309/2020/V19N3A3
J. D. Toit, R. Salkinder, M. Burger, G. D. Preez, R. P. Lamberts
Background: Femoral diaphyseal fracture is a common paediatric orthopaedic injury; however, the management of these fractures remains controversial in children between the ages of 6 and 13 years. The preferred approach for children appears to be surgical, enabling early mobilisation. Some studies have reported that submuscular bridge plating (SBP) might be a good alternative treatment method with favourable outcomes. The aim of this study was to determine whether SBP a) leads to union in length-unstable fractures with a low complication rate; b) leads to reasonable alignment and leg length equality; and c) has acceptable clinical outcomes in a South African tertiary hospital setting. Methods: All patients with predominantly length-unstable femoral diaphyseal fractures who were treated between 1 January 2011 and 31 December 2012 were included in this study. Patients were treated with SBP using standard of care techniques, and hardware removal was performed at approximately eight months post operatively. The nine months post-operative assessment between the affected and unaffected leg was used to assess the effectiveness of the SBP intervention. Results: A total of 29 patients (mean age 9±2 years) were included. The majority of the fractures (n=27, 93%) were length-unstable. Two patients (7%) had transverse fractures with >2 cm overlap and/or weighing >45 kg. All fractures healed within expected time frames. No overall leg length discrepancy (p=0.94) or coronal mechanical axis deviation (p=0.51) was observed between the affected and unaffected lower limbs at nine months post-surgery. No differences between the operated and non-operated sides were observed for hip flexion (p=0.88), hip external rotation (p=0.36), hip internal rotation (p=0.12) or knee flexion (p=0.96). Conclusion: SBP provides reliable outcomes in children with diaphyseal femoral fractures and is our preferred method of fixation for a) length-unstable fractures; b) fractures close to the metaphysis; and c) children weighing more than 45 kg. Level of evidence: Level 4
{"title":"Short-term outcomes of submuscular bridge plating of length-unstable paediatric femoral shaft fractures in children - Insights from a South African tertiary hospital setting","authors":"J. D. Toit, R. Salkinder, M. Burger, G. D. Preez, R. P. Lamberts","doi":"10.17159/2309-8309/2020/V19N3A3","DOIUrl":"https://doi.org/10.17159/2309-8309/2020/V19N3A3","url":null,"abstract":"Background: Femoral diaphyseal fracture is a common paediatric orthopaedic injury; however, the management of these fractures remains controversial in children between the ages of 6 and 13 years. The preferred approach for children appears to be surgical, enabling early mobilisation. Some studies have reported that submuscular bridge plating (SBP) might be a good alternative treatment method with favourable outcomes. The aim of this study was to determine whether SBP a) leads to union in length-unstable fractures with a low complication rate; b) leads to reasonable alignment and leg length equality; and c) has acceptable clinical outcomes in a South African tertiary hospital setting. \u0000Methods: All patients with predominantly length-unstable femoral diaphyseal fractures who were treated between 1 January 2011 and 31 December 2012 were included in this study. Patients were treated with SBP using standard of care techniques, and hardware removal was performed at approximately eight months post operatively. The nine months post-operative assessment between the affected and unaffected leg was used to assess the effectiveness of the SBP intervention. \u0000Results: A total of 29 patients (mean age 9±2 years) were included. The majority of the fractures (n=27, 93%) were length-unstable. Two patients (7%) had transverse fractures with >2 cm overlap and/or weighing >45 kg. All fractures healed within expected time frames. No overall leg length discrepancy (p=0.94) or coronal mechanical axis deviation (p=0.51) was observed between the affected and unaffected lower limbs at nine months post-surgery. No differences between the operated and non-operated sides were observed for hip flexion (p=0.88), hip external rotation (p=0.36), hip internal rotation (p=0.12) or knee flexion (p=0.96). \u0000Conclusion: SBP provides reliable outcomes in children with diaphyseal femoral fractures and is our preferred method of fixation for a) length-unstable fractures; b) fractures close to the metaphysis; and c) children weighing more than 45 kg. \u0000Level of evidence: Level 4","PeriodicalId":32220,"journal":{"name":"SA Orthopaedic Journal","volume":"19 1","pages":"145-149"},"PeriodicalIF":0.0,"publicationDate":"2020-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44851640","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-08-26DOI: 10.17159/2309-8309/2020/V19N3A8
P. Maré, DM Thompson
Infantile Blount’s disease results in multi-planar proximal tibial deformity consisting of varus, procurvatum, internal rotation and shortening. The deformity is attributed to disordered growth of the posteromedial proximal tibial physis. The aetiology is multifactorial. It is associated with childhood obesity and African ethnicity. The ability to differentiate between infantile Blount’s disease and physiological bowing depends on the findings of focused clinical examination, X-ray appearance, tibial metaphyseal-diaphyseal angle and tibial epiphyseal-metaphyseal angle. The gold standard of treatment is proximal tibial metaphyseal corrective osteotomy before the age of 4 years. The limb should be realigned to physiological valgus. The recurrence rate after realignment osteotomy is high. Recurrence is associated with age at osteotomy, obesity, higher Langenskiold stage and medial physeal slope ≥60°. The surgical management of severe, recurrent or neglected infantile Blount’s disease is challenging. Comprehensive clinical examination and multi-planar deformity analysis with standing long leg X-rays are essential to identify all aspects of the deformity. Distal femur coronal malalignment and significant rotational deformity should be excluded. Knee instability due to intra-articular deformity should be corrected by elevation of the medial tibial plateau. Lateral epiphysiodesis should be done at the same time as medial plateau elevation and when medial growth arrest is certain to prevent recurrence. Level of evidence: Level 5
{"title":"Infantile Blount's disease","authors":"P. Maré, DM Thompson","doi":"10.17159/2309-8309/2020/V19N3A8","DOIUrl":"https://doi.org/10.17159/2309-8309/2020/V19N3A8","url":null,"abstract":"Infantile Blount’s disease results in multi-planar proximal tibial deformity consisting of varus, procurvatum, internal rotation and shortening. The deformity is attributed to disordered growth of the posteromedial proximal tibial physis. \u0000The aetiology is multifactorial. It is associated with childhood obesity and African ethnicity. The ability to differentiate between infantile Blount’s disease and physiological bowing depends on the findings of focused clinical examination, X-ray appearance, tibial metaphyseal-diaphyseal angle and tibial epiphyseal-metaphyseal angle. \u0000The gold standard of treatment is proximal tibial metaphyseal corrective osteotomy before the age of 4 years. The limb should be realigned to physiological valgus. \u0000The recurrence rate after realignment osteotomy is high. Recurrence is associated with age at osteotomy, obesity, higher Langenskiold stage and medial physeal slope ≥60°. \u0000The surgical management of severe, recurrent or neglected infantile Blount’s disease is challenging. Comprehensive clinical examination and multi-planar deformity analysis with standing long leg X-rays are essential to identify all aspects of the deformity. Distal femur coronal malalignment and significant rotational deformity should be excluded. Knee instability due to intra-articular deformity should be corrected by elevation of the medial tibial plateau. \u0000Lateral epiphysiodesis should be done at the same time as medial plateau elevation and when medial growth arrest is certain to prevent recurrence. \u0000Level of evidence: Level 5","PeriodicalId":32220,"journal":{"name":"SA Orthopaedic Journal","volume":"19 1","pages":"173-182"},"PeriodicalIF":0.0,"publicationDate":"2020-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47723389","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-08-26DOI: 10.17159/2309-8309/2020/V19N3A2
A. Hirschmann, T. Pillay, K. Fang, M. Ramokgopa, C. Frey
Background: On 11 March 2020 the World Health Organization (WHO) declared COVID-19 a worldwide pandemic and a threat to global public health. In this paper we aim to describe the measures implemented to combat the COVID-19 pandemic in the Department of Orthopaedic Surgery at Chris Hani Baragwanath Academic Hospital (CHBAH), Soweto, Johannesburg, the largest hospital in Africa with approximately 3 200 beds and about 6 760 staff members. At the time of writing this report, we have transitioned from level 5 to level 3 lockdown. Methods: We performed a literature review and drew on the experiences of previous pandemic response plans worldwide. A working group comprising all relevant disciplines was created to develop standard operating procedures in line with governmental policy. Results: We found that by developing a multi-phase plan, we were able to maintain service delivery to all emergent patients while protecting medical staff and patients alike. This plan also allowed coordination with other disciplines and made provision for staff from within the Department of Orthopaedic Surgery to be made available to work within other departments as and when required. The implementation of this plan had to evolve constantly, adjusting to the changes in the national lockdown level and the demands of the developing situation. Conclusion: We hope that by sharing our plan with our colleagues domestically and abroad, we can promote discussion and improve our ability to better prepare and deal with this unprecedented healthcare scenario. In order for us to win as individuals, we must fight as a team. Level of evidence: Level 5
{"title":"DEFCON 5: The Chris Hani Baragwanath Academic Hospital orthopaedic department's COVID-19 proactive action plan","authors":"A. Hirschmann, T. Pillay, K. Fang, M. Ramokgopa, C. Frey","doi":"10.17159/2309-8309/2020/V19N3A2","DOIUrl":"https://doi.org/10.17159/2309-8309/2020/V19N3A2","url":null,"abstract":"Background: On 11 March 2020 the World Health Organization (WHO) declared COVID-19 a worldwide pandemic and a threat to global public health. In this paper we aim to describe the measures implemented to combat the COVID-19 pandemic in the Department of Orthopaedic Surgery at Chris Hani Baragwanath Academic Hospital (CHBAH), Soweto, Johannesburg, the largest hospital in Africa with approximately 3 200 beds and about 6 760 staff members. At the time of writing this report, we have transitioned from level 5 to level 3 lockdown. \u0000Methods: We performed a literature review and drew on the experiences of previous pandemic response plans worldwide. A working group comprising all relevant disciplines was created to develop standard operating procedures in line with governmental policy. \u0000Results: We found that by developing a multi-phase plan, we were able to maintain service delivery to all emergent patients while protecting medical staff and patients alike. This plan also allowed coordination with other disciplines and made provision for staff from within the Department of Orthopaedic Surgery to be made available to work within other departments as and when required. The implementation of this plan had to evolve constantly, adjusting to the changes in the national lockdown level and the demands of the developing situation. \u0000Conclusion: We hope that by sharing our plan with our colleagues domestically and abroad, we can promote discussion and improve our ability to better prepare and deal with this unprecedented healthcare scenario. In order for us to win as individuals, we must fight as a team. \u0000Level of evidence: Level 5","PeriodicalId":32220,"journal":{"name":"SA Orthopaedic Journal","volume":"19 1","pages":"138-144"},"PeriodicalIF":0.0,"publicationDate":"2020-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48729869","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-08-26DOI: 10.17159/2309-8309/2020/V19N3A5
M. V. Heukelum, C. Blake, T. Franken, M. Burger, N. Ferreira, G. Gobetz
Background: Peri-articular infiltrations (PAI) in total knee arthroplasty (TKA) offer effective analgesia, and are cost effective, safe and easy to perform. Currently there is no gold standard technique based on evidence-based medicine; described methods are based on consensus recommendations. The latest literature supports PAI including complex and multiple drug combinations, such as liposomal bupivacaine, ropivacaine and ketorolac, which are not available in all settings. This study aims to prove that a basic PAI technique using widely available and inexpensive agents offers good and effective outcomes in a resource-poor environment. Methods: A double-blind randomised control trial compared the effectiveness of PAI with a simple, widely available anaesthetic solution (bupivacaine and adrenalin) to a normal saline control group. Infiltration volumes were calculated at 1 ml/kg and the infiltration technique followed a specific protocol. Post-operative outcomes included visual analogue scores (VAS), ambulation scores, morphine use, knee range of motion (ROM) and time to discharge. Results: Two comparable groups of 26 patients each were included (intervention: 81% female, mean age 64.8±8.8 years vs control: 65% female, mean age 67.0±7.6 years). All pain-related measures favoured the intervention group but failed to reach statistical significance at 24 and 72 hours. Mean VAS scores at 48 hours were significantly lower in the intervention group. (VAS score 3.0±1.6 vs 4.1±1.2, p=0.013). The other parameters measured strongly favoured the intervention group but did not prove to be significant. Conclusions: A volume per kilogram PAI technique making use of widely available, cost-effective agents provides a statistical reduction in VAS scores at 48 hours post TKA. This suggests that in a resource-poor environment PAI is still a valuable addition to the multimodal analgesia pathway in the post-operative management of TKA. Maximum drug doses may show even more promising results, specifically in the first 24 hours post-operatively. Further studies investigating PAI for TKA in resource-restrained environments are indicated. Level of evidence: Level 2
背景:全膝关节置换术(TKA)中关节周围浸润术(PAI)具有镇痛效果好、成本低、安全、操作方便等优点。目前还没有基于循证医学的金标准技术;所描述的方法是基于共识的建议。最新文献支持PAI，包括复杂和多种药物组合，如布比卡因脂质体、罗哌卡因和酮咯酸，这些药物并非在所有情况下都可用。本研究旨在证明，在资源贫乏的环境中，使用广泛可用且价格低廉的药物的基本PAI技术可以提供良好而有效的结果。方法:一项双盲随机对照试验比较了PAI使用一种简单、广泛使用的麻醉溶液(布比卡因和肾上腺素)与生理盐水对照组的有效性。浸润体积以1 ml/kg计算，浸润技术遵循特定的方案。术后结果包括视觉模拟评分(VAS)、行走评分、吗啡使用、膝关节活动度(ROM)和出院时间。结果:两组患者各26例(干预组:81%女性，平均年龄64.8±8.8岁;对照组:65%女性，平均年龄67.0±7.6岁)。所有与疼痛相关的措施都有利于干预组，但在24和72小时时没有达到统计学意义。干预组48小时VAS平均评分明显降低。(VAS评分3.0±1.6 vs 4.1±1.2,p=0.013)。测量的其他参数强烈支持干预组，但没有证明是显著的。结论:每千克体积PAI技术使用广泛可用的、成本效益高的药物，可在TKA后48小时统计上降低VAS评分。这表明，在资源贫乏的环境中，PAI仍然是TKA术后管理中多模式镇痛途径的一个有价值的补充。最大药物剂量可能会显示出更有希望的结果，特别是在术后最初的24小时内。指出了在资源受限环境中进一步研究PAI对TKA的影响。证据等级:二级
{"title":"Peri-articular infiltration in the resource-restrained environment - still a worthwhile adjunct to multimodal analgesia post total knee replacement","authors":"M. V. Heukelum, C. Blake, T. Franken, M. Burger, N. Ferreira, G. Gobetz","doi":"10.17159/2309-8309/2020/V19N3A5","DOIUrl":"https://doi.org/10.17159/2309-8309/2020/V19N3A5","url":null,"abstract":"Background: Peri-articular infiltrations (PAI) in total knee arthroplasty (TKA) offer effective analgesia, and are cost effective, safe and easy to perform. Currently there is no gold standard technique based on evidence-based medicine; described methods are based on consensus recommendations. The latest literature supports PAI including complex and multiple drug combinations, such as liposomal bupivacaine, ropivacaine and ketorolac, which are not available in all settings. This study aims to prove that a basic PAI technique using widely available and inexpensive agents offers good and effective outcomes in a resource-poor environment. \u0000Methods: A double-blind randomised control trial compared the effectiveness of PAI with a simple, widely available anaesthetic solution (bupivacaine and adrenalin) to a normal saline control group. Infiltration volumes were calculated at 1 ml/kg and the infiltration technique followed a specific protocol. Post-operative outcomes included visual analogue scores (VAS), ambulation scores, morphine use, knee range of motion (ROM) and time to discharge. \u0000Results: Two comparable groups of 26 patients each were included (intervention: 81% female, mean age 64.8±8.8 years vs control: 65% female, mean age 67.0±7.6 years). All pain-related measures favoured the intervention group but failed to reach statistical significance at 24 and 72 hours. Mean VAS scores at 48 hours were significantly lower in the intervention group. (VAS score 3.0±1.6 vs 4.1±1.2, p=0.013). The other parameters measured strongly favoured the intervention group but did not prove to be significant. \u0000Conclusions: A volume per kilogram PAI technique making use of widely available, cost-effective agents provides a statistical reduction in VAS scores at 48 hours post TKA. This suggests that in a resource-poor environment PAI is still a valuable addition to the multimodal analgesia pathway in the post-operative management of TKA. Maximum drug doses may show even more promising results, specifically in the first 24 hours post-operatively. Further studies investigating PAI for TKA in resource-restrained environments are indicated. \u0000Level of evidence: Level 2","PeriodicalId":32220,"journal":{"name":"SA Orthopaedic Journal","volume":"19 1","pages":"156-161"},"PeriodicalIF":0.0,"publicationDate":"2020-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45511580","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-08-26DOI: 10.17159/2309-8309/2020/V19N3A6
L. Noconjo, M. Nortje
Background: Highly porous Trabecular Metal™ acetabular components are increasingly being used in revision hip arthroplasty as they facilitate ingrowth, provide a useful mechanism to deal with bone loss and may decrease the risk of infection. The purpose of this audit was to describe: 1) the total number of hip arthroplasty surgeries over five years, the ratio of revision to primary hip arthroplasty and indications for revision; 2) the short-term outcomes of revision hip arthroplasty with Trabecular Metal™ components and augments. Methods: A retrospective folder and radiograph review of all patients who had revision total hip arthroplasty (THA) at a tertiary level hospital from February 2012 to February 2017 was done. Results: There were 979 THAs performed over the period – 863 (87%) primary THAs, and 116 (12%) hip revision cases performed in 107 patients. Of the 116 (107 patients) hip revisions, there were seven (6%) re-revisions in five patients. The indications for revision were aseptic loosening 67 (59%), septic loosening 11 (10%), liner wear 18 (16%), periprosthetic fracture five (4%), other 15 (13%). Trabecular Metal™ was used for revision in 16 hips (14 patients), which is 14% of the total 116 revisions. There were ten females and four males with an average age of 61 years. The average duration of follow-up in this group was 18.5 months (1.5–39.2). In these 16 Trabecular Metal™ hips, there were three (19%) early failures of fixation due to technical errors. Conclusion: In our institution, 12% of the arthroplasty is revision surgery. The indications for revision are similar to published literature. Trabecular Metal™ revisions had a 19% early failure rate due to technical error. Level of evidence: Level 4
{"title":"The short-term outcome of hip revision arthroplasty with Trabecular Metal™ components and augments","authors":"L. Noconjo, M. Nortje","doi":"10.17159/2309-8309/2020/V19N3A6","DOIUrl":"https://doi.org/10.17159/2309-8309/2020/V19N3A6","url":null,"abstract":"Background: Highly porous Trabecular Metal™ acetabular components are increasingly being used in revision hip arthroplasty as they facilitate ingrowth, provide a useful mechanism to deal with bone loss and may decrease the risk of infection. The purpose of this audit was to describe: 1) the total number of hip arthroplasty surgeries over five years, the ratio of revision to primary hip arthroplasty and indications for revision; 2) the short-term outcomes of revision hip arthroplasty with Trabecular Metal™ components and augments. \u0000Methods: A retrospective folder and radiograph review of all patients who had revision total hip arthroplasty (THA) at a tertiary level hospital from February 2012 to February 2017 was done. \u0000Results: There were 979 THAs performed over the period – 863 (87%) primary THAs, and 116 (12%) hip revision cases performed in 107 patients. Of the 116 (107 patients) hip revisions, there were seven (6%) re-revisions in five patients. The indications for revision were aseptic loosening 67 (59%), septic loosening 11 (10%), liner wear 18 (16%), periprosthetic fracture five (4%), other 15 (13%). Trabecular Metal™ was used for revision in 16 hips (14 patients), which is 14% of the total 116 revisions. There were ten females and four males with an average age of 61 years. The average duration of follow-up in this group was 18.5 months (1.5–39.2). In these 16 Trabecular Metal™ hips, there were three (19%) early failures of fixation due to technical errors. \u0000Conclusion: In our institution, 12% of the arthroplasty is revision surgery. The indications for revision are similar to published literature. Trabecular Metal™ revisions had a 19% early failure rate due to technical error. \u0000Level of evidence: Level 4","PeriodicalId":32220,"journal":{"name":"SA Orthopaedic Journal","volume":"19 1","pages":"162-166"},"PeriodicalIF":0.0,"publicationDate":"2020-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48011005","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-08-26DOI: 10.17159/2309-8309/2020/V19N3A7
K. Coetzee, N. Gibson
Background: Basic competency in musculoskeletal medicine is necessary for all graduating doctors due to the growing burden of disease. Globally and nationally research has shown deficiencies in musculoskeletal knowledge according to the Freedman–Bernstein test. In South Africa, different health science faculties show different approaches to training; this article considers if any of these demonstrate adequate training and whether significant differences exist between the faculties’ results. The aim of the study is to determine whether there are significant differences between musculoskeletal learning outcomes between graduates from different health science faculties. Methods: A multi-centre, cross-sectional study was performed in which medical interns completed the Freedman–Bernstein test after graduation and prior to commencing their formal two-month block in orthopaedics. Data was then analysed to determine whether significant differences existed between the test scores of the eight health science faculties’ graduates. Results: A total of 259 completed tests were analysed. The mean score was 46% (range 4-88%, 95% CI 44-48%), and 244 of the 259 interns failed the test (94% failure rate). The lowest and highest mean scores, by health science faculty, was 34% (95% CI 28-40%) and 60% (95% CI 55-64%) respectively. An ANOVA test indicated statistically significant differences between test scores of the different health science faculties (p<0.001). Conclusion: We have demonstrated competency scores consistent with previous literature from South Africa and shown that there are statistically significant differences between the health science faculties based on Freedman–Bernstein test scores. This evidence suggests differing levels of musculoskeletal knowledge attained at health science faculties in South Africa, and no improvement in undergraduate education in the last decade. Level of evidence: Level 4
背景:由于疾病负担的增加，肌肉骨骼医学的基本能力对所有即将毕业的医生都是必要的。根据弗里德曼-伯恩斯坦测试，全球和全国的研究都显示出肌肉骨骼知识的不足。在南非，不同的卫生科学学院表现出不同的培训方法;这篇文章考虑的是这些是否证明了充分的训练，以及教师之间的结果是否存在显著差异。本研究的目的是确定不同健康科学学院的毕业生在肌肉骨骼学习结果之间是否存在显著差异。方法:进行了一项多中心的横断面研究，在该研究中，医学实习生在毕业后和开始正式的为期两个月的骨科培训之前完成了Freedman-Bernstein测试。然后对数据进行分析，以确定八所健康科学学院毕业生的测试成绩之间是否存在显著差异。结果:共分析了259例已完成的检测。平均得分为46%(范围4-88%，95% CI 44-48%)， 259名实习生中有244名没有通过测试(失败率94%)。卫生科学学院的最低和最高平均得分分别为34% (95% CI 28-40%)和60% (95% CI 55-64%)。ANOVA检验显示，不同卫生科学院系的考试成绩差异有统计学意义(p<0.001)。结论:我们已经证明了能力分数与南非先前的文献一致，并表明基于弗里德曼-伯恩斯坦测试分数的健康科学院系之间存在统计学上的显著差异。这一证据表明，南非卫生科学学院的肌肉骨骼知识水平不同，在过去十年中，本科教育没有任何改善。证据等级:四级
{"title":"Freedman-Bernstein musculoskeletal competence testing of South African intern doctors: is there a difference between health science faculties?","authors":"K. Coetzee, N. Gibson","doi":"10.17159/2309-8309/2020/V19N3A7","DOIUrl":"https://doi.org/10.17159/2309-8309/2020/V19N3A7","url":null,"abstract":"Background: Basic competency in musculoskeletal medicine is necessary for all graduating doctors due to the growing burden of disease. Globally and nationally research has shown deficiencies in musculoskeletal knowledge according to the Freedman–Bernstein test. In South Africa, different health science faculties show different approaches to training; this article considers if any of these demonstrate adequate training and whether significant differences exist between the faculties’ results. The aim of the study is to determine whether there are significant differences between musculoskeletal learning outcomes between graduates from different health science faculties. \u0000Methods: A multi-centre, cross-sectional study was performed in which medical interns completed the Freedman–Bernstein test after graduation and prior to commencing their formal two-month block in orthopaedics. Data was then analysed to determine whether significant differences existed between the test scores of the eight health science faculties’ graduates. \u0000Results: A total of 259 completed tests were analysed. The mean score was 46% (range 4-88%, 95% CI 44-48%), and 244 of the 259 interns failed the test (94% failure rate). The lowest and highest mean scores, by health science faculty, was 34% (95% CI 28-40%) and 60% (95% CI 55-64%) respectively. An ANOVA test indicated statistically significant differences between test scores of the different health science faculties (p<0.001). \u0000Conclusion: We have demonstrated competency scores consistent with previous literature from South Africa and shown that there are statistically significant differences between the health science faculties based on Freedman–Bernstein test scores. This evidence suggests differing levels of musculoskeletal knowledge attained at health science faculties in South Africa, and no improvement in undergraduate education in the last decade. \u0000Level of evidence: Level 4","PeriodicalId":32220,"journal":{"name":"SA Orthopaedic Journal","volume":"19 1","pages":"167-172"},"PeriodicalIF":0.0,"publicationDate":"2020-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48312788","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-08-26DOI: 10.17159/2309-8309/2020/V19N3A4
P. Panchoo, J. I. Wiegerinck, V. Boskovic, M. Laubscher, S. Maqungo, G. McCollum, R. Dey
Background: High-energy Lisfranc injuries are relatively uncommon but can lead to severe disability and morbidity. Primary fusion is a treatment option that can improve outcomes and reduce the reoperation rate. The aim of this study was to evaluate our series of primary fusions for high-energy Lisfranc injuries, looking specifically at type of fusion, time to union, non-union rates, reoperation rates and quality of reduction. Methods: Patients who underwent surgery for Lisfranc injuries were identified from the REDCap surgical database and then retrieved from records. Only cases of primary fusion in adults were included. We excluded low-energy sprains and athletic injuries, ipsilateral lower limb injuries and cases where reduction and fixation were done. Radiographs were analysed from the iSite Enterprise PACS system (Philips®). Results: Between 2013 and 2018, 12 cases of high-energy Lisfranc injuries were identified where primary fusion was done. Seven patients (58%) underwent fusion of the first, second and third tarsometatarsal (TMT) joints. The first and second TMT joints were fused in only one case (8%), and the second and third TMT joints were fused in four cases (33%). Only one patient (8%) had removal of implants. Compression plating was the technique of choice used for fusion. There was 100% union rate and average time to union was 84 days. Acceptable reduction was observed in nine cases (75%). Three cases (25%) of malreduction were found, among which one patient had pre-existing hallux valgus. Conclusion: The majority of patients who underwent primary fusion of at least one TMT joint had good radiological outcome. Further studies with better clinical follow-up are needed. Level of evidence: Level 4
{"title":"Outcomes of primary fusion in high-energy Lisfranc injuries at a tertiary state hospital","authors":"P. Panchoo, J. I. Wiegerinck, V. Boskovic, M. Laubscher, S. Maqungo, G. McCollum, R. Dey","doi":"10.17159/2309-8309/2020/V19N3A4","DOIUrl":"https://doi.org/10.17159/2309-8309/2020/V19N3A4","url":null,"abstract":"Background: High-energy Lisfranc injuries are relatively uncommon but can lead to severe disability and morbidity. Primary fusion is a treatment option that can improve outcomes and reduce the reoperation rate. The aim of this study was to evaluate our series of primary fusions for high-energy Lisfranc injuries, looking specifically at type of fusion, time to union, non-union rates, reoperation rates and quality of reduction. \u0000Methods: Patients who underwent surgery for Lisfranc injuries were identified from the REDCap surgical database and then retrieved from records. Only cases of primary fusion in adults were included. We excluded low-energy sprains and athletic injuries, ipsilateral lower limb injuries and cases where reduction and fixation were done. Radiographs were analysed from the iSite Enterprise PACS system (Philips®). \u0000Results: Between 2013 and 2018, 12 cases of high-energy Lisfranc injuries were identified where primary fusion was done. Seven patients (58%) underwent fusion of the first, second and third tarsometatarsal (TMT) joints. The first and second TMT joints were fused in only one case (8%), and the second and third TMT joints were fused in four cases (33%). Only one patient (8%) had removal of implants. Compression plating was the technique of choice used for fusion. There was 100% union rate and average time to union was 84 days. Acceptable reduction was observed in nine cases (75%). Three cases (25%) of malreduction were found, among which one patient had pre-existing hallux valgus. \u0000Conclusion: The majority of patients who underwent primary fusion of at least one TMT joint had good radiological outcome. Further studies with better clinical follow-up are needed. \u0000Level of evidence: Level 4","PeriodicalId":32220,"journal":{"name":"SA Orthopaedic Journal","volume":"19 1","pages":"150-155"},"PeriodicalIF":0.0,"publicationDate":"2020-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42809884","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-05-29DOI: 10.17159/2309-8309/2020/v19n2a5
J. McCaul, A. Horn, M. McCaul, S. Dix-Peek
Background: In paediatric trauma, measured increase in prevertebral soft tissue thickness on a lateral cervical spine (C-spine) X-ray is interpreted as swelling, raising suspicion of C-spine injury. Defining swelling in absolute measurements is cumbersome – children’s sizes vary. Published recommendations are largely lacking in evidence. There may be potentially more consistent tools, for example, to measure soft tissue thickness as a ratio of vertebral body width. The aim of this study was to determine whether consistent, measurable prevertebral soft tissue to vertebral body width ratios exist for use as simple diagnostic tools in the assessment of swelling and injury in paediatric C-spine trauma. Patients and methods: C-spine trauma X-rays taken at a South African children’s hospital were randomly sampled. Seventy-one unintubated X-rays from 85 controls were used to identify normal ratios. The authors measured vertebral bodies and soft tissue at each level, created all possible ratios, then chose the two least variable – one for the upper and one for the lower C-spine. Twenty cases aided in determining diagnostic accuracy for C-spine injury. Results: Mean soft tissue at the second cervical vertebral level (c2) was 38% of the seventh vertebra (C7) (95% confidence interval [CI]: 34–41.9%, standard error [SE]: 2.0%). Mean c6 soft tissue was 65.6% of C7 vertebra (95% CI: 61.9–69.3%, SE: 1.9%). In diagnosing C-spine injury, a receiver operating characteristic (ROC) curve calculation gave an empirical optimal cut-point of 53.9% and 74.4% respectively. Using practical cut-offs of 55% at c2 and 75% at c6 yielded specificities of 93.8% (95% CI: 84.8–98.3%) and 81.8% (95% CI: 70.4–90.2%), with negative predictive values of 90.9% (95% CI: 81.3–96.6%) and 91.5% (95% CI: 81.3–97.2%) respectively. Conclusion: Consistent and specific ratios exist in the upper and lower paediatric C-spine. Both ratios have poor sensitivities and positive predictive values and so are poor screening tools; however, a positive result can raise suspicion of C-spine injury in high-risk individuals. This can help to motivate for further investigations such as computer tomography (CT) or magnetic resonance imaging (MRI), which may not be easily accessible in under-resourced settings. However, further research is required to validate the diagnostic value of these ratios. Level of evidence: Level 4
{"title":"Correlation of Soft tissue Projection in Injured NEcks (CSPINE) - Prevertebral soft tissue measurement in paediatric cervical spine trauma","authors":"J. McCaul, A. Horn, M. McCaul, S. Dix-Peek","doi":"10.17159/2309-8309/2020/v19n2a5","DOIUrl":"https://doi.org/10.17159/2309-8309/2020/v19n2a5","url":null,"abstract":"Background: In paediatric trauma, measured increase in prevertebral soft tissue thickness on a lateral cervical spine (C-spine) X-ray is interpreted as swelling, raising suspicion of C-spine injury. Defining swelling in absolute measurements is cumbersome – children’s sizes vary. Published recommendations are largely lacking in evidence. There may be potentially more consistent tools, for example, to measure soft tissue thickness as a ratio of vertebral body width. The aim of this study was to determine whether consistent, measurable prevertebral soft tissue to vertebral body width ratios exist for use as simple diagnostic tools in the assessment of swelling and injury in paediatric C-spine trauma. \u0000Patients and methods: C-spine trauma X-rays taken at a South African children’s hospital were randomly sampled. Seventy-one unintubated X-rays from 85 controls were used to identify normal ratios. The authors measured vertebral bodies and soft tissue at each level, created all possible ratios, then chose the two least variable – one for the upper and one for the lower C-spine. Twenty cases aided in determining diagnostic accuracy for C-spine injury. \u0000Results: Mean soft tissue at the second cervical vertebral level (c2) was 38% of the seventh vertebra (C7) (95% confidence interval [CI]: 34–41.9%, standard error [SE]: 2.0%). Mean c6 soft tissue was 65.6% of C7 vertebra (95% CI: 61.9–69.3%, SE: 1.9%). In diagnosing C-spine injury, a receiver operating characteristic (ROC) curve calculation gave an empirical optimal cut-point of 53.9% and 74.4% respectively. Using practical cut-offs of 55% at c2 and 75% at c6 yielded specificities of 93.8% (95% CI: 84.8–98.3%) and 81.8% (95% CI: 70.4–90.2%), with negative predictive values of 90.9% (95% CI: 81.3–96.6%) and 91.5% (95% CI: 81.3–97.2%) respectively. \u0000Conclusion: Consistent and specific ratios exist in the upper and lower paediatric C-spine. Both ratios have poor sensitivities and positive predictive values and so are poor screening tools; however, a positive result can raise suspicion of C-spine injury in high-risk individuals. This can help to motivate for further investigations such as computer tomography (CT) or magnetic resonance imaging (MRI), which may not be easily accessible in under-resourced settings. However, further research is required to validate the diagnostic value of these ratios. \u0000Level of evidence: Level 4","PeriodicalId":32220,"journal":{"name":"SA Orthopaedic Journal","volume":"19 1","pages":"84-91"},"PeriodicalIF":0.0,"publicationDate":"2020-05-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47956825","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-05-29DOI: 10.17159/2309-8309/2020/v19n2a8
C. Blake, GF Van Staden, J. V. D. Merwe, S. Matshidza
Femur neck fractures in young adults account for 3–10% of all hip fractures, and management remains a challenge for the orthopaedic surgeon. Reoperation rates remain high after fixation of these fractures due to avascular necrosis, non-union, implant failure and removal of hardware. Complication rates are higher in displaced fractures, and patients who undergo revision to total hip arthroplasty (THA) have poorer outcomes compared with primary THA. Injury factors, fracture pattern, physiological age, timing of surgery, the role of capsulotomy and implant choice all need to be carefully considered in managing these fractures. Preserving the native hip joint is the standard of care in these patients but primary THA is becoming an attractive option due to the improvements in bearing surfaces and longevity of implants. There is no role for conservative management of fractures in this age group. Absolute anatomic reduction and stable fixation remains the goal of hip-preserving surgery. Open reduction is often necessary. Various fixation options are available from the more commonly used cannulated screws and dynamic hip screw to the newer generation hybrid plates with telescoping screws. Cannulated screws (CS) are adequate for stable fracture (Garden 1 and 2) patterns, whereas the dynamic hip screw (DHS) is biomechanically superior for unstable fractures. Neck shortening after using sliding screws is common but does not seem to influence clinical outcomes. Cephalomedullary nails are an acceptable load-bearing alternative. Proximal femur locking plates have high failure rates and should be avoided. New generation hybrid plates have shown promising results with fewer non-union rates than CS and DHS systems. Primary THA can be considered in exceptional cases where there are significant comorbidities, poor bone stock or in a patient that will be unable to tolerate a second surgery if fixation fails. Hemiarthroplasty should be avoided in this age group. The management of these fractures in South African government hospitals should be supervised by experienced surgeons whenever possible. Level of evidence: Level 5
{"title":"Management of femur neck fractures in young adults under the age of 60 years","authors":"C. Blake, GF Van Staden, J. V. D. Merwe, S. Matshidza","doi":"10.17159/2309-8309/2020/v19n2a8","DOIUrl":"https://doi.org/10.17159/2309-8309/2020/v19n2a8","url":null,"abstract":"Femur neck fractures in young adults account for 3–10% of all hip fractures, and management remains a challenge for the orthopaedic surgeon. Reoperation rates remain high after fixation of these fractures due to avascular necrosis, non-union, implant failure and removal of hardware. Complication rates are higher in displaced fractures, and patients who undergo revision to total hip arthroplasty (THA) have poorer outcomes compared with primary THA. Injury factors, fracture pattern, physiological age, timing of surgery, the role of capsulotomy and implant choice all need to be carefully considered in managing these fractures. \u0000Preserving the native hip joint is the standard of care in these patients but primary THA is becoming an attractive option due to the improvements in bearing surfaces and longevity of implants. There is no role for conservative management of fractures in this age group. Absolute anatomic reduction and stable fixation remains the goal of hip-preserving surgery. Open reduction is often necessary. \u0000Various fixation options are available from the more commonly used cannulated screws and dynamic hip screw to the newer generation hybrid plates with telescoping screws. Cannulated screws (CS) are adequate for stable fracture (Garden 1 and 2) patterns, whereas the dynamic hip screw (DHS) is biomechanically superior for unstable fractures. Neck shortening after using sliding screws is common but does not seem to influence clinical outcomes. Cephalomedullary nails are an acceptable load-bearing alternative. Proximal femur locking plates have high failure rates and should be avoided. New generation hybrid plates have shown promising results with fewer non-union rates than CS and DHS systems. \u0000Primary THA can be considered in exceptional cases where there are significant comorbidities, poor bone stock or in a patient that will be unable to tolerate a second surgery if fixation fails. Hemiarthroplasty should be avoided in this age group. The management of these fractures in South African government hospitals should be supervised by experienced surgeons whenever possible. \u0000Level of evidence: Level 5","PeriodicalId":32220,"journal":{"name":"SA Orthopaedic Journal","volume":"19 1","pages":"103-108"},"PeriodicalIF":0.0,"publicationDate":"2020-05-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41968584","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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